Hi ,
Many organisations are hitting that point in their PSIRF journey where they’re starting to think about reviewing their patient safety incident investigation priorities.
My first response? Hang on just a sec…Before we rush into selecting new priorities, we need to have an honest conversation about whether the current ones have actually delivered what we need them to.
The questions we need to ask first
1. Have your previous priorities delivered meaningful change against the risk identified in that priority?
And I mean really delivered change. Not “we did 6 investigations” or “we identified some actions.” I mean: Are things actually different? Safer? Better? Can you evidence the improvement? (this is really hard, but this is what the local priorities were set up to do – help us learn about an area of risk to safety in our organisations and then deliver the change needed to reduce the risk).
2. What have you learnt about those areas of work?
Is that learning now in the organisational memory bank, or is it spread through a few separate reports? How can others in the organisation access and summarise what you learned, and what we’re doing to reduce the risk when they need it?
3. Do the board know what the status of improvement against this priority is?
Not just “we investigated three incidents and 2 more are overdue” I mean – do they know what changed, whether it’s working, and whether the original risk has reduced?
4. Did we get the balance between investigation and improvement on our priorities right?
It is tempting to spend the most resource on investigating and documenting, use this as an opportunity for reflection to take a look at this balance, and if we didn’t get this right – what do we need to shift for the next period?
What Meaningful Change Actually Looks Like
When I talk about meaningful change, I’m looking for evidence like:
Measurable improvement in the priority area (not just “we haven’t had another serious incident” – absence of evidence isn’t evidence of absence)
System changes that are embedded – not reliant on individual people remembering to do things differently
Staff confidence that the changes make their work safer and easier
Learning that’s accessible – not trapped in individual reports
Board-level understanding of progress, not just activity
Sustainability – the changes are still in place 6, 12, 18 months later
If you can’t demonstrate these things, changing your priorities is just rearranging deck chairs.
So What Should You Do?
If you can’t answer these questions confidently, perhaps we’re not quite ready to delve into developing new priorities.
Perhaps we’ve not quite closed the loop on these ones.
That’s not a failure – it’s useful information. It tells you where to focus your development efforts:
Complete the work you committed to
Evaluate what’s actually been achieved against your current priorities
Build systems for organisational memory
Strengthen your board reporting on improvement, not just investigation
Review your capacity and capability for both investigation and improvement
Learn from what didn’t work, so you don’t repeat the same patterns
When Changing Priorities Makes Sense
Don’t get me wrong – sometimes changing priorities is absolutely the right thing to do:
You’ve genuinely addressed the original risk and have evidence to prove it
Your risk profile has changed significantly
You’ve learned something from your investigations that reveals a more significant underlying issue
Your incident data shows a new pattern that needs attention
But these should be evidence-based decisions, not calendar-based ones. If you’re currently in this position, reach out – I’m always happy to be a sounding board for teams figuring this out. Sometimes I even actually help in those decisions 😉
Lauren.
