Why We Never Learn Development of a Learning Organisation

1. Why We Never Learn? Development of a Learning Organisation Tracey L Roberts Cuffin Head of Library & Knowledge Services University Hospitals Morecambe Bay NHS Trust HLG 2010 Why as NHS organisations we don�t learn Librarians in lemming mode or genetic flaw! Our role within the current environmentWhy as NHS organisations we don�t learn Librarians in lemming mode or genetic flaw! Our role within the current environment

2. 19th July 2010 TLRC July 2010 HLG Salford Background Theory Plan Actions/Outcomes

3. 19th July 2010 TLRC July 2010 HLG Salford Background KELD Knowledge Education Learning & Development National/Local Drivers NHSLA Complaints PCT Money Timing Research/libraries education/under & post/L&D/Clinical skills/resuc/audit/pharmacy ed/PEFs Make a difference to the Trust Research/libraries education/under & post/L&D/Clinical skills/resuc/audit/pharmacy ed/PEFs Make a difference to the Trust

4. 19th July 2010 TLRC July 2010 HLG Salford Theory success is always celebrated; mistakes are a cause for reflection, not blame; individuals are empowered to act; information is widely shared; experimentation, innovation, & positive risk-taking are actively encouraged; managers actively support the development of their team members change is embraced willingly; Perhaps the clearest list of criteria for a Learning Organisation is outlined by Mintzberg information is widely shared; sessions exploring lessons learned are commonplace; experimentation, innovation and positive risk-taking are actively encouraged; individuals regularly bring in ideas from outside the organisation; stress is acknowledged and effectively managed; Perhaps the clearest list of criteria for a Learning Organisation is outlined by Mintzberg information is widely shared; sessions exploring lessons learned are commonplace; experimentation, innovation and positive risk-taking are actively encouraged; individuals regularly bring in ideas from outside the organisation; stress is acknowledged and effectively managed;

5. 19th July 2010 TLRC July 2010 HLG Salford Davies and Nutley [4] define three types of learning. 'Single-loop learning' entails an audit identifying the gap between intended and identified performance and installing corrective action A hospital examines its care of obstetric patients. Through a clinical audit, it finds various gaps between actual practice and established standards (derived from evidence based guidelines). Meetings are held to discuss the guidelines, changes are made to working procedures, and reporting and feedback on practice are enhanced. These changes increase the proportion of patients receiving appropriate and timely care (that is, in compliance with the guidelines). This is an example of single loop learning In 'double-loop learning' wider lessons are learned about organisational performance from audits and evaluations and larger adjustments are made at the level of organisational goals and direction, with implications for organisational structures and working practices [43]. There is a transfer of learning from an example to one or more others. In examining its obstetric care, some patients are interviewed at length. From this it emerges that the issues which are bothering women have more to do with continuity of care, convenience of access, quality of information, and the interpersonal aspects of the patient-professional interaction. To prioritise these issues, obstetric care is completely reconfigured to a team system led by midwives. The standards laid down in the evidence based guidelines are not abandoned but are woven into a new pattern of interactions and values. This is an example of double loop learning Third, there is 'learning about learning'. This entails people in learning organisations taking stock, not just of the content of organisational lessons but the process by which this learning took place [37] � a form of reflexivity for the betterment of the organisation. Learning organisations would achieve this higher order type of learning or 'meta-learning,' not just accumulate single- and double-loop lessons. The experience of refocusing obstetric services better to meet patient needs and expectations is not lost on the hospital. Through its structure and culture, the organisation encourages the transfer of these valuable lessons. The factors that assisted the reconfiguring (and those that impeded it) are analysed, described, and communicated within the organisation. This is not done through formal written reports but through informal communications, temporary work placements, and the development of teams working across services. Thus, the obstetric service is able to share with other hospital services the lessons learned about learning to reconfigure. This is an example of learning about learning or meta-learning Davies and Nutley [4] define three types of learning. 'Single-loop learning' entails an audit identifying the gap between intended and identified performance and installing corrective action A hospital examines its care of obstetric patients. Through a clinical audit, it finds various gaps between actual practice and established standards (derived from evidence based guidelines). Meetings are held to discuss the guidelines, changes are made to working procedures, and reporting and feedback on practice are enhanced. These changes increase the proportion of patients receiving appropriate and timely care (that is, in compliance with the guidelines). This is an example of single loop learning In 'double-loop learning' wider lessons are learned about organisational performance from audits and evaluations and larger adjustments are made at the level of organisational goals and direction, with implications for organisational structures and working practices [43]. There is a transfer of learning from an example to one or more others. In examining its obstetric care, some patients are interviewed at length. From this it emerges that the issues which are bothering women have more to do with continuity of care, convenience of access, quality of information, and the interpersonal aspects of the patient-professional interaction. To prioritise these issues, obstetric care is completely reconfigured to a team system led by midwives. The standards laid down in the evidence based guidelines are not abandoned but are woven into a new pattern of interactions and values. This is an example of double loop learning Third, there is 'learning about learning'. This entails people in learning organisations taking stock, not just of the content of organisational lessons but the process by which this learning took place [37] � a form of reflexivity for the betterment of the organisation. Learning organisations would achieve this higher order type of learning or 'meta-learning,' not just accumulate single- and double-loop lessons. The experience of refocusing obstetric services better to meet patient needs and expectations is not lost on the hospital. Through its structure and culture, the organisation encourages the transfer of these valuable lessons. The factors that assisted the reconfiguring (and those that impeded it) are analysed, described, and communicated within the organisation. This is not done through formal written reports but through informal communications, temporary work placements, and the development of teams working across services. Thus, the obstetric service is able to share with other hospital services the lessons learned about learning to reconfigure. This is an example of learning about learning or meta-learning

