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Abstract

Background
National patient safety investigation bodies conduct system-level investigations and produce recommendations intended to drive improvement. Evidence that such recommendations translate into meaningful improvement is weak and the reasons for this are poorly understood. This paper examines how recommendations produced by the Health Services Safety Investigations Body (HSSIB), England's independent national patient safety investigation body, are produced by investigators and received by the national organisations to whom they are directed.

Methods
A qualitative multi-method design was used including documentary analysis of 22 investigation reports produced by the Healthcare Safety Investigation Branch (HSIB), predecessor to HSSIB, two focus groups with HSSIB patient safety investigators (n = 12) and semi-structured interviews with 11 senior representatives of national organisations, recipients of HSSIB recommendations. Data were analysed using reflexive thematic analysis, guided by institutional logics.

Results
Documentary analysis showed that HSIB recommendations were non-directive, clustering at the weakest level of the hierarchy of risk controls and favouring administrative measures. Two competing institutional logics were constructed using reflexive thematic analysis. HSSIB investigators deploy a safety science logic focusing on systems thinking, collaborative engagement and non-punitive learning, while recipient organisations enact a managerial-operational logic prioritising resource management and operational feasibility. Four consequences follow: i) recommendations are attenuated through nominal co-production; ii) recipients navigate priority thickets in which political salience, strategic fit and resource availability govern implementation; iii) accountability among recipients is diffuse; and iv) HSSIB's transparency carries limited traction within the managerial-operational logic.

Conclusions
These conditions produce a paradox: HSSIB's structural separation from the organisations it investigates, while central to its legitimacy as a learning body, can distance it from the operational realities that govern whether recommendations are acted upon. Overcoming this paradox requires deliberate logic-building strategies that address how recommendations are framed, how accountability is constructed, and how the governance landscape is coordinated.

Publication Type:	Article
Additional Information:	© The Author(s) 2026. Published by Oxford University Press on behalf of International Society for Quality in Health Care. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
Subjects:	R Medicine > RA Public aspects of medicine > RA0421 Public health. Hygiene. Preventive Medicine
Departments:	School of Health & Medical Sciences
SWORD Depositor:	Symplectic Administrator

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