Why We Never Learn? Development of a Learning Organisation

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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

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• Background
• Theory
• Plan
• Actions/Outcomes

Fool me once, shame on you. Fool me twice, shame
on me !
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Background

• KELD
• Knowledge Education Learning Development
• National/Local Drivers
• NHSLA
• Complaints
• PCT
• Money
• Timing

The mind is like a parachute. It doesnt work
unless its open
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Theory
What is a learning organisation?

• 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

An investment in knowledge always pays the best
interest.
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Process Loops Single Double Meta Learning
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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
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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
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• 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, its
better than no inspiration at all
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Bringing People Together
Steering group

• Patient Safety leads
• Head of RD Health Safety
• Staff Side
• Productive Ward
• Clinical Governance Audit leads

• NHSLA Lead
• Consultant Governance lead
• Facilities
• Complaints
• Knowledge Services

Teamworkmeans never having to take all the blame
yourself
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Identify Actions

• Current learning from incidents, complaints
  claims policy to be revised to include best
  practice
• Working title renamed Learning Lessons to
  reflect its ongoing nature

• 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

There is a light at the end of every tunnel.just
pray its not a train!.
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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.
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Where are we?

• Incident reporting
• Knowledge Sharing
• Regular alerts
• Bulletin
• Reporting to Trust Board

Two things are infinite the universe and human
stupidity Im not sure about the universe
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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
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•  Be careful what you wish for

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Thank you