Today brings some new developments to the story that began with the ‘Mid Staffs’ scandal a few years ago.
The Health Secretary, Jeremy Hunt, will today be announcing a series of measures aimed at encouraging both openness and honesty about mistakes, as well as demonstrable learning from them.
Details will no doubt emerge later today but this article on the Huffington Post website summarises the expected announcements, with the key points, and my comments thereon, being:
· Legal protection for anyone coming forward with information relating to hospital mistakes – this is a welcome move that may yet embed the elusive ‘just culture’ approach to handling error and balancing the need for accountability and learning;
· Independent review and confirmation of the causes of all deaths in UK hospitals from 2018 – whilst this sounds a good idea, more details are needed as there remains the risk that good governance is simply being outsourced and that another adversarial interface has been created;
· A so-called ‘Learning from Mistakes League’ that will measure the level of openness across NHS organisations – again, more details are needed but this sounds good as it is making it clear that learning and openness are expected; however, this needs to be managed carefully as inter-organisational learning will not happen if such a league is used as some form of internal competition – nothing kills the sharing of good practice dead more effectively than rewarding people for what they know, rather than what they share.Effective lesson learning requires a framework within which lessons are identified, analysed, managed and then implemented. Such a framework requires 4 enablers:
· People with defined roles and accountabilities;
· Processes by which lessons are identified, captured, shared and embedded in daily practices;
· Technology through which lessons are captured, shared and managed to completion;
· Governance by which managers clarify their expectations for lessons to be learned, reward good lesson learning performance and support such activities through the allocation of time, money and people.The presence and effectiveness of these enablers is best measured through some form of audit or assessment, like the one we offer at Knoco.
Let’s await further details with interest and perhaps also think about how well our own organisations identify, manage and implement lessons from experience, good and bad alike.
For a conversation about lessons learned, please contact me direct or via the Knoco website.