- Specialty-specific multidisciplinary sessions at which attendance is compulsory, other than for those offering emergency care, are powerful ways to share learning.
- Other effective methods include sharing standard templates of issues and learning, email alerts, newsletters and intranet content as well as a dedicated quality team with resources, support and training.
- Incident reports must contain robust and achievable action plans not only for the local site/service but also the rest of the organisation and these must be monitored to ensure actions are completed to a schedule.
- There should be suitably expert risk and safety staff who move around the network and are able to challenge operational and clinical staff effectively.
- Staff at all sites must seriously consider how this could apply to their location and not have a ‘it couldn’t happen here’ attitude.
- Learning after serious incidents and never events is often well done but learning from more minor situations is more challenging.
“When an innovation at a site has gone well, there needs to be effort to roll it out across the network.”
“Any network relying heavily on email for important communications must make serious effort to ensure all staff use this address for all their work communication, check it regularly and act on it appropriately.”
“It’s important to be completely realistic and not to include actions that are vague, cannot be done or won’t actually improve safety but are there just for the sake of it.”
“Quality partners at local sites are extremely helpful but it’s a challenging role to fill.”
Sources of learning
Learning that should be shared can be gained from a wide range of sources including:
- serious incidents, never events and lower harm incident reports.
- internal reviews, quality reports, CQC reports and preparation materials, compliance work.
- external reviews and visits.
Relevant, well-planned meetings have a role to play in spreading learning.
- Multidisciplinary half days during which all but emergency activity is rescheduled.
– Use a standardised agenda covering key areas like audit, outcomes, guidelines.
– Invite speakers, trainers or local leads to present learning from other sites.
– Ensure full participation of all staff types, not just clinical.
– Use an attendance register, provide minutes with clear actions to be shared across sites and monitored by risk staff.
– Make recordings of the event available via the intranet.
- Area-specific meetings, such as a theatres learning group, are also useful but be sure to include and give a voice to all staff types.
- Senior clinicians and managers’ forum to receive/disseminate quality and safety information.
- Operational quality meetings such as risk and clinical governance.
Other ways of learning
- Observation of practice and networking across site provides learning for both trainee and trainer and promotes consistent practice.
- Training the trainer – staff at sites are trained to pass on their learning down the hierarchy at their sites.
- Some training may be best delivered to provider employees by staff at the host site such as safeguarding, fire, resuscitation – also promotes functional links between partners.
- When possible, staff should be able to access online learning and assessments or view teaching or lecture videos as well as distance learning resources.
Patients are a rich source of information and learning. This can come from patient participation stories, the Friends and Family Test, social media and complaints, among other routes.
- Sharing standard templates of issues and learning across sites, emails and email alerts, newsletters and intranet clinical governance pages.
- Be wary of over reliance on email – think: how will I know everyone who needs to will get this done by the deadline?
Other thoughts about learning
- Learning from significant adverse events often requires anonymised learning so that staff can be open in reporting and do not feel there is any ‘finger pointing’ or denigration of particular sites.
- Reporting may need to be available more frequently with headline figures and scorecards or summary templates and less frequently with detailed breakdowns and analyses.
- Whatever is used must be consistent and look familiar across the organisation.
- It must be clear that action has been taken as a result of learning.
- It is important that staff learning from an event at another site see the relevance to them.
- Don’t rely on brief feedback in electronic incident reporting systems.
- Our experience is that learning after serious incidents and never events is generally better done than learning from near misses and lower harm incidents.
- Remember to liaise with the host site over any actions involving them.
- Using staff as peer reviewers of other parts of a network is powerful.
- Consider external advice for difficult issues.