System Safety Improvement Programme (PSIRF)

The introduction of the PSIRF in 2022 marked a significant shift in how NHS organisations approach patient safety. As a nationally mandated framework for all organisations holding an NHS Standard Contract, PSIRF moves the system away from prescriptive investigation requirements and towards a more learning‑focused, proportionate, and system‑oriented model for responding to patient safety incidents.  

It aims to strengthen the overall patient safety incident response system by emphasising four core principles:  

• compassionate involvement of those affected.  
• the use of system-based learning methodologies.  
• proportionate responses.  
• supportive oversight centred on improvement. 

Now four years later a new programme has been launched: PSIRF Insight to Improvement. 

This programme moves beyond implementation of PSIRF and focusses on understanding and developing the infrastructure needed to support the translation of insight, from systems-based learning responses, into improvement.  

It aims to lay the foundations for processes which support the consistent measurement of impact, capturing evidence of improvement across distinct safety improvement programmes. 

PSIRF has driven a shift towards systems-based learning. The new programme builds on this to:

• Reduce variation in the NHS’s ability to translate learning from patient safety incidents into sustained improvement.
• Build the capability, infrastructure, and governance required to move from insight to action.
• Connect the learning from improvement activity with strategic priorities.

Health Innovation East Midlands’ offer to provider partners - Year 1 

The PSIRF - Insight to Improvement programme provides a structured, whole‑system approach to building safety improvement capability and oversight. HIEM will support its East Midland’s provider partners to: 

• Undertake a diagnostic assessment of the current position to create baseline understanding of system capability, gaps and barriers to assess its readiness for improvement. 

• Establish connections between patient safety and improvement teams & strategies    

• Support Executive teams to strengthen their oversight, governance, and assurance of safety improvement through facilitated sessions and workshops. 

• Promote consistency while enabling local flexibility and ownership.  

The Patient Safety Collaborative anticipates that this programme will be delivered over a three-year period. 

• Year 1, the focus will be on establishing the position. 

• Year 2, on building capability and undertaking pilot initiatives.  

• Year 3, on embedding sustainable practices.  

By this stage, processes and systems should enable the generation of actionable insights to inform improvement, underpinned by consistent national metrics and measures for tracking progress. 

At the end of year 3 anticipated impacts include: 

Patient benefits: 

• Improved quality of care associated to programmes of change. 

• Increased confidence that lessons learnt mean improvements to safety. 

Workforce benefits:  

• Support to design and deliver improvement projects informed by learning response insight. 

• Clearer purpose and impact from safety and PSIRF activity. 

• Improved capability in applying improvement science to safety challenges. 

• Reduced frustration and duplication, with stronger peer support networks. 

System and organisational benefits:  

• Improved board‑level confidence and oversight of safety improvement.  

• Stronger alignment between PSIRF, quality strategies and improvement programmes. 

• A sustainable, embedded culture of learning and improvement. 

PSIRF – resources from the implementation support programme April 2023-March 2025 

From April 2023 to March 2025 Patient Safety Collaboratives (PSCs) were commissioned to support PSIRF implementation, working with their related integrated care systems (ICSs) and integrated care boards (ICBs) in addition to NHS England regional teams.  

PSIRF is an opportunity to change the culture towards investigations and ensure patients and their families are at the heart of this process. We anticipate PSIRF will bring a new approach to learning, which will lead to improvements.