Keith Conradi is the chief investigator at the Healthcare Safety Investigation Branch. He explains the organisation's work and its significance for UK healthcare professionals.
What is the Healthcare Safety Investigation Branch?
Keith Conradi: Our purpose is to undertake independent investigations across the NHS in England with the aim of driving improvements at the system level. A government inquiry into clinical incident investigations had recommended the creation of an independent body, and in 2015 an expert advisory group was set up to shape HSIB’s model of governance and operation.
We have been operational since April 2017, and we are the first in the world to carry out healthcare investigations in this way, drawing on approaches from aviation and other transport investigation branches. I'm proud of the way HSIB continues to develop, with a strong team that brings a range of skills and expertise from varying backgrounds.
The Air Accident Investigation Branch has a successful track record of developing recommendations that focus on system change rather than attributing individual blame. I see some parallels with the system and the culture in healthcare but some significant differences as well. Our vision at the HSIB is not only to deliver high quality national investigations but also to develop safety investigation as a profession within the sector. We'll use facts to establish what went wrong, make recommendations and address these to those best placed to bring change forward at a national level.
What and how does the HSIB investigate?
KC: Our aim is to investigate events that are happening system-wide, not just at trust level. We use a trigger event to start an investigation and work with staff, patients and their families throughout to understand what happened. However, we always broaden out and look at the wider thematic issues that emerge across the sector. These investigations can be to any part of the health sector that receives NHS funding.
HSIB has an open referral system, and any cases that we receive will be considered against our criteria. We look at the impact of the event, which often means we are looking at serious incidents which have resulted in harm. Consideration is then given to the systemic risk; how common the issues and whether they span other areas of healthcare. Finally, we consider the potential for learning and where HSIB could add a new perspective in that area.
What are the HSIB's aims and priorities?
KC: Our immediate priority is to develop a methodology and process for the maternity investigations which will commence in the next few months. There will be ongoing recruitment throughout the year to fill the maternity investigator posts with experienced clinicians and safety experts.
We'll continue to release updates and bulletins relating to our current national investigations and aim to publish the first of our final investigation reports this summer.
The Draft Health Service Safety Investigations Bill was published in September 2017; how does the HSIB's approach differ to the Bill's, and (how) do your objectives align?
KC: We welcome the publication of the Draft Bill primarily because it will establish the HSIB as an independent body and give us the powers necessary to undertake a thorough investigation. It is important that those who present evidence to us trust that we will hold that information in confidence; my previous experience is that legislation is the best way to achieve this.
It is important that those who present evidence to us trust that we will hold that information in confidence.
How might the HSIB's work influence or affect MDU members?
KC: We trust that our work will be positive for medical professionals across the NHS; our recommendations are intended for learning and improvement rather than to attribute blame. From what we've seen so far, there is an openness and willingness in the NHS to change, and those working in the sector can help to spread the message of the work we are doing and why.
What force will your safety recommendations have?
KC: Our final report will be published on our website, and all the safety recommendations will be included, with a clear address to the regulators and professional bodies that need to act on them. The Draft Bill indicates that a response to our Safety Recommendations will be mandatory and we will make all these responses public.
In doing so, they will be more widely shared and promote further debate about the issues in question. We are not a regulator and do not consider it our role to enforce any action promised by an addressee but do see this as an issue that needs to be resolved.
Visit www.hsib.org.uk for more information, how we investigate and our current live investigations, and follow us on Twitter @hsafetyIB.
The MDU's Dr Michael Devlin comments on the HSIB's aims and relevance for MDU members
One of the frustrating things about patient safety initiatives over the last 20 years is that direct evidence of clinical improvements arising from them often is hard to come by. But the successes of the Scottish Patient Safety Programme, most notably in reducing hospital standardised mortality ratios, shows that it can be done.
Two factors that seem important to the success of the Scottish programme are long-sighted methodology (rather than goals that are set for delivery in short timescales), and the whole-system approach, rather than the fragmented analysis that tends to categorise most organisations' current approach.
Therefore, the creation of HSIB, which will seek to produce recommendations that focus on system change, is an important step to ensuring healthcare organisations in England have every opportunity to learn from incidents.
MDU members will be reassured by the independence of HSIB, and the fact that their focus is in developing recommendations that will help foster safer clinical practice, rather than attributing blame or seeking to punish. Therefore, we encourage members to cooperate with HSIB investigations and invite any members involved in such investigations to contact our expert medico-legal advisory team for any additional advice or support if needed.
Prior to taking up his role with HSIB, Keith was chief inspector with the Air Accident Investigation Branch (AAIB) between 2010 and 2016 and was involved in many accident and serious incident investigations throughout the world, including the search for MH370.
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