Learning out loud
Learning from failure and making good apologies.
A short, focused look at what happens after things go wrong: black box thinking, just culture, building a learning system, candour and good apology.
- Level
- Focus
- Learning time
- 2 hours 30 minutes
- Where
- Complaints, Ombudsmen and Learning from Failure
- Price
- £69
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, or Certificate of Completion and Assessment with a short assessment
Overview and Outcomes.
Who It's For
Leaders responsible for learning, assurance and candour after service failures
Overview
A complaint closed is not a lesson learned. This programme turns to what organisations do after something goes wrong, drawing on Matthew Syed's black box thinking, Amy Edmondson's three kinds of failure, James Reason's system approach and Swiss cheese model, and Sidney Dekker's just culture as practised at Mersey Care. It moves into building a learning system, using the principles of the Patient Safety Incident Response Framework, triangulation and honest board reporting, then explores candour through Hillsborough and the duties of candour in Wales and England. A capstone reads the Trivallis, WASPI and Post Office cases to test whether organisations are genuinely willing to hear.
Aims
The aim is to develop leaders who respond to failure with curiosity rather than blame: who ask what happened before who did it, fix the system as well as the case, give boards evidence that offers real assurance, and practise candour early and plainly, so that apology and accountability become part of how the organisation leads.
In summary, you will be able to:
- Distinguish basic, complex and intelligent failures, and explain why a just culture differs from a no blame culture and how double-loop learning fixes the system.
- Apply learning review habits, restorative questions and triangulation to a real complaint or incident, and plan board reporting that tests assurance rather than offering reassurance.
- Lead a candid organisational response to failure, using the duties of candour and the Trivallis, WASPI and Post Office cases to judge whether remedy and redress are real.
What you'll develop
Through this Focus course, you will build 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.
- 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.
- Explain how delayed truth becomes a second injury, using the Hillsborough case and the Bishop James Jones report.
- Apply the five lenses to the Trivallis case to identify how repeat reports, records, vulnerability, complaint handling and governance contributed to harm.
Built from 2 parts.
2 hours 30 minutes of learning.
- 01Failing well, learning fastLearning from failure and service improvementBitesize2 modules
- 02Saying sorry and meaning itDuty of candour, apology and accountabilityBitesize2 modules
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 hereFocus, 2 hours 30 minutes, £69
- The whole topicExplore, When things go wrong, 5 hours 30 minutes, £129. Already own the Focus? You pay £60.
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