Patient Safety and Quality

High-quality care in the NHS means that patients have a good overall experience of care, which is clinically effective and delivered safely. An organisation committed to delivering high-quality care is always striving to be even better. At the Trust, we are committed to being a world-leading orthopaedic hospital with the best patient care and staff experience in the NHS.

Safe care ensures avoidable error and harm have been effectively removed. Safe care can be measured in several ways, for example by looking at our rates of hospital-acquired infections, thrombosis, pressure damage and falls. It can also be demonstrated through analysis of the rates of incident reporting within the hospital. We know that when staff are focused on improving the safety of care provided, we can expect to see high levels of incident reporting. Each incident report provides further opportunities for quality improvement and learning within the hospital.

The Trust places great importance on ensuring patients and their families have a good experience. We continue to work to find better ways of getting patient feedback to improve our services.

Delivering high-quality care means being able to recognise that in the provision of complex specialist services, we do not always get it right. Being open and honest with our patients, our regulators and ourselves, when we get things wrong, is the most important step we can take to improve the quality of our care and be even better.

The newly mandated NHS Patient Safety Incident Response Framework (PSIRF) has been fully implemented at RNOH. PSIRF sets a completely new direction for how the NHS and the RNOH plans to respond to patient safety incidents in comparison to the current Serious Incident Framework. This is not simply a name change, but a full change in process. Introducing PSIRF

Now that PSIRF has gone live, we will increasingly focus primarily on effective learning & improvement, compassionate engagement, and embedding a patient safety culture.

The RNOH aims to achieve this by ensuring that those affected by an incident, including patients, families and staff, continue to be treated with compassion and are able to be part of any learning investigation. We are focusing on understanding how incidents happen rather than focusing on who was responsible. This will support the NHS and the RNOH to learn and improve and to make care safer for everyone! NHS England - PSIRF

The Trust is increasingly focusing on systematic, compassionate and proportionate responses to patient safety incidents:-

By Systematic, we mean we will look at better understanding and learning from the impact of systems and human factors on the occurrence of patient safety incidents. Staff are encouraged to complete Level 1 of the patient safety syllabus found on the Trust’s Learning Hub and to support behaviours associated with a Just Culture.

By Compassionate, we mean giving patients, families and staff, better opportunities to become involved in the learning investigation process from start to finish (including what to expect, timelines and continuous updates). It is important that we increasingly prioritise and respect the needs of people who have been affected by a patient safety incident, always treating them with the highest level of compassion.

By Proportionate, we mean we will use a range of review tools such as After Action Reviews and Hot Debriefs to establish learning and improve our systems, with the tool selected balanced against the incident under review. Staff who will be involved in reviewing and identifying learning from incidents will be offered comprehensive training organised by the Patient Safety Team.

We are also very pleased to have a volunteer Patient Safety Partner (PSP), who has knowledge of NHS practices and experience of being a patient and family member of a patient. Our PSP acts as an advocate for our patients in guiding our decision-making.

In brief, the following points are important takeaways:

  • More focus on compassionate engagement
  • More focus on system changes, rather than blame
  • Focus on proportionate responses to incidents
  • No change to the Duty of Candour process
  • New learning tools to review incidents
  • Out with RCAs, in with AARs and PSIIs
  • More focus on learning
  • All harm types can have a review, not just moderate and above
  • Focus on contributing factors, not root causes

Please click on the links below to access our full PSIRF Policy and Plan and Patient Guide.

PSIRF policy

PSIRP (plan)

PSIRF Patient Guide


The key contacts for the team are:

Zaki Kramer, Deputy Director of Quality: 020 3947 0421
Patient Safety team: 020 8909 5609
Complaints & PALS team: 020 8909 5717
Patient Involvement & Volunteering team: 020 8909 5394
Clinical Audit team: 020 8909 5883

For general enquiries about the Quality Team, please contact:
Krupa Shah, Quality Coordinator, 020 8909 5378.

CQC website: www.cqc.org.uk
NICE website: www.nice.org.uk