systematic learning from mistakes: achievements and challenges andy sutherland, nhs information...
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Systematic learning from mistakes: achievements and challenges
Andy Sutherland, NHS Information Centre for health and social care
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“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)
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Summary
• Background and approach• Incidents – handling and analysis• Publication process• Improvement cycle• Present position• Reflections and next steps
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Background
• No consistent approach to handling• Internal panic• External and internal blaming• Perception of repeating errors• Low customer confidence
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Approach
• A system for handling things that go wrong• A system for learning from them
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Adverse incidents process
• Notification• Confirmation• Evaluation• Handling plan• Handling
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or
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AAHAA…
• AlertInternally to Director and Head of Profession
• AssessImpact, options, considerations
• Handling planWhat to do, who to tell, when;
• Authorisation• Action
The first ‘A’ does not stand for ‘Action’!
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And then
• Review• Learning• Implementing changes
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…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
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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
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Root cause analysis scoring
• None• Evidence of thought, but not cause• A cause, but not a root cause• A reasonable root cause analysis
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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.”
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Lessons learned scoring
• No evidence• Evidence of thought• Lessons described• Evidence of lessons implemented
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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…”
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Incidents by month, March 08 – May 11
0
4
8
12
16
20
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Incidents by month - Root cause found?
0
4
8
12
16
20
root cause
cause
thought
none
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Incidents by month – lessons learned?
0
4
8
12
16
20
implemented
described
thought
no
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Number of incidents by department - lessons learned?
0
20
40
60
80
100
a b c d e f g h i j k l m n o p
implemented
described
thought
none
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Source of incidents
publication
data
pq
other
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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
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Publication process
• Systematic approach• Guidance on each stage• Clear responsibilities• Clear records
A process to improve!
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Publication process
Production
Publication
ReviewingCompleted Publication
PlanningProcess Initiation
Input Guidance and
Templates
Output Documents,
Approvals and Records
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Planning
Process Initiation
ProductionPublication Mandate
Mandate Approval
Publication Mandate
Brief
Publication Brief
Approval
Publication Brief
Plan
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
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Production
Planning PublicationData
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
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Publication
Production ReviewingPre-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
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Review
Publication
Opportunities for improvement
guidance
Publication review approval
Publication review with
users
Completed publication
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Mandate Approval
Responsibilities
Chief Executive
EDG (Directors)
Head of Profession
Programme Head
Programme Manager
Section Head
Quality Programme Manager
BriefDesign and Dev
Briefing and Press Rel.Review
PlanCreate the TeamDesign and Dev
Process/Pub Rev
BriefDesign and Dev
Process/Pub Review
Design and DevData Preparation
AnalysisFinal Draft approval
BriefingPress releasePrepublication
Printing
Press Release
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Records…Template
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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
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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
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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
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Present position
• Better handlingReduced 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…
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…
• Improvement still needed on root causes• Some good but some bad practice• Learning needs to be promulgated across the
organisation
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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
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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
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“A man’s errors are his portals of discovery”
(James Joyce)
“This is also true for organisations”
(Andy Sutherland)