Learning lessons when things go wrong… for real

The phrase “We’ll learn the lessons from…” is often used. Whether in national politics, in the aftermath of disasters, in the wake of a failure in a local service, after accidents, or when things just plain go wrong, there is likely to be a spokesperson acknowledging an investigation and voicing a commitment to “learning lessons”. Back in 2000, the Department of Health published An organisation with a memory, making recommendations on how to learn lessons from serious incidents to minimise patient harm in the future, and many investigations and recommendations have followed in the subsequent years.

But sometimes it seems that the statement that “lessons will be learned” feels almost an end point in itself; an attempt at drawing a line under an issue, perhaps geared to deflecting attention and scrutiny.

I’ve been reflecting on what “learning lessons when things go wrong… for real” might look like and some key questions that might be worth considering.

 

1. What needs to be done immediately?

There are times when the “learning lessons” process can get so protracted that potential quick solutions and helpful responses get lost. It is important to focus on the critical factors that need dealing with quickly.

For example, are any service users, patients, staff, or members of the public at immediate risk, whether in terms of physical, mental and emotional health and wellbeing? If so, focus on getting them safe.

Is there a physical setting that is dangerous? Then fix it, or close it until it can be fixed. This may have short-term costs, but the likelihood is these will be much less than the costs of the issue recurring and affecting other people.

Has someone in authority actually said “Sorry” to those poorly affected? If not, make this happen! Saying sorry – and meaning it (not one of those weasel-y “I’m sorry if you felt that….” non-apologies) – is not tantamount to opening up a lawsuit. Rather, it is an expression of common decency. Having overseen service user complaints in a number of organisations, the single thing by far that most complainants wanted was for someone to say, “I’m sorry that happened. I’m sorry we let you down.”

 

2. What do staff need?

There is no more valuable asset to an organisation than its staff, and we should treat them as such. If staff are involved, then look to their safety too.

Even if staff may have been involved in an incident, they deserve our care, and to be held to account, but not blamed. If they are to be taken off duties or put into a formal process, this should be done within clear guidelines in place before the incident. The basic principle of “assumed innocence” should apply, even when, for issues of protection, staff must be taken away from a situation. Ensure those staff have appropriate support too – in terms of their physical, mental and emotional health and wellbeing. Have they access to employee assistance or a staff wellbeing service? To family and friends? To a union representative or other representative support?

In any incident there will be staff further away from the incident who are differently affected, like the ripples from a stone thrown into a stream. We need to consider the possible impacts on staff outwith the immediate incident: is there a risk that a wider service will be scrutinised, or a wider service user group will have concerns about their own care? Is there a reputational risk to the organisation that means anyone linked to it may be viewed negatively?

 

3. How are actions agreed, delivered, and checked?

Assuming there is a process of investigation and identifying lessons to be learned, it is important to confirm how they will be agreed as the right lessons from the incident, how any actions that follow will be taken (including by whom, and by when), and how their successful implementation will be measured and checked.

 

4. How do we confirm assimilation of learning when the incident itself is long past?

Reviews of lessons learned from incidents often show a tailing off of implementation over time. This can be exacerbated in areas of high turnover where there might soon be a team without members with direct experience of the incident that was investigated.

Be clear about the detail of information needed at the level in which you are involved. For example, those implementing any “lessons learned” actions will need a greater level of information than a Board or governing body. The latter will need to know the timelines of the overall action plan, the milestones that will demonstrate actions are completed, and to have agreed evidence measures that show that the completed actions are having the effect that was anticipated. And they will need clear information on steps being taken if timescales and targets fall behind. Such a framework will mean a Board not only carries out its appropriate oversight, but also is in a position to change its strategic response to lesson learned, if needs be.

Building in a programme of regular reviews of the expected continued implementation over the years following an incident can help ensure learning is truly assimilated. Annual checks on assimilation may be valuable, won’t necessarily be time-consuming, and can be effective in helping ensure lessons learned aren’t inadvertently forgotten.

 

5. How is the responsibility for governance carried out?

Always identify where the governance oversight of lessons learned sits, and ensure there is real ownership of that governance. A commitment to publicly demonstrating good governance is both consistent with a commitment to candour and transparency, but also helps concentrate governance on demonstrating lessons have really been learned.

And ensure there is a strong, clear audit trail documenting the governance discussions and decisions supporting the oversight of lessons learned.

 

6. How will other people know lessons have really been learned?

It is important to identify who needs to know that lessons have really been learned. Families and carers of people hurt (or worse) in incidents often say that their prime focus is on ensuring the incident won’t happen again. They need open, honest feedback on steps taken, and clear information to give them confidence that an incident won’t be able to recur, but also the evidence to back such claims up. It is important to go at the pace of the families and carers in such circumstances. I know of an NHS Trust that only lets complainants formally close complaints (rather that the Trust itself). There is a strong emphasis on securing a resolution that meets sufficient satisfaction of the complainant, and clearly positions power in the assessment of that resolution with the complainant.

 

7. Applying emotional intelligence – how do I feel?

If I’m going to have any chance of really learning lessons and of applying the tools outlined above, I also need to take time to look inside myself. The way I am feeling about a situation or issue completely affects how I subsequently deal with it, and I need to be alert to my emotional responses as, without some critical introspection, I may unintentionally sabotage the learning process, particularly in the early stages of the learning. For example:

• Do I feel embarrassed? Then I can try and put it to one side, as embarrassment only serves to either freeze me and prevent me taking action, or risks me taking actions designed more to help me feel better rather than resolve the issue at hand
• Do I feel defensive? Then I need to do a reality check: am I really being attacked, or are people trying to hold me to account? Perhaps their language is a bit clumsy; perhaps they’re driven by their own anger or other feelings? If I can understand this, I can try and hear the message behind their emotion rather than denying it with my defensiveness
• Do I feel angry or scared? Is this a manifestation of my embarrassment or defensiveness, or is it an anger on others’ behalf? If I feel unsafe, what would help me feel more safe? Is this situation taking me into unknown territory? Are my surroundings unsafe or do I feel isolated in dealing with the learning of lessons? If so, is there an ally or friend I can call on to help? Would it be so bad if I acknowledged feeling scared, and then got on with the learning anyway?

And let’s remember, we also need to learn lessons from the times when things go well! Sometimes doing things well is regarded as “just” what we should expect, and gets little attention. But if we do something well, it is worth taking some time to see if there are lessons that can be learned and applied to other activity, as well as pausing to acknowledge and celebrate that success.