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Organisational Learning: A Foundation for Patient Safety
A four part series on Learning and Patient Safety
Satyan Chari
September 10, 2024
Introduction
One of the great privileges of my career has been the opportunity to serve as faculty on the Queensland Healthcare Improvement Fellowship Program from 2019 to 2023. In my first year, we were fortunate to have one of my mentors, Paul Plsek, an expert in complex systems and healthcare improvement, join an enthusiastic and engaged fellowship group for a virtual fireside chat.
The conversation ranged freely, covering topics from complexity in healthcare to innovation and metrics. Towards the end, we landed on the subject of safety, and a Fellow asked Paul for his perspective on the merits and pitfalls of adopting zero-harm targets in patient safety. In his inimitable style, Paul decided to share a story.
I remember Paul describing a period in his life when his daily commute took him past the front gates of a local manufacturing facility. Outside the gates stood a prominent safety sign. Beneath the obligatory 'safety first' message was a panel, which would be updated every morning to display the company’s safety record: the number of days that had passed without a serious incident.
Paul recounted how he would always glance at the numbers as he drove past. The figures would steadily climb, often for many months. However, every so often, the panel would be solemnly reset to zero.
Paul reflected with the group, wondering what it must have been like at the factory on those days. For those in management, did the incident come as a complete surprise? Was it a previously unknown risk or a freak set of circumstances beyond anyone’s control?
Because if the opposite were true—if the incident could have been realistically foreseen or if the company’s workers knew an accident was inevitable—then the organisation has a deeper problem than just safety. An issue that no amount of safety messaging or target-setting can fix.
This issue of The Human Stream marks the start of a series on the topic of learning: what it represents in the context of systems safety in healthcare, how organisations create and curate a healthy capacity to learn, how learning from failure is different to learning from success and everyday operations, what gets in the way of effective learning and practical strategies to circumvent these barriers.
Learning as the Foundation for Patient Safety
In the calculus of resource allocation, building our ‘capacity to learn’ often takes a back seat to more typical safety priorities: setting patient safety goals, writing strategy, promoting diligence in reporting, emphasising procedural compliance, gaining efficiency in incident investigation and closure, and cataloguing these efforts as ‘evidence’ for periodic external surveys.
As these practices become ritualised, organisations can become blind to the actual lessons that might be available to learn along the way. Or, as Mark Sujan argues in a 2018 paper, they may begin to "learn about the wrong things in the wrong way."
Pick up any formal review, inquest, or external inquiry into unsafe care, and you will likely find the same themes across most of them - many missed learning opportunities or even systematic disregard for obvious signals of rising risk or deteriorating practices.
While such reports abound globally, consider this handful of examples from the UK:
The NHS does not, in our experience, learn effectively and actively from failures. Too often, valid lessons are drawn from adverse events but their implementation throughout the NHS is very patchy. Active learning is mostly confined to the individual organisation in which an adverse event occurs. The NHS is par excellence a passive learning organisation.
The absence of a systematic approach to learning from things that went wrong prevented effective remedial action from being taken.
...there were failures of risk assessment and care planning that resulted in inappropriate and unsafe care; and the response to adverse incidents was grossly deficient, with repeated failure to investigate properly and learn lessons.
Together, these factors comprised a lethal mix that, we have no doubt, led to the unnecessary deaths of mothers and babies.
The families who have contributed to this review want answers to understand the events surrounding their maternity experiences, and their voices to be heard, to prevent recurrence as much as possible. They are concerned by the perception that clinical teams have failed to learn lessons from serious events in the past.
Clearly, the road to large-scale systemic failure in patient safety is, by definition, paved with a multitude of missed opportunities to learn. Equally, such patterns are not unique to healthcare. Reports after Piper Alpha, Deepwater Horizon, and the Grenfell Tower Fire tell a similar story.
In fact, a recognition of this phenomenon in the study of modern industrial accidents played an important role in the gradual de-emphasis of human error in incident investigations (see https://thehumanstream.com/p/problem-error and https://thehumanstream.com/p/beyond-blame) because it was found to impede learning, and thus create the conditions for more catastrophic future failures.
(Stained Glass - Chernobyl, Ukraine) Photo by Viktor Hesse on Unsplash
Despite clear evidence that a capacity to learn underpins much of what we regard as important in the pursuit of patient safety, it seems healthcare organisations are naturally inclined to gradually lose this capacity. Further, as their capacity to learn (about themselves, their evolving profile of risks and opportunities) erodes, patient safety work progressively devolves into an exercise in outward penitence (for harms caused) rather than a critical function whose raison d’être is improvement (above all else). The focus of this series of articles is to explore what organisations and their leaders can do to guard against, and even reverse, such predispositions.
Learning the ‘Right’ Lessons when Things go Wrong
One way to talk about organisational learning is to do so in familiar linear terms, as a natural byproduct of a clear process of analysis, interpretation, implementation, scale and spread. However, as Sir Liam Donaldson noted a quarter of a century ago, the lessons available to us are entirely dependent on the tools we use for sense-making when failures occur. The lack of sufficient adoption of systems-based thinking and tools for learning was as big of a problem then as it is now (a question we will look at more closely in subsequent issues).
“It is far more difficult for effective learning to take place if the initial understanding of what has occurred is seriously flawed. In particular, it is important to consider experiences in the context of the various systems in place and the way these interact, because only in this way is it possible to come to sound conclusions about the nature of potential and actual risks faced.”
Only a few years after ‘An Organisation with a Memory’ was published, Amy Edmondson examined the barriers to learning from harm in healthcare organisations on the other side of the Atlantic (link to paper included in resources section below).
“Healthcare organisations that systematically and effectively learn from failures occurring in the care delivery process are rare. There are pervasive barriers embedded in healthcare’s organisational systems that make shared, or organisational, learning from failure difficult.”