November 10 th , 2009 Learning from PSE Study Dissemination Day

1. November 10th, 2009Learning from PSE Study Dissemination Day What kind of PSE learning behaviours are Ontario hospitals engaging in?

2. Outline • Can we only learn from Catastrophe? • Is there variation in learning from PSEs across Ontario hospitals? • What learning behaviors do we engage in most often…least often? • The case of hospital size • Using (and misusing) these data

3. Learning Behaviours / Responses to PLEs • Identification & Reporting • Analysis of Causes • Change Implementation • Dissemination / communication

4. 4-Always 3-Usually 2-Sometim 1-Never 3.61 2.88 Dissem Analysis Event learning n=54 Event learning Event learning Event learning 1.Can we only learn from Catastrophe?Learning Responses to 4 types of PSEs

5. Matryoshka DollsLearning from patient safety events takes place in only a very small subset of events

6. 4. Recognized, discussed and reported: A – in the chart B – to a paper or on-line IR system C – to person / team with mandate & resources to investigate and make change 1. Safety incidents A B 5. Recognized, and locally investigated C 2. Recognized safety incidents 3. Recognized and discussed incidents

7. 2. Is there variation in learning from PSEs across Ontario hospitals?

8. Minor event learning scores for 54 Ontario hospitals

9. Moderate event learning scores for 54 Ontario hospitals

10. Major NM learning scores for 54 Ontario hospitals

11. Major event Analysis learning scores for 54 Ontario hospitals

12. Major event Dissemination learning scores for 54 Ontario hospitals

13. 3. What learning behaviors do we engage in most often…least often?

14. % engaging in learning response “always/almost always” OR “usually”

15. % engaging in learning response “always/almost always” OR “usually”

16. 4. Do PS leadership and hospital size explain variance in learning from PSEs?

17. Organizational Leadership for PS and Learning from PSEs

18. Moderate event learning in small and large hospitals under conditions of strong and weak PS leadership weak strong

19. Major event communication in small and large hospitals under conditions of strong and weak PS leadership weak strong

20. 5. Using (and misusing) these data Challenges of KT • Different purposes/uses for data • Different data for research and QI • Ethics • Timelines • Grant to results • Staff change: 50% PSO, 46% CEO

21. … Using (and misusing) these data • Comparison with peers • Comparison over time • Starting conversations • Do the PSE learning instrument with the right people: assess current practice • Take the results (and process?) up and down the organization: goal setting • Getting CEOs involved through an in-depth PSE case study (Conway, 2008) • PSE Learning instrument concrete tool to reduce the knowing-doing gap (Pfeffer & Sutton, 2000): action reduces this gap

22. “In our experience, most boards and leaders overestimate the frontline staff’s ability to improve. In such cases, even with sufficient will and great ideas…execution stalls” (Conway, 2008)  Single-loop learning – quick fixes  Double-loop learning – correcting the underlying causes of a problem