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

Sujan, M. An organisation without a memory: a qualitative study of hospital staff perceptions on reporting and organisational learning for patient safety. Reliability Engineering & System Safety, 2015, 144;45-52.

The section below provides more information that you can use to support your improvements.

Resources

A framework for measuring and monitoring safety, The Health Foundation.
A practical guide to using a framework for measuring and monitoring safety in the NHS

Learning from excellence community.
This webpage is a source of open-access resources for learning from excellence, including learning from what works well and positive feedback to staff.

A national approach to learning from adverse events through reporting review and the sharing of learning, Healthcare Improvement Scotland.
This webpage offers links to adverse event related resources in Scotland including reviews, learning, management and feedback.

Quality improvement made simple, The Health Foundation, 2021.
This guide highlights popular quality improvement methods currently used in healthcare and factors that can help them improve quality of care processes, pathways and services.

Systems for learning case study. SPSP Perinatal and Paediatric Programmes (SPSP PP) formerly MCQIC. This case study focuses on learning systems and their importance in a quality management system. More information on SPSP PP case studies and related webinars can found on the SPSP PP webpage.