December 2013

We want to learn in our organisation.  Specifically we want to learn about how to learn.  That may seem peculiar because we are a high ranking educational provider.  We have just had our three year undergraduate medical review and it is hard to imagine a more glowing report.  We have good partnerships with two nursing schools.  And, are developing further academic relationships across the city.

But the knowledge we want to spread is about what works well and where we make mistakes.  Our view is that if we are excellent at those goals, then we will be a safer place to work, to study and to receive care.  Now this is, obviously, not a simple task.  We provide care in 150 locations.  We employ 7500 people.  Many of those people are members of many teams.  Our emergency care, theatre and outpatient systems all comprise part time team members whose working week interweaves each discipline.  And in purely professional learning terms the body of knowledge required of a clinician has grown exponentially over the last thirty or forty years.

Some of our current strengths should help us.  We are among the highest reporters of incidents in our sector – these are near misses or concerns.  Our system for reviewing learning from unexpected in-hospital deaths is being borrowed widely in the region – 80% of these deaths are peer reviewed.  Our Table Top Review (TTR) model for incidents is widely used to scrutinise a variety of practice deviations or issues of concern.  And we work hard to embed an audit and clinical effectiveness culture.

However, the challenge is one of distilling learning, but presenting it in a manner that encourages consideration by the audience.  Some of us learn because we know we have to. Some are persuaded by data.  But most people demand empathy with what they are examining in order to truly take in what they hear.  So a near-miss is a tricky story to tell.  Typically, harm was slight.  Often there are specific circumstances that make it casually easy for the listener to separate their work experience from what has happened elsewhere in our organisation.  That separation is the heart of our learning issue.  To take the experience of elsewhere into my workplace and my team means I need to apply learning.  Not just receive knowledge.

And our traditional models of learning give us knowledge or instruction (we tend to call them policies).  We are experimenting with media that help us to learn in different ways.  We have used actors and role play.  We are developing quite a trend for videos.  For the last few days we have been re-telling the story of a Christmas Carol with a twist about sepsis.  Sepsis is the unrecognised killer behind a fair number of the mortality case reviews I cited earlier.  And a bundle (in effect a checklist) of actions known as the Sepsis Six is widely evaluated as effective in tackling the problem.  But introducing additional work, and quite formulaic style work, into medicine is often a challenge – as it has been to make VTE assessment a norm NHS wide.  We are soon to launch a new video on patient identification, as we try to prevent any repeat of a Never Event which happened in our laser eye team in November.  Thankfully our patient is unharmed but we missed opportunities to check their ID, even though they presented as the patient called by our doctor.  It was unacceptable, and was immediately reviewed by all involved and discussed in public with our Board of Directors.  Now we want to make sure that the many similar locations where surgery is undertaken in an outpatient setting learn from what happened in that particular outpatient setting.

Part of the key is learning together in teams.  Because shared knowledge and shared understandings are what drive behaviours.  But also create peer expectations.  There is a common language.  Those bonds arguably make it easier to then challenge deviation or mistakes.  Our first Never Event of this financial year, also in ophthalmology, could have been prevented with more teamwork and a willingness to question each other across hierarchy and professional boundaries.  That is why our teams are going through video practice at the moment to scrutinise how they work together – a bit like athletes after a game.

This issue of learning lies at the heart of the safety culture we want to build.  We are very open to lessons from other places and other sectors.  We think it will make the difference in the years ahead as we look to improve on a developing model of clinical excellence in which mortality has reduced in our Trust (see the recent Dr Foster report here), and infection and pressure damage remain low.  And we work to spread that success to issues of concern such as acute adult readmission rates and deteriorating sub-acute patients.

Our new year’s resolution to become that listening organisation is worthwhile but tough.

Below are links to our sepsis story and to our video on identification:

Sepsis video




Patient identification video