HM meets…Dr Cathy Cale

The new Patient Safety Incident Response Framework (PSIRF) being rolled out for all providers that treat NHS-funded patients represents a huge cultural shift. Dr Cathy Cale, group medical director at Spire Healthcare, talks to HM about how the system is being implemented across its portfolio and why focusing on learning and change rather than apportioning blame benefits both staff and patients

We can’t be successful unless we’re safe and deliver high quality care, so an awful lot of work goes into driving patient safety and to do that you need to learn from when things go wrong as well as from when they go right,’ Spire Healthcare group medical director Dr Cathy Cale tells me when we meet to talk about the Group’s roll out of the new Patient Safety Incident Response Framework (PSIRF).

Spire has been a proactive adopter of PSIRF, which is being implemented across the NHS and is mandatory for all providers treating NHS-funded patients. Replacing the decade-old NHS Serious Incident Framework, it is designed to provide a deeper understanding of how and why an incident has occurred and learn from it rather than apportion blame.

Safety culture can be a nebulous concept and one which my 60 minutes with Cale cannot possibly do justice, but her easy manner and enthusiasm breathe welcome clarity into the conversation.

‘Culture is king. If you get culture right, you’ll get safety right,’ says Cale. ‘We tackle it in lots of different ways, but talking is key and at Spire we talk about safety all the time.’

Originally trained as a doctor at University of Birmingham, Cale was deputy medical director at Great Ormond Street Hospital and medical director of Hillingdon Hospitals NHS Foundation Trust before joining Spire in 2020. Over her career, she says, the way we talk about safety in healthcare has evolved.

‘Approaches to safety in healthcare have moved on hugely since the Serious Incident Framework was put in place and rather than concentrating on who was at fault it is much more focused on asking why. What went wrong in the system? Why didn’t it work? Nobody gets up in the morning thinking I’m going to go to work and do a really bad job. It’s systems and processes that let people down,’ she says.

No blame-game
PSIRF aims to move away from blame culture in responding to patient safety incidents and instead focus on maximising learning and improvement. It is based on four key pillars: compassionate engagement with all those involved; application of a range of system-based approaches to learning, considered and proportionate responses, and supportive oversight focused on strengthening response system functioning and improvement.

According to Cale, Spire already had a positive safety culture. The Group was one of, if not the first in the independent sector, to introduce Freedom to Speak up Guardians. It now has a network of 58 Guardians across its sites. It has also had surgical safety champions in all its theatre complexes, long encouraged open dialogue via regular colleague listening forums, and undertakes patient engagement events. However, she says, it had started to think about next steps when ‘PSIRF landed in our laps’.

‘It was great timing. The focus of PSIRF is very much on learning and how we can do things differently. It’s about how we can compassionately engage with people using a proportionate approach and those together are a very different way of thinking,’ Cale explains.

It might sound simple, but it is a stark contrast to the Serious Incident Framework, which prescribes what incidents to investigate, how to investigate them, delivery of a Root Cause Analysis and written action plan.

It has also taken what can be perceived as an adversarial element out of patient safety investigations. Subtle changes in language, such as asking those involved to provide their ‘account’ of what happened rather than a ‘statement’ have shifted the emphasis on blame to meaningful learning and change.

‘What PSIRF has enabled us to do is just pause and ask what is the best way of getting people to think about what actually happened? And it’s pretty simple, you just get them to talk to one another,’ adds Cale.

Implementing change
Over the past year, Spire has been piloting a range of tools across its 39-strong hospital portfolio designed to do just that. The idea, says Cale, is to get people together relatively quickly after the incident to discuss what happened. A variety of terms are used – swarms, huddles, roundtables – but the aim is the same: get everybody talking and talking together.

‘Where we’ve been piloting these tools, it’s not just the richness of the learning, but the right learning that comes out,’ she says. ‘It’s a much more engaging mechanism and where we have been rolling it out in our hospitals, they love it because they are spending time thinking about how to do things differently.’

PSIRF not only changes how hospitals respond to patient safety incidents but what they respond to. Providers have more flexibility in how they respond which in essence, means they can focus on the incidents that offer the greatest learning opportunities.

‘Because we’ve got a range of tools we can use, rather than everything having to have a Root Cause Analysis, we can say actually, we’ve looked at this particular incident and don’t think there’s any great learning from it,’ Cale explains. ‘It might be that it was something unavoidable, such as an unavoidable complication of surgery. There would still be a discussion about it, because there is always something that you can learn but it might be a shorter review. That means you can spend more time where you think there’s going to be more learning.’

Although PSIRF is only mandatory in England and when treating NHS patients, Spire has decided to roll it out across its hospitals in England, Wales and Scotland for both NHS and private patients. Cale admits it made sense on a practical level to have a single framework in place for all patients, but says the primary reason was simply that it’s a better system and one that resonated with Spire’s existing safety culture.

‘It’s the right methodology and it fits. Even as we started trialling it, it made such a difference and has had such a positive impact that it would be wrong not to use it,’ she says.

Cale and her team have spent the last year preparing for all of Spire’s 39 hospitals to go live with the framework in April. That has involved 48 training days and training for more than 600 key members of staff, alongside close collaboration with NHS England (NHSE) and health authorities in Scotland and Wales where PSIRF is not in use.

Given the scale of the project, Cale is remarkably unphased. ‘Implementing anything that’s new and is replacing something that people are incredibly familiar with is always a challenge. But for us in Spire, we’ve been pushing at an open door. Our hospitals have absolutely embraced it and welcomed it because they get it, they understand it. They understand why we are trying to do things differently,’ she says.

Perhaps the biggest challenge for Spire has been geography. PSIRF was designed with English NHS trusts in mind, rather than a group operating across 42 separate integrated care boards and three nations. As part of the process, Spire has had to develop an action plan setting out which levels of investigation it plans to use for different incidents, in addition to what is mandated by NHSE. Most NHS trusts would only need to do this once, but for a multi-site provider this could have meant multiple policies for each hospital and each ICB.

Meaningful data
However, according to Cale NHSE has been ‘incredibly supportive’ and agreed early on to assign Spire a host ICB which would approve its plan and share it with the other ICBs where Spire hospitals operate. Health authorities in Scotland and Wales have also agreed to Spire using PSIRF in their geographies, meaning it can roll the framework out across its entire portfolio.

Because it encourages open, transparent dialogue from the outset, PSIRF should also promote learning and the sharing of best practice across the entire health system.

‘We do lots of learning and I think as PSIRF takes off, and we get more rich, meaningful learning, that will help people really understand the story,’ says Cale. ‘My experience in healthcare is that telling stories works. Telling stories about what happened to the patient and giving the reasons for a change in policy works.’

Although it is still early days, Spire is already embedding PSIRF within its quality improvement programme and plans to use its methodology to make changes arising from actions from PSIRF investigations. Indeed, Cale says the introduction of PSIRF is having a much broader impact than just incident investigations. Although it is distinct from its complaints framework, one of the unintended consequences has been a change in the way governance leads approach initial conversations with patients – in part because of the PSIRF training they received.

Spire is also planning to launch a new incident management system in the middle of April, which will use machine learning to help scrutinise its vast mine of data. This, says Cale, will also work alongside PSIRF to help it pick up trends and ask the right questions faster.

‘It’s about really building on what we’ve got, using all of that fantastic richness of data and then continuing to work with our colleagues in the NHS and the ICBs and that local level to strengthen their sector wide learning.’