Sharing lessons learned: The capacity to learn from experience and improve safety in healthcare
Co-authored by Melissa Campbell, MBA, CPPS, Director of Product Management, Safety & Reliability
Safety in healthcare is foundational to fostering the Human Experience for patients and team members. It also directly impacts patient experience, clinical outcomes, and all other metrics of success. As healthcare organizations seek to continually improve patient and workforce safety, we can look toward other high reliability industries, and how they approach their work through a safety lens.
Admiral Hyman G. Rickover (1900–1986), known as “the Father of the Nuclear Navy,” directed the original development of naval nuclear propulsion and led its operations for 30 years. His commitment to excellence was undeniable, his performance standards were high, and many of his leadership principles are still relevant in the modern era.
One of Rickover’s management principles, described in The Rickover Effect: How One Man Made a Difference, is simply: “Develop the capacity to learn from experience.” And we must apply this principle to healthcare, as we continuously strive to raise the bar on experiences, improve clinical outcomes, and drive toward zero harm.
In healthcare, while learning from your own experience is important, learning from the experience of others is imperative.
Learning from experience is a cornerstone competency for individuals, leaders, and organizations—especially in high-risk, high-consequence industries like nuclear power, and healthcare. In healthcare, while learning from your own experience is important, learning from the experience of others is imperative. The strength of an organization’s learning system is determined by how comprehensive it is. Consider your own learning system and its comprehensiveness. Does it include:
- Learning from internal failures and external failures?
- Learning from internal successes and external successes?
- All types of harm—physical as well as emotional?
- All impacted, including patients and workforce?
- All sites of care—acute, ambulatory, long-term care, home care, health plans?
- Sharing lessons learned externally?
- Learning across the entire healthcare delivery system?
Find a starting-off point for learning from experience in healthcare
As is often said, the best place to start is at the beginning. So look inward first. Develop and sharpen your capability to learn from internal failures. A prerequisite is a strong root cause analysis process with clearly defined principles and practices for understanding proximate causes, discerning individual and system failure mechanisms, and determining root causes and corrective actions to prevent further occurrence. Then share those lessons learned not just with those involved in the event, but across the department, across the facility, and across the organization. Regardless of the type of event, everyone can learn from the root causes of the event. As a best practice, establish a closed-loop process for ensuring that other departments and facilities (1) assess for the presence of the root causes and, if the same root causes exist, (2) implement the corrective actions to prevent the root causes.
Press Ganey's High Reliability Platform: Enabling learning from experience
Press Ganey’s High Reliability Platform (HRP) now includes a lessons learned module to facilitate experience sharing and accountability tracking (Figure 1). This new capability encourages sharing across safety, patient feedback, and peer review events enterprise-wide. Additionally, the module provides a utility for front-line team members to share lessons learned from day-to-day events.
Figure 1
If you’re interested in learning more about the effectiveness of our cause analysis program, or if you’d like to explore the Press Ganey High Reliability Platform, reach out to a safety and high reliability expert here.