System Safety
Supporting and sustaining Insights to Improvement with PSIRF
Patient Safety Incident Response Framework (PSIRF) is embedding in NHS trusts and related organisations
Translating insights into sustainable, system-wide improvements
Strengthening system learning and improvement capability
The Challenge
NHS trusts need a systems-based approach to learning from patient safety incidents, focusing on improvement rather than blame.
As NHS trusts and related organisations move beyond the initial implementation of the Patient Safety Incident Response Framework (PSIRF), the focus is now on developing the infrastructure required to translate learning from systems-based responses into demonstrable, sustainable, joined up, improvement.
The Solution
PSIRF enables and supports involvement for those affected by patient safety incidents through the application of a range of system-based approaches to learning from patient safety incidents.
For patients and families, PSIRF promotes compassionate engagement and involvement following safety incidents, fostering trust and transparency.
For healthcare providers, PSIRF supports a structured approach to learning from incidents, leading to system improvements and better patient outcomes.
For healthcare staff, PSIRF encourages a fair and open culture that facilitates continuous learning and improvement.
The Insight to Improvement programme, commissioned by NHS England, is aiming to create a sustainable framework that enables healthcare organisations to consistently translate patient safety insights into measurable change, strengthening learning and system-wide improvement capability while supporting the delivery of safer care.
The programme will facilitate this by:
- Gaining insight into the existing infrastructure, processes, and governance arrangements that drive system-wide safety improvement.
- Strengthening connections between patient safety and improvement teams, programmes, and organisational strategies.
- Identifying gaps and opportunities that limit the effective translation of insight and learning into sustained improvement.
- Supporting providers, Integrated Care Boards (ICBs), and regional teams.
- Enabling purposeful planning that aligns improvement activity with organisational safety priorities, quality objectives, and strategic goals.
- Exploring systems and methodologies that may support the consistent measurement of impact through a shared or “common currency” approach, enabling evidence of improvement to be captured and compared across diverse safety improvement programmes.
- Promoting a sustainable improvement culture aligned with PSIRF, quality improvement, and organisational learning strategies.
PSIRF implementation is being driven by NHS England’s System Safety Improvement Programme. Find out more about PSIRF on the NHS England website.
Our work in partnership
We are working with Integrated Care Boards, NHS trust providers, Patient Safety Specialists, national bodies/experts, research organisations and quality improvement teams in the South West to support and sustain Insight from Improvement with PSIRF.
Previously, in 2025-25, we supported the PSIRF Maturity Assessment pilot across seven South West providers in partnership with Health Innovation West of England, to establish a baseline for PSIRF maturity and create the right conditions for improvement.
In 2025-26, the System Safety Improvement Programme was put on hold. During this time, we focused on system oversight and were involved in an evaluation of a PSIRF maturity pilot.
Our impact to date
In 2024-25, we supported Devon Integrated Care Board to transition from an implementation mindset to a collaborative learning space through a stakeholder group and digital cross-organisational channel.
Our partnership with the Health Services Safety Investigations Body also ensured that 24 system colleagues received specialist training in Safety Engineering Initiative for Patient Safety tools and approaches, boosting system capability in learning from patient safety incidents.
In Spring 2025, we hosted our first PSIRF learning community event, convening partners from across the South West to share practical insights, and laying the groundwork for collaboration across the region.
What’s next?
The Insight to Improvement programme is now underway across England, with Health Innovation South West leading this initiative across the South West region.
Working with partners across the system, we aim to strengthen the connection between learning and action, helping organisations demonstrate how insights from patient safety incidents lead to measurable, sustainable improvements in care.
