System for learning
Leadership to promote a culture of safety at all levels
Some ideas that your team could try:
The sections below provide more information about why these are important. You will find practical examples, evidence, tools, templates and training resources that you could use to support your improvements.
- Why systems for learning are important
Systems for organisational learning aim to accelerate the sharing of learning and improvement work through a range of learning opportunities from all safety events.
A learning system that captures information and tracks improvement builds trust and the capacity to drive improvement. Leaders play a key role in creating and maintaining the learning system. By ensuring that the learning system is visible and functional, leaders send an important cultural message – that staff are valued and their feedback needs to be acted on (Michael Leonard & Allan Frankel, 2012).
A system for learning should include a measurement system to understand and drive improvements in care (using both qualitative and quantitative data), and learning from excellence to identify and share best practice in safe care. SPSP Essentials of Safe Care activity should be linked to wider organisational work supporting the delivery of safe care.
A ‘Just Culture’ within an organisation encourages learning and reflection on all safety events, free of blame. This can include learning from adverse events, to ensure that effective critical event review processes are in place, to learn from:
- complaints as they relate to the safety of care, and
- duty of candour, specifically from events with harm.
- Evidence, examples and training resources to support systems for learning
The guidance to support this rationale is based on best practice. Examples of this can be seen in:
- An organisation without a memory: A qualitative study of hospital staff perceptions on reporting and organisational learning for patient safety, Mark Sujan (2015).
- How can leaders influence a safety culture?, Michael Leonard & Allan Frankel (2012).
- Measuring safety culture, The Health Foundation (2011).
- The measuring and monitoring of safety, The Health Foundation (2013).
- Templates and tools to support systems for learning
- Learning from Excellence. Learning for Excellence is a model to capture excellence in health and care services and learn from what goes well in our work.
- NHS Education for Scotland Achieving Sustainable Change.