A Learning Culture Learns from Errors Through Tracking, Analysis, and Sharing of InformationExpand the buttons below for descriptions and tools.
Being a learning organization does not mean that senior leaders are eager to try each new idea that emerges from the literature, a workshop, or a consultant. Being a learning organization means:
- formal and informal safety reporting systems provide information about safety systems
- there is a just and straightforward way to decide if an event warrants disciplinary action
- structured communication in the context of teamwork ensures that an organization is flexible - authority gradients are not a barrier to effective communication
- the will exists to act - to execute and evaluate - the changes indicated by safety reporting systems
- a learning organization systematically makes sense of events that occur to achieve the goals of eliminating risks and hazards to patient safety and providing evidence-based reliable care
A simple fable helps learning organizations overcome resistance to change
Kotter J, Rathgeber H. (2006). Our iceberg is melting: Changing and succeeding under any conditions. New York: St. Martin's Press.
This book is an enjoyable fable that explores the elements necessary to implement organizational change. The fable follows Fred, a particularly observant penguin, who realizes his colony lives on a melting iceberg. Once the colony understands the need for change, several penguins with varying personalities and leadership styles rise to the challenge of finding a new home using the eight-step framework for change. Beginning with the need to create a sense of urgency and ending with the creation of a new culture, the lessons the penguins learn are relevant to hospitals as they create a culture of safety. While the fable teaches valuable lessons about the process of change, it also keeps the reader engaged with endearing penguin characters that can remind us of people in our own organization. In the end, Our Iceberg is Melting will provide those involved in patient safety and quality improvement with a framework to learn about the role of teamwork and communication in managing organizational change.
An Introduction to Patient Safety Principles for Rural Healthcare Providers and Governing Boards
Root cause analysis (RCA) retrospectively makes sense of a single event
Root cause analysis is a process for identifying the basic or causal factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event. A root cause analysis focuses primarily on systems and processes, not individual performance. It progresses from special causes in clinical processes to common causes in organizational processes and identifies potential improvements in processes or systems that would tend to decrease the likelihood of such events in the future, or determines, after analysis that no such improvement opportunities exist.
Aggregate RCA retrospectively makes sense of multiple similar events
Aggregate RCA is a process for identifying trends and system sources of error across groupings of similar events. The process requires multiple steps to analyze a process, select a focus for improvement, and design and evaluate interventions. Aggregate RCA efficiently uses the limited resources in small rural hospitals to identify chronic hazards within systems. These chronic hazards are the near-misses and nonharmful errors reported by front-line workers in direct contact with patients. Source: Using Aggregate Root Cause Analysis to Improve Patient Safety