6. 19th July 2010 TLRC July 2010 HLG Salford The Plan Scope existing practice Bring like minded people together Identify actions Get some quick wins

7. 19th July 2010 TLRC July 2010 HLG Salford Scoping Existing Practice Single Loop Learning Health Informatics Prince 2 project plan Audit & Clinical Governance depts. Customer Care - Complaints Double Loop learning Resuscitation Team debrief Surgery/midwifery Risk management framework Pharmacy Single Loop Learning Health Informatics Prince 2 project plan � review undertaken and key messages recorded, documents changed where required though overall delivery of projects remains the same Audit & Governance depts. � both have very effective systems for recording adherence to standards but no real evidence of trend analysis and dissemination Customer Care dept records complaints effectively but there is no evidence to suggest any trend analysis ***** Double Loop learning Resuscitation Team debrief following incidents � lessons incorporated into training sessions and routinely reviewed Surgery/midwifery Risk management framework � Lessons recorded and disseminated to wider teams Pharmacy record all drug errors and disseminate them to a prescribing mailing list, but there is no evidence to support them being read Single Loop Learning Health Informatics Prince 2 project plan � review undertaken and key messages recorded, documents changed where required though overall delivery of projects remains the same Audit & Governance depts. � both have very effective systems for recording adherence to standards but no real evidence of trend analysis and dissemination Customer Care dept records complaints effectively but there is no evidence to suggest any trend analysis ***** Double Loop learning Resuscitation Team debrief following incidents � lessons incorporated into training sessions and routinely reviewed Surgery/midwifery Risk management framework � Lessons recorded and disseminated to wider teams Pharmacy record all drug errors and disseminate them to a prescribing mailing list, but there is no evidence to support them being read

8. 19th July 2010 TLRC July 2010 HLG Salford Meta Learning One Stop Urology Clinics Students use of reflective practice/problem based learning Bare below the elbow Corporate Induction Meta Learning One Stop Urology Clinics � full service review was undertaken following an extensive service review and investigation into best practice Students use of reflective practice/problem based learning � using everyday incidents to review and change their practice Bare below the elbow � evidence based implementation which is constantly reviewed to ensure it�s incorporated into practice Corporate Induction � feedback from both individuals and departments contributed to the complete reconfiguration of the event to make it fit for purpose. Meta Learning One Stop Urology Clinics � full service review was undertaken following an extensive service review and investigation into best practice Students use of reflective practice/problem based learning � using everyday incidents to review and change their practice Bare below the elbow � evidence based implementation which is constantly reviewed to ensure it�s incorporated into practice Corporate Induction � feedback from both individuals and departments contributed to the complete reconfiguration of the event to make it fit for purpose.

9. 19th July 2010 TLRC July 2010 HLG Salford Bringing People Together Patient Safety leads Head of R&D & Health & Safety Staff Side Productive Ward Clinical Governance & Audit leads NHSLA Lead Consultant Governance lead Facilities Complaints Knowledge Services

10. 19th July 2010 TLRC July 2010 HLG Salford Identify Actions Review existing bulletins and their dissemination Investigate involvement in key risk areas Needle-stick Medicines safety Falls Scoping report to be disseminated again Stream line access to trust policies Current �learning from incidents, complaints & claims� policy to be revised to include best practice Working title renamed � Learning Lessons� to reflect its ongoing nature

11. 19th July 2010 TLRC July 2010 HLG Salford Quick Wins Existing bulletins have a single home on our intranet Medicines Safety Falls Trust Policies � Learning Lessons Bulletin

12. 19th July 2010 TLRC July 2010 HLG Salford Where are we? Incident reporting Knowledge Sharing Regular alerts Bulletin Reporting to Trust Board

13. 19th July 2010 TLRC July 2010 HLG Salford Lessons? Some things must go wrong today, to sprout hope for a better tomorrow �Experience that most brutal of teachers. But you learn, by God do you learn� � �Be careful what you wish for

14. 19th July 2010 TLRC July 2010 HLG Salford Thank you