Building on her plenary at Quality Forum 2020, Penny Pereira, Director of the Q initiative, shares her thoughts on the role that learning and sharing plays as an inherent part of improvement. The Q initiative brings together thousands of people leading improvement across the UK. Q is funded and delivered by the Health Foundation and NHS England and NHS Improvement.
Back in 2013, a review by Don Berwick concluded that the most important change in the English NHS would for it to become ‘a system devoted to continual learning and improvement’. ’Learning’ here means the transparency and rigour in responding to error that is central to a good safety culture. At UK charity the Health Foundation, we’ve also taken this to speak more broadly of the imperative to understand and share what’s working and what’s not working across the health and care system.
The challenge of spreading learning has been a consistent theme in UK improvement before 2013 and since. This blog shares links and resources that have helped move our thinking and practice forward and explores why it’s still such a big challenge.
This is partly about scarce time and capacity, that draws us to be overly absorbed in our immediate deliverables. All too often improvement work is done to over-ambitious timescales, by teams with limited protected time and resources. In our haste to get on and deliver, it’s tempting to rely on ideas and perspectives we have readily available, rather than invest scarce time in learning from what others have done.
Mary Dixon Woods has demonstrated how this means improvement teams can end up implementing interventions that are known not to be effective, or doing the right things but without paying attention to all the elements that need to be in place for them to work. She argues that this is part of a pattern of continually losing learning, often reinventing the wheel by focusing on multiple small QI projects, even when a system-wide solution is what’s needed.
It’s understandable, but precisely because resources are so tight and the breadth of challenges facing health and care so vast, there’s a strong strategic rationale to make the most of what we all know. When I walk around a hospital and see things not working that others have cracked, it brings home that there’s a human and ethical as well as an economic imperative for us to get much better at learning and sharing.
So, what helps? Ultimately, it’s people who share and learn. Research commissioned by the Health Foundation proposes that sustainable improvement requires people to master learning alongside technical and soft skills.
It takes skill partly because we now know that – inconvenient as it might be – we cannot rely on case studies, best practice databases or journals alone. Improvement work often relies on using practical wisdom to translate ideas into the complex reality of any new place. This is wisdom that’s best shared person to person.
This means networking deserves respect as a critical part of how we ensure we’re delivering effectively for those we serve. Practical ideas and energy are unleashed when we enable people to connect with the people and information that’s important to them – there’s huge appetite for people to work in a more joined up way. In the UK, over 3,600 people have so far joined a major long-term community that’s been established to make it easier for people to learn, share and collaborate.
Liberating Structures are spreading fast through the community, as a way of helping deliver our work in more effective, participative way. Through the Q community, we have also curated a set of creative approaches to problem solving with instructions that can be freely downloaded. Through the Q Improvement Lab, we are understanding what it takes to address complex challenges collaboratively: in a way that brings together all those with an interest in a topic so that more rounded and effective solutions emerge.
To really enable learning to spread effectively needs action at multiple levels. These tools and methods can help anyone connect in way that will help them shortcut the process of discovery or find richer solutions. To start to embed the culture and practice of effective sharing within and across organisations needs other things to be in place. This report shines a light on organisations that have embedded improvement as part of how they work and this review of the evidence on networks in healthcare, helps you create cross-boundary structures that allow for organic sharing of knowledge.
The idea of Quality Management Systems is getting a lot of attention in the UK – as an approach that will allow us to move away from small pockets of improvement at the margins of how we operate to a more embedded and holistic approach. The most developed versions of this approach – for example in Scotland – recognises that cultivating an effective learning system – underpinned by co-design, co-production and relationships – deserves central place in your strategy for improvement.
Whether we’re thinking individually, as a team, organisation or whole system, our capacity to learn is an inherent part of our capacity to improve. There’s method to both that’s worthy of attention. Ultimately there’s no improvement without learning, and no scale without sharing.