Many organisations have systems in place that could be used to transform the organisation into a truly learning company, removing the blame and improving outcomes for their clients but do they really understand the process, use it to its advantage and allow the staff to grow? The private sector is clearly behind the starting line on the transformation from a blame culture to a learning organisation. That is because there is a pressure on a private sector provider of health and social care services to almost adopt a blame culture to demonstrate they are taking incidents that occur seriously.
We know that the journey to a learning organisation is not an easy one and revolves around good governance. When we conduct mock inspections and visit establishments one of the things we ask about is: complaints, incidents and accidents. We see very small numbers of these recorded and the usual answer to incident reporting is: We haven’t had any, or one or two incidents are reported. We know immediately from that comment that the organisation is not using the processes to help people, teams and the organisation learn.
We would suggest that to start the journey to become a truly learning organisation within the health and social care arena you need to start with a policy review. When reviewing your policies, procedures, working practices or guidelines ask the following questions:
Are they fit for purpose?
Do staff work to them, if not, is that because they need reviewing or is it the staff cannot access them?
Are the forms discussed in the documents fit for purpose?
Are the correct processes discussed in the documents actually in use?
One pitfall we often see, are the policies were written for a paper based system and the provider has moved to a computer system. Making it impossible to marry the two processes and causing confusion.
The next step is understanding what is going wrong in the organisation and this means you need to understand complaints incidents and accidents. Ensuring every incident accident and complaint is documented is vital no matter how small. You may need to redefine with your staff what should be recorded. There is a common misconception that small “niggles” are not complaints, that a “minor issue” is not an incident, that is simply not the case.
There needs to be a quick and simple way of documenting every complaint and incident/accident. This allows for a review, to ensure that learning can be taken from it and the reporter gets an outcome. Without blame the staff are informed about incidents and what needs to happen to stop it happening again and the senior management team can ensure where required policies procedures etc. are updated to ensure incidents do not reoccur.
This system can go a long way towards a service being rated highly in the “Safe” “Responsive” and “Well led” categories.
Most companies by virtue of being registered with a care regulator have the building blocks to achieve this but few use them effectively to achieve really great governance, our team can help