Introduction to the Learn from Patient Safety Events (LFPSE) Service

1. The Learn from Patient Safety Events (LFPSE) Service Online service ‘go live’ 30 September 2023 happyhealthylives.uk

2. What is LFPSE? • LFPSE is initially replacing the NRLS, and subsequently, STEIS • It is a digital mechanism to allow records of patient safety events to be collated centrally to support NHS England’s statutory duties around understanding safety and providing advice and guidance on how to improve this • There are two main channels by which LFPSE receives data: via connected compatible LRMS (most secondary care), and via the online service where LRMS are not used (most primary care). The ICB will transition to the online service only • It is also a service for healthcare providers of all kinds, and their integrated care systems, to share information about patient safety events that have been recorded within their areas, to facilitate collaborative responses where necessary • It offers two kinds of access to safety record data: aggregate quantitative data through the Data Access app, and record-level data including the free text through the online Record and View service Location Data type Uses Data Access App High level aggregate quantitative data To understand overall patterns of recording To support prioritisation of safety responses and improvement work Online Record and View service >> “View events in my organisation(s)” Record-level data, including the free text Reviewing and updating by recorder, or governance staff within their organisation Reviewing and updating by governance staff in the organisation the record relates to, if created elsewhere Read-only review access for “commissioners” happyhealthylives.uk

3. How is LFPSE different from NRLS/STEIS? Feature Benefits Supports historically low-recording sectors; ability to save drafts, update records, and undertake responses within the provider, with ICS visibility New online portal for primary care and others Learning-focussed data collection, minimising blame and promoting analysis of how things go wrong, to better support targeted improvement Revised taxonomy ML-enhanced anonymisation to reduce identifiability. Under development: real-time ability to analyse free text, suggest learning resources to providers, and identify new or under-recognised risks across all harm levels for more responsive, comprehensive national action Machine learning Live automatic data sharing between local and national systems, meaning more timely response to issues and provision of feedback, reducing harm to patients; reduced extract- upload burden on providers Two-way communication via APIs No more analysis bottleneck in the national team. With users, we’ll develop customisable data outputs to meet local needs, support prioritisation, learning and improvement Self-service data access Faster, more direct ways to support e.g. CQC and MHRA to fulfil their duties around safety and learning Improved data linkage and sharing options Streamlined recording; all learning data in one place to support improvement locally and across the system PSIRF module (TBA) happyhealthylives.uk

4. What is the expectation for ICBs using LFPSE? • The LFPSE service is one part of the patient safety strategy and sits alongside other new developments such as PSIRF, Patient Safety Partners etc. It is a tool that will underpin changes to working practices as part of the delivery of the strategy, all of which contribute to the overarching aim of improving patient safety. • To align with the ethos of PSIRF, NHSE anticipates that ICBs will work differently using LFPSE than they did with NRLS and/or STEIS • With the move to a more holistic view of patient safety events, and away from reflex investigations with strict timescales, ICB are to take an interest in safety data and the picture it represents overall, and less in the detail of individual events and their management • Access can be granted by local providers to record-level data where they feel this is appropriate or helpful; this will most likely be in the form of read-only access, so that the ICB can review the record, but not edit it • More frequently, however, NHSE anticipate that the ICB will be interested in the aggregate data to understand patterns and trends that exist across or between providers, in order to help prioritise and coordinate improvement action, and support providers to undertake its delivery happyhealthylives.uk

5. Preview: Patient Safety Incident Response Framework (PSIRF) module (At this time continue to follow the Serious Incident Framework and report SIs to STEIS.) Type of response Recommendations Actions happyhealthylives.uk

6. Supportive oversight of PSIRF 1.Improvement is the focus Oversight Mindset 1.Blame restricts insight Should underpin oversight approach from provider boards, ICBs and CQC 1.Learning from patient safety incidents is a proactive step towards improvement 1.Collaboration is key 1.Psychological safety allows learning to occur 1.Use a variety of data Oversight Approach 1.Reduce the information collection burden Principles to consider when designing an approach to oversight 1.Oversight is not ‘one size fits all’ 1.Capture meaningful insight from patients, families and staff 1.Metrics require clarity and purpose 1.Be aware of perverse incentives happyhealthylives.uk

7. How does LFPSE support safety learning culture? happyhealthylives.uk

8. PSIRF system relationships happyhealthylives.uk