‘Lessons must be learned’
It is a sad fact that in many parts of the public sector the phrase ‘lessons will be learned’ has become seriously devalued. There is no doubt that senior leaders are genuine when they include this phrase high-up in their response to families, regulators or media following a public shaming. But in truth, the regularity with which these words are deployed by bodies like NHS trusts show the opposite is true – lessons are actually being ignored.
What are the lessons here?
At Eva we believe there are two very important ones.
The first is to learn the lessons from previous relevant investigations, reports and other organisational failings which are readily available and free. This could and should be a role for the organisational governance lead, senior leaders and the Board.
For example, there are over 15 years of expert analysis on the Verita website as a free resource to draw on and check against. A short browse of through these summaries will show that there are common themes in these reports, for example the failure to track the behaviour of an individual or lack of Board-level oversight and challenge. Verita is not alone and every healthcare organisation will have its own library of serious incident reports with common themes running throughout. The existence of these themes is, sadly, further evidence that lessons are not being learned.
Putting that to one side, our new digitised investigation system Eva, creates the opportunity to interrogate this library and will add further granularity to future safety investigations, providing further levels of insight to learn from. The power of investigations will be harnessed by digitising a currently manual process which will allow lessons to truly be learnt.
The second lesson is the importance of running a thorough investigation when a serious incident occurs — or is narrowly avoided. At the heart of this is safety. One of the Care Quality Commission’s (CQC) first questions when inspecting health and social care is “Is it safe?” As the CQC say, one of the most common causes that sits behind serious incidents is “the way that organisations investigate, communicate and learn when things go wrong”.
The CQC are clear on what makes a robust investigation.
These same parameters would be true in other sectors as well.
- Serious incidents that require full investigation should be prioritised and alternative methods for managing and learning from other types of incident should be developed.
- Patients and families should be routinely involved in investigations.
- Staff involved in the incident and investigation process should be engaged and supported.
- Using skilled analysis to move the focus of investigation from the acts or omissions of staff, to identifying the underlying causes of the incident.
- Using human factors principles to develop solutions that reduce the risk of the same incidents happening again.
These points are obviously correct but will be daunting to many organisations faced with operational pressures or time, resource or training constraints. At Eva, one of our mantras is that sunlight is the best disinfectant. To be truly open and transparent, to get to the real roots of an issue, does require a level of commitment far above the ”quick and dirty” approach.
But one clear lesson is that a poor investigation usually fails the organisation, its staff and the people they serve. Too often we see distressed families, regulatory action, reputational damage, Board and executive purges and staffing issues as the legacy of inadequate investigations. And of course, the same safety, safeguarding and practice issues cropping up time after time.
So the lesson for today?
First, learn from and check against previous failures to strengthen your own organisation. Secondly, invest to protect and learn. Don’t believe a quick-fix investigation is ever anything but second best for your staff and the services they provide. A final third lesson — learn from the experts in the field and how our knowledge and experience can help strengthen the way you work.
The Eva Investigation Application is a new and exciting way to manage patient safety investigations. Easy to integrate with existing patient safety processes, this powerful technology designed by the UK’s leading investigation firm Verita will help you:
- Guide investigators through simple processes, with the added support of training tools and automated tips
- Pool information into a centralised dashboard where investigators can monitor progress and detect themes in real-time
- Aide investigators in the creation of rich, formatted reports populated with a simple click of a button
- Help share data across hospitals, sites and the NHS, with state-of-the-art security and privacy features, for shared learning and broader patient safety improvements
For more information about the Eva investigation application and to request a demonstration to your organisation, get it touch by calling 020 7494 5676 or email [email protected].
Written by Stephen Webb.