Failing well, learning fast
Learning from failure and service improvement.
- Level
- Bitesize
- Learning time
- 1 hour 15 minutes
- Where
- Complaints, Ombudsmen and Learning from Failure
- Price
- £39
When you step up to a higher level, what you paid in the last 12 months for lower-level courses inside the bigger course comes off its price, in proportion to how much of each is inside it, whichever topic it's from. Courses at the same or a lower level don't give credit against each other. A Focus course or above always costs at least £15. Read the full terms
Certificate of Completion
Overview and Outcomes.
Overview
Failure is data; hiding it is the real failure. This module draws on Matthew Syed's black box thinking, Amy Edmondson's three kinds of failure, James Reason's person and system approaches and Swiss cheese model, and Sidney Dekker's just culture as applied at Mersey Care. It distinguishes a just culture from a no blame culture and uses Argyris and Schon's double-loop learning to show why leaders must fix the system, not just the case. A complaint closed is not a lesson learned. This module sets out four habits of useful learning reviews, the four aims of NHS England's Patient Safety Incident Response Framework and why its principles travel beyond health, and what a board should actually see. It explores triangulating evidence from people, staff and independent bodies, why one good number is not assurance, and how to use the ombudsman's published insight, ending with a simple test of learning.
What you'll develop
In this Bitesize, you will develop the ability to:
- Distinguish Edmondson's basic, complex and intelligent failures and choose a proportionate leadership response to each.
- Apply Reason's system approach and the restorative questions used at Mersey Care to shift the first question from who to what happened.
- Explain why a just culture is not a no blame culture and how double-loop learning helps leaders fix the system, not just the case.
- Apply the four habits of useful learning reviews and the four aims of the Patient Safety Incident Response Framework to a complaint or incident in your own setting.
- Plan board reporting on complaints that covers volume and trend, themes and causes, timeliness, ombudsman findings, changes made, and equality and access.
The Modules.
1 hour 15 minutes of learning.
- 06Learning from Failure: The TheoryFailure is data; hiding it is the real failure. This module draws on Matthew Syed's black box thinking, Amy Edmondson's three kinds of failure, James Reason's person and system approaches and Swiss cheese model, and Sidney Dekker's just culture as applied at Mersey Care. It distinguishes a just culture from a no blame culture and uses Argyris and Schon's double-loop learning to show why leaders must fix the system, not just the case.37 min
- 07From Complaint to Change: Building a Learning SystemA complaint closed is not a lesson learned. This module sets out four habits of useful learning reviews, the four aims of NHS England's Patient Safety Incident Response Framework and why its principles travel beyond health, and what a board should actually see. It explores triangulating evidence from people, staff and independent bodies, why one good number is not assurance, and how to use the ombudsman's published insight, ending with a simple test of learning.35 min
Keep going.
Part of the Complaints, Ombudsmen and Learning from Failure topic, also sold whole as When things go wrong.
Go deeper, and pay only the difference
- You are hereBitesize, 1 hour 15 minutes, £39
- Next stepFocus, Learning out loud, 2 hours 30 minutes, £69. Already own the Bitesize? You pay £30.
- The whole topicExplore, When things go wrong, 5 hours 30 minutes, £129. Already own the Bitesize? You pay £90.
When you step up to a higher level, what you paid in the last 12 months for lower-level courses inside the bigger course comes off its price, in proportion to how much of each is inside it, whichever topic it's from. Courses at the same or a lower level don't give credit against each other. A Focus course or above always costs at least £15. Prices per person. Read the full terms
Also part of: Leading homes and communities, When things go wrong, Holding to account
