Dr AK Khandelwal, Medical Director, AnandaLoke Hospital & Neurosciences Centre, and NABH Assessor, recommends making a healthcare set up into a learning organisation for development and progress
A hospital is a complex organisation. Problems or errors are bound to occur in any complex human endeavour, and healthcare is no exception. Medical errors are ubiquitous and the costs (human and financial) are substantial. Preventable medical errors are responsible for around 90000 deaths per year in the US (IHI). It is the second leading cause of deaths in the UK.1
Approximately, 80 per cent of medical errors or failures are system-derived.2 Simply, good people working hard will be insufficient to overcome the complexities inherent in today’s systems of care and prevent errors and harm to patients. The solution lies in learning from these failures to prevent the recurring of these mistakes in future.
Unfortunately research literature reveals that, in spite of increased emphasis on these issues, hospitals are not learning from the daily problems and errors encountered by their workers. So, it is imperative that a healthcare organisation should learn from its failures.
Why aren’t hospitals learning from their failures or errors?
- Emphasis on individual vigilance in healthcare: Each caregiver tend to work on their task without altering the underlying process
- Unit efficiency concerns: Each staff is interested in maximising their unit output
- Empowerment: No power to take corrective action
What is organisational learning?
Argyris (1977) defines organisational learning as the process of detection and correction of errors.
How can an organisation learn from its failures or errors?
Literature mentions that there are two methods of process improvement3 or problem solving.4
They are as follows:
First order improvement or first order problem solving: First-order process is implemented by hospital staffs when they compensate for a problem by getting the supplies or information needed to finish a task that was blocked or interrupted. In such situations, hospital staff does not address the underlying causes, thus not reducing the likelihood of a similar problem or failure or error occurring in the future. This first-order improvement process can be counterproductive. It keeps communication of problems isolated so that they do not surface as learning opportunities. Sometimes this can create problems in other areas. Thus, first-order improvement, ironically, can preclude improvement by obscuring the existence of problems and errors and preventing operational and structural changes that would prevent the same failures from happening again. Thus, this process does not help in organisation learning.
What they do: Simply solve problem as they face, avoid unpleasant task of contacting higher authority to prevent it further.
Second order improvement or the second order problem solving: The second-order improvement requires that hospital staff not only solve the problem so that the immediate task at hand can be completed, but also takes action to address underlying causes.
Example of second-order improvement: Hospital staff communicates about the problem to the person or the department responsible for handling it; and bring it to the manager’s attention. Hospital staffs also share ideas about what caused the situation and how to prevent recurrence with the appropriate authority so that necessary changes can be implemented to ensure that the changes have the desired effect. The second-order improvement process help in organisational learning and it achieves both detection and correction of error.
| How does learning organisation differ? | ||
| Problem or error | Typical response | Learning organisation’s response |
| Missing materials or information | Adjust to shortcomings in materials and supplies without bothering managers or others |
Remedies immediate situation but also inform the manager and supply department regarding failure |
| Others’ errors | Seamlessly correct for errors of others – without confronting the person about their error |
Report about error without blaming |
| Own errors | Create an impression of never making mistakes | Take responsibility of error and report as per organisation protocol. |
How to make a learning organisation?
Peter Senge, a leading researcher in the area of learning organisations, describe five disciplines that must be mastered when introducing learning into an organisation.6 A successful organisation in Senge’s theory has the capacity to change and manage change where individuals in an organisation adopt systemic thinking, attain personal mastery, share mental models, have shared vision and learn as a team.
Five requirements for a learning organisation
Shared vision: Literature mentions that the shared vision of a healthcare organisation must be built on the individual visions of its members. Healthcare organisations should develop shared vision of its team members. The leader of a healthcare organisation should ensure that the organisation’s vision is not created by the leader; rather the vision should be created through interaction with all team members of the healthcare organisation.
Team learning: Researchers opine that team building is the process of aligning and developing the capacity of a team to create the results its members truly desire. It builds on the discipline of developing shared vision. It also builds on personal mastery, for talented teams are made up of talented individuals.
Systemic thinking: It is the process of integrating all five disciplines, fusing them into a coherent body of methods, tools, and principles, all oriented to looking at the interrelatedness of forces, and seeing them as part of a common process
Mental models: The assumptions held by individuals and organisations are called mental models. Leaders in learning healthcare organisations should be getting in touch with the thinking going on about change in their workplace, challenge or clarify assumptions and encourage people to rethink in order to build shared thinking.
Personal mastery: As per researchers,6 personal mastery applies to individual learning and organisations cannot learn until their members begin to learn. So leaders’ job in the learning healthcare organisation is to be the teacher or coach who helps to unleash the creative energy in each individual.
What’s the leader’s role in a learning organisation?
Experts opine that a leader’s role in a learning organisation is that of a designer, teacher, and steward who can build shared vision and challenge prevailing mental models. A leader is responsible for building organisations where people are continually expanding their capabilities.
Leaders have an essential role – assisting with problem-solving efforts, providing support for workers who attempt to improve their work systems, and valuing them as motivated employees. By reframing workers’ perceptions of failures from sources of frustration to sources of learning, leaders can engage employees in system improvement efforts that would otherwise not occur.
Recommendations
- Leaders must make an effort to be regularly available for at least part of all shifts. The physical presence of leaders increased the likelihood of their being informed of problems occurring on the unit; this, in turn, allowed leaders to investigate and support possible work system changes. Next, leaders can counteract time pressure by providing assistance for frontline problem-solving efforts. In addition, by acting as role models of second order improvement, leaders can teach staffs to think about what could be done to prevent similar problems from occurring in the future.
- To learn from failures, people need to be able to talk about them without fear of ridicule or punishment. Leaders can help create an environment where staffs feels safe taking the interpersonal risks that second-order improvement or problem-solving entails, thereby making this behaviour more psychologically feasible.
- Leaders must respond to initiative by following through on these suggestions and facilitating boundary-crossing improvements that help reduce the rate of problem emergence. In short, if second-order problem-solving effort does not lead to any positive changes; workers will be discouraged about spending their time on this in the future.
- Leaders should encourage staff to learn from other organisations. Ensure that the best industry practices are uncovered, analysed, adapted and implemented
Conclusion
Hospital administrators should ensure that healthcare organisations adopt the culture of learning organisations to make their organisation safe. Safe patient care is facilitated by individual professional learning, team learning and organisation learning.
Top management should ensure that staffs are continuously learning to deliver best possible care.
References:
1. Botwinick L, Bisognano M, Haraden C. Leadership Guide to Patient Safety. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2006.
2. Leonard M, Frankel A, Simmonds T, with Vega K. Achieving Safe and Reliable Healthcare: Strategies and Solutions. Chicago, Illinois: Health Administration Press; 2004, p. 5.
3. N. Repenning and J.D, Sterman, “Capability Traps and Self-Confirming Attribution Errors in the Dynamics of Process Improvement.” AdministrativeScience Quarterly, 47 (2002): 265-295
4. A Tucker, A.L., and Edmondson, A.C. (2003). “Why hospitals don’t learn from failures: Organisational and psychological dynamics that inhibit system change.” California Management Review,45,2: 55-72.
5. Argyris, Chris. May/June 1991. Teaching Smart People How to Learn. Harvard Business Review, Vol. 69, No. 3, pp. 99-109
6. Senge, Peter. 1990. The Fifth Discipline: the Art and Practice of the Learning Organization. New York: Doubleday.