Constant learning, continuous improvement - lessons from Francis

2013 will go down as a year when the NHS did a lot of soul searching.

In February, Sir Robert Francis QC published his report following the Mid Staffordshire Public Inquiry. The Inquiry uncovered a trust board that ‘failed to tackle an insidious negative culture involving a tolerance of poor standards’, and a plethora of organisations that failed in their job to detect and remedy the safety concerns that patients and the public had been trying to raise for years.

The Inquiry triggered investigations into 14 other NHS organisations that had been persistent outliers on mortality indicators. Led by Sir Bruce Keogh, they found some unique problems in individual organisations, and concluded all had become ‘trapped in mediocrity’ to the detriment of patients.

It also led to the government setting up six independent review groups, all of which searched for answers as to how to make sure the tragic events at Mid Staffordshire never happened again.

Most recently, in November, the government produced its full response to the Inquiry, accepting - at least in principle - all but 9 of the 290 recommendations. Of the many actions being taken, there will be a tougher approach taken to the inspection and regulation of NHS organisations; additional duties on providers and professionals to be open with patients in the event of a serious mistake; and a range of initiatives designed to develop the capability of organisations and the system as a whole to improve safety.

There has, and will continue to be, much debate around the focus and practical application of these actions (download our briefing on the government’s response).

But of greater significance than the nuance and complexity of the arguments around a duty of candour, or the proposed registration scheme for healthcare assistants, is the issue that bubbles beneath all of this. An issue which arises whenever the NHS is faced with a significant failing in care – that of properly and fundamentally learning and changing from experience. Our new interactive timeline of milestones in patient safety over the last 50 years demonstrates this ongoing challenge with learning and adapting.

So will we look back in another 10 years and be faced with another crisis in care? I am hopeful that we are beginning to have the system of learning we need to break the cycle, but I wonder if the focus of that learning is yet adequate to avoid future crises. The NHS has made great progress on specific high profile and discreet causes of harm, such as healthcare associated infections and falls.

However, looking back at the work that has dominated approaches to improving safety, beyond isolated examples of advanced practice, have we yet developed the right sort of learning to tackle the more complex, system wide challenges such as those at Mid Staffordshire? 

As part of the government’s response to the Francis report, Don Berwick was asked to undertake a review with the aim of making zero harm a reality in the NHS. This review quite rightly corrected the ambition to be the ‘continual reduction’ of harm; where the battle for safety is never won, but rather always in progress. It concluded that rules and regulations have a role in making care safer, but they pale into insignificance when compared to the power of constant learning. 

I believe that by committing ourselves to creating a system of constant learning, we will be able to break the cycle of scandal followed by inquiry followed by legislation, and instead continually improve. Constant learning should manifest itself in a number of ways:

• Frontline professionals changing their practice following the poor experience or outcome of a patient, or as they understand the hazards in their services
• Executive teams creating an environment in which people at all levels feel able to discuss risks and mistakes knowing that it will lead to improvement
• The government, national agencies and regulators leaving healthcare providers empowered to own their safety data, detect and remedy their risks and problems first, and learn from mistakes when they do happen.

This learning should be geared not just to understanding and addressing specific causes of harm encountered in the past, but increasingly the wider underlying challenges and latent hazards that make care unsafe and will continue to do so. 

In 2014, the Health Foundation will remain focused on a programme of work to support improvements in safety that has an ethic of learning at its heart. In particular, we will work to make the measurement and monitoring of safety more comprehensive, inviting NHS organisations to put the framework developed by Charles Vincent and colleagues into practice so that they can target their efforts on areas in most need of improvement.

By making this contribution we hope to play a part in achieving the changes needed to fulfil Don Berwick’s overarching goal that the NHS should 'continually and forever reduce patient harm by embracing wholeheartedly an ethic of learning'.

Penny is Assistant Director at the Health Foundation, www.twitter.com/PennyPereira1