1. Systematic learning from mistakes: achievements and challenges Andy Sutherland, NHS Information Centre for health and social care

2. “All men make mistakes, but only wise men learn from their mistakes” (Winston Churchill) “Learn from the mistakes of others – you can never live long enough to make them all yourself” (John Luther)

3. Summary Background and approach Incidents – handling and analysis Publication process Improvement cycle Present position Reflections and next steps

4. Background No consistent approach to handling Internal panic External and internal blaming Perception of repeating errors Low customer confidence

5. Approach A system for handling things that go wrong A system for learning from them

6. Adverse incidents process Notification Confirmation Evaluation Handling plan Handling

7. or

8. AAHAA… Alert Internally to Director and Head of Profession Assess Impact, options, considerations Handling plan What to do, who to tell, when; Authorisation Action The first ‘A’ does not stand for ‘Action’!

9. And then Review Learning Implementing changes

10. …by means of Review meetings Analysing root causes and drawing out lessons Openly available documentation –Library of incidents –Library of root causes and lessons Regular learning fora (therapy and action) alerts

11. Analysis 352 incidents March 2008 to May 2011 Categorised by potential damage to NHS IC 33 high 199 medium 120 near miss – eg trapped internally

12. Root cause analysis scoring None Evidence of thought, but not cause A cause, but not a root cause A reasonable root cause analysis

13. Good and bad root causes “The cause of the problem was most likely due to the template being copied from another table.” “High level of risk identified but not effectively managed” “Not having a system… that was proven to meet clear and specific requirements.”

14. Lessons learned scoring No evidence Evidence of thought Lessons described Evidence of lessons implemented

15. Lessons learned – good and bad “Additional checks to be implemented on the final report” “Processes will become ever more robust now that the work has been brought within the IC” “All web entries should have clear review dates attached …process for reviews…”

16. Incidents by month, March 08 – May 11

17. Incidents by month - Root cause found?

18. Incidents by month – lessons learned?

19. Number of incidents by department - lessons learned?

20. Source of incidents

21. Reflection Incidents being reported Handling improved (better feedback) Root causes and lessons learned patchy Little evidence of learning across organisation Scope for action on publications

22. Publication process Systematic approach Guidance on each stage Clear responsibilities Clear records A process to improve!

23. Publication process Production Publication Reviewing Completed Publication Planning Process Initiation Input Guidance and Templates Output Documents, Approvals and Records

24. Planning Process Initiation Production Publication Mandate Mandate Approval Publication Mandate Brief Publication Brief Approval Publication Brief Plan Approval Publication Plan Template Create the Team Approval: Roles and Responsibilities defined. Confirm agreement to policies and procedures Guidance on creating the publication team Design and Development Design Approval including customers and stakeholders Design and Development guidance

25. Production Planning Publication Data Preparation Data Preparation approval Approved set of data Data Preparation guidance Analysis Data analysis approval Data Analysis process Protocols for checking the analysis Prepare draft publication Final draft approval Style Guide Preparing the draft publication guidance

26. Publication ProductionReviewingPre-publication Pre-Publication approval Pre-Publication guidance Guide to press release production Printing and distribution guidance Approval and record of confirmation of proof reading Printing and Distribution

27. Review Publication Opportunities for improvement guidance Publication review approval Publication review with users Completed publication

28. Mandate Approval Responsibilities Chief Executive EDG (Directors) Head of Profession Programme Head Programme Manager Section Head Quality Programme Manager Brief Design and Dev Briefing and Press Rel. Review Plan Create the Team Design and Dev Process/Pub Rev Brief Design and Dev Process/Pub Review Design and Dev Data Preparation Analysis Final Draft approval Briefing Press release Prepublication Printing Press Release

29. Records…Template

30. Links to incidents The Planning stage includes review of lessons learned across the NHS IC The Production stage incorporates lessons (eg extra checks) from incidents The Review stage includes drawing out lessons learned from incidents during production… …and feeds back into planning

31. Improvement cycle Incidents lead to lessons Lessons lead to Alerts Improved processes Publication process holds improved processes and ensures they are implemented Improved processes lead to Fewer incidents

32. Example Breach of the Code of Practice – pre-release access list issued late Root cause: excessive willingness to accommodate late changes Lesson: set cut off time and freeze Implemented and promulgated through process No further incidents

33. Present position Better handling Reduced panic Involvement of Directors Engagement of external stakeholders Better feedback High level of reporting? Few unreported incidents coming to light Salutary examples of complications from not reporting Evidence of lessons learned But…

34. … Improvement still needed on root causes Some good but some bad practice Learning needs to be promulgated across the organisation

35. Reflections Organisational change is hard It takes time It is necessary to Make it easy for people to do the right thing Avoid blame but Keep up the pressure Be open: a mistake made feels bad; a mistake learned from feels good

36. Next steps Stronger management emphasis on drawing out root causes and lessons - KPIs Developing experts to help with this Continuing support – learning fora More regular ‘alerts’ Benchmarking

37. “A man’s errors are his portals of discovery” (James Joyce) “This is also true for organisations” (Andy Sutherland)