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

19 th July 2010TLRC July 2010 HLG Salford  Background  Theory  Plan  Actions/Outcomes Fool me once, shame on you. Fool me twice, shame on me !

19 th July 2010TLRC July 2010 HLG Salford Background  KELD  Knowledge Education Learning & Development  National/Local Drivers  NHSLA  Complaints  PCT  Money  Timing The mind is like a parachute. It doesn’t work unless it’s open

19 th July 2010TLRC July 2010 HLG SalfordTheory  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; What is a learning organisation? An investment in knowledge always pays the best interest.

19 th July 2010TLRC July 2010 HLG Salford Process Loops Single Double Meta Learning

19 th July 2010TLRC July 2010 HLG Salford The Plan  Scope existing practice  Bring like minded people together  Identify actions  Get some quick wins Experience is simply the name we give our mistakes

19 th July 2010TLRC 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 There are no failures – just experiences and your reactions to them

19 th July 2010TLRC July 2010 HLG Salford  Meta Learning  One Stop Urology Clinics  Students use of reflective practice/problem based learning  Bare below the elbow  Corporate Induction A deadline is negative inspiration. Still, it’s better than no inspiration at all

19 th July 2010TLRC 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 Steering group Teamwork…means never having to take all the blame yourself

19 th July 2010TLRC 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 There is a light at the end of every tunnel….just pray it’s not a train!.

19 th July 2010TLRC July 2010 HLG Salford Quick Wins  Existing bulletins have a single home on our intranet  Medicines Safety  Falls  Trust Policies …  Learning Lessons Bulletin I look at victory as milestones on a very long highway.

19 th July 2010TLRC July 2010 HLG Salford Where are we?  Incident reporting  Knowledge Sharing  Regular alerts  Bulletin  Reporting to Trust Board Two things are infinite : the universe and human stupidity; I’m not sure about the universe

19 th July 2010TLRC 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

19 th July 2010TLRC July 2010 HLG Salford Thank you