Learning from Complications: a pilot study on the quality of learning strategies in a hospital.

One in every ten hospitalized patients suffