This blog has previously looked (here,
here,
here,
here
and here!)
at the various ways in which the British National Health Service (NHS) has
grappled with knowledge management in general and, specifically, has sought to
learn from both managerial and clinical mistakes.
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.