Leading change

A Mental Health Nurse led the development and implementation of a ‘Learning Lessons’ framework at North Staffordshire Combined Healthcare NHS Trust (NSCHT). This has improved patient safety and outcomes, staff and patient experience, the use of resources and demonstrable learning from incidents.

Where to look

NHS England’s ‘Serious Incident Framework – Supporting learning to prevent recurrence’ (revised 2015) guides staff providing and commissioning NHS funded services in England who may be involved in identifying, investigating or managing a serious incident. The framework describes the circumstances in which such a response may be required and the process and procedures for achieving it, to ensure that Serious Incidents are identified correctly, investigated thoroughly and, most importantly, learned from to prevent the likelihood of similar incidents happening again.

The Framework aims to facilitate learning by promoting a fair, open, and just culture that abandons blame and promotes the belief that ‘incidents cannot simply be linked to the actions of the individual healthcare staff involved but rather the system in which the individuals were working’. Looking at what was wrong in the system helps organisations to learn lessons that can prevent the incident recurring.

To support this, tools such as the Manchester Patient Safety Framework (MaPSaF) (2013) support NHS organisations and healthcare teams to assess their progress in developing a safety culture through facilitating reflection, stimulating discussion and supporting changes in practice.

The mental health nurse at NSCHT identified unwarranted variation in the learning of lessons – including thematic analysis of groups of incidents – within the Trust and saw an opportunity to lead an improvement piece to address this.

What to change

The mental health nurse identified that the Trust’s serious incident management process included a routine analysis of all serious incidents and subsequent development of action plans, however the process did not include any organisation-wide sharing of incident learning or the developing any learning culture. Serious incident investigations were completed by clinical staff focusing upon the incident at hand and weren’t routinely prompted to consider sharing the learning widely.

It also became increasingly clear that staff often didn’t feel involved or engaged in investigations or updated on the themes and trends emerging from incidents more widely across the Trust. Aligned with this, the safety culture of the Trust had not been assessed with regards to how staff learned from incidents.

The mental health nurse identified the opportunity to develop a structured “learning lessons” framework to provide staff access to learning from both incidents and complaints. This framework also aimed to develop a safety culture within the Trust that would enable staff to feel confident in highlighting when things have gone wrong and to share best practice.

How to change

With the support of the Trusts senior team, the nurse developed a “Learning Lessons” framework, constituting six core elements:

1. Bulletins – circulated to all staff on a bi-monthly basis, including good practice regarding patient safety and experience sharing;
2. Learning Lessons sessions – held monthly and available to all staff;
3. Learning Lessons Leads – development of a virtual group of 50+ staff in the Trust to establish a culture of learning and development based on national and international dissemination of knowledge;
4. Debriefing sessions – following incidents for both staff and patients to support understanding and learning;
5. Incident feedback pathways – to support timely feedback and changes in practice where needed;
6. Developing a learning culture – to establish a ‘safety culture’ and lessons learnt as business as usual.

The monthly ‘Learning Lessons’ sessions are facilitated by the nurse to reflect on learning from incidents, complaints, duty of candour incidents and more widely other organisations’ major incidents. Sessions are delivered by staff who have been directly involved in incidents and relevant experts in their fields.

The MaPSaF tool has been adopted and is used to assess the culture of both inpatient and community teams to create action plans for each individual team to improve the Trust’s safety culture. Local team led investigations into less serious/no harm incidents has begun and includes the involvement of patients or relatives are shared, in line with the Trust’s ‘Being Open’ policy.

The framework is promoted throughout the Trust by use of posters, banners and other communications channels including short video clips.

Adding value

Better outcomes – Staff engagement through the monthly Learning Lessons sessions has been extremely positive, with continually increasing attendance; in excess of 325 staff members attend the sessions. Qualitative feedback from these sessions has demonstrated the evolving learning across the trust and the team are observing changes in practice showing demonstrable translation.

Better experience – The opportunity to learn has been well received by staff, with engagement shown through positive feedback as well as suggestions to shape future sessions and continual improvement. Staff feedback includes:

• “I found all of the session very interesting and informative.”
• “Really enjoyed the Learning Lessons session and felt inspired.”
• “We had an excellent speaker and an interested audience.”

Better use of resources – The monthly Learning Lessons bulletin is distributed to every member of staff, reinforcing the key messages. The engagement of staff with the Learning Lessons programme has been central to assisting the organisation to change its culture around incidents, particularly around the topic of suicide. The improvement is palpable, but time-saving and other resource implications have not yet been calculated.

The work was recognised by the Care Quality Commission (CQC) as a learning framework that is well embedded in the Trust. North Staffordshire and Stoke-on-Trent Clinical Commissioning Groups noted: “The Trust openly share evidence of the good practice and we regularly receive copies of the Learning Lessons bulletin.”

Challenges and lessons learnt for implementation

People learn best through listening, discussing and seeing – staff are interested in hearing about incidents and how they were dealt with. The sessions due to their successes have been expanded to welcome other agencies – multi-agency reflection following incidents. This includes police teams, the fire service and adult social care.

It was challenging at first to secure staff engagement due to busy schedules, but once they had attended they generally returned to further sessions.

Celebrate your successes and be positive about the good work that is done as well as looking at what can be improved.

Find out more

For more information contact:

• Lesley Whittaker, Registered Mental Health Nurse and Patient Safety Manager, North Staffordshire Combined Healthcare NHS Trust, lesleyp.whittaker@combined.nhs.uk