21.05.14
Improving corporate memory as a patient safety strategy
Guest blog by Lorri Zipperer of Zipperer Project Management, who argues that special attention to enhancing organisational knowledge-sharing could serve to improve learning from care failures.
The National Health Service has been handed some marching orders for improvement. With the publication of the Francis Inquiry report and publications responding to it, innovative thinking and committed energy has been applied to seeing the outing of failures at Mid Staffordshire Trust as an opportunity to inform wide-spread systemic improvement.(1)
However, one element of the failure hasn’t seen so much attention. In the report’s executive summary, the failure of curating and cultivating corporate memory to support a culture of open discussion to enable trusts – or the healthcare system as a whole – to learn from failure was highlighted as an important future consideration.
Vincent, Berwick and others have noted the lack of effective capacity to fold softer intelligence and information analysis skills into the work of safety.(2) To address these concerns, an additional focus on improved sharing of published evidence, information and tacit knowledge (EIK) is in order. The emphasis should not only be on the critical work of applying EIK effectively at the ‘sharp end’ (i.e. for direct patient care) but on the system for sharing what is known on the administrative and regulatory side of the care process – the ‘blunt end’. James Reason’s metaphor for describing systemic disconnects has served the patient safety community well in teasing out the causes for system failure (3), but has not collectively been applied to ineffective EIK behaviours and processes as contributors to failures.
Seeing these elements of healthcare as distinct factors to be approached from this system-oriented, high-reliability standpoint could help ensure that EIK is shared without gaps and managed so learning occurs. As long as EIK identification and sharing process problems remain unidentified, unmeasured and undiscussed, they’ll continue to serve as latent accessories to failures such as those identified in the Francis analysis.
Until sensitivity to this problem is embraced by clinicians and healthcare executives alike, effective access, use and sharing of EIK will unfortunately only be assumed to be happening – and patients, practitioners and organisations won’t truly benefit from its power.
References
1) Francis R. Report of the Mid Staffordshire NHS Foundation Trust: Public Inquiry. London, UK: The Stationary Office; 2013. ISBN: 9780102981469. Full text: http://www.midstaffspublicinquiry.com/report Executive summary: http://www.midstaffspublicinquiry.com/sites/default/files/report/Executive%20summary.pdf
2) Vincent C, Burnett S, Carthey J. Safety measurement and monitoring in healthcare: a framework to guide clinical teams and healthcare organisations in maintaining safety. BMJ Qual Saf. 2014 Apr 24; [Epub ahead of print]. http://dx.doi.org/10.1136/bmjqs-2013-002757
3) Reason JT. Managing the Risks of Organizational Accidents. Aldershot, Hampshire, England: Ashgate; 1997.
For more information: [email protected]
http://www.linkedin.com/pub/lorri-zipperer/0/661/904
