The lessons learned framework is about how we:
- Identify learning from a range of sources including incidents and feedback
- How we share that learning so harm incidents are not repeated and positive practise is spread..
- How we track our planned actions to be implemented so we are sure improvements are continuously being made to our services.
We have many sources of learning from: serious incidents (SIs); 72 hour reviews; thematic learning from falls or safeguarding and audits.
As a learning opportunity occurs, it is vital that we capture what happened, along with the key learning points and actions that we need to take.
If you have want to share an example of learning from an incident; or an example of best practice, please ask your matron, Head of Quality or Assistant Clinical Director (ACD) to work with you to complete and submit a lessons learned briefing to email@example.com
Learning can also be shared this way by chairs of trust wide work programmes or governance services for examples: thematic learning from a care collaborative; complaints team; CQC action plan
There are many sources of learning including: trust forums; local QSSG and PSP meetings; incidents, complaints and audits for example. The Lessons learned framework includes resources/templates to use to work out valuable learning from an incident or event. Templates are in the resources section for you to reference and download; they are:
- An ‘expected practise review template and example;
- An After Action review template and example.
- An SBAR ‘situation, background, assessment and recommendations template.
There is also a learning tools guide to support with using the above templates.
Once you have all the information you need, complete the lessons learned e-briefing template to summarise: the incident; what you learned and any actions needed to make improvements and to prevent incidents of harm from recurring.
- Take the learning to meetings for discussion eg Trust forums; team meeting; local patient safety panels (PSP) or QSSG
- Fill in a lessons learned briefing template to summarise: the incident; what you learned and any actions needed to make improvements and to prevent incidents of harm from recurring. .
- Make sure there is no patient or team identifiable information on the lessons learned briefing .
- Email the briefing to lessonslearned
@nwbh.nhs.ukso your briefing can be reviewed and shared more widely across the Trust
- You are also encouraged to email it to Trust groups where relevant, such as: borough assistant clinical directors (ACDs) for local patient safety panels; suicide prevention group, CAMHS, later life and memory services (LLAMS) or learning disability groups.
Trust forums/work programmes will also share learning via Lessons learned framework briefings.
It depends on the learning:
- Sometimes a reflection and discussion about the shared learning will be enough to raise awareness and knowledge
- Sometimes actions will be needed.
Actions will be agreed locally through your Trust forum, patient safety panel (PSP) or equivalent meetings. There will be an action plan tracker managed by this meeting
There are some worked examples in the resources and a guide. You can also ask your assistant clinical director (ACD), matron or head of quality for advice.
For anything else, email: firstname.lastname@example.org
All the briefings we receive will be added to the sharing learning section on this platform. Where appropriate, lessons learned will also be highlighted regularly through our internal communications channels.
Our culture values learning and quality improvements.
There are workshops, courses and coaches who can support you with this.
Ask your line manager or matron about courses in quality improvement; just and learning culture, or root cause analysis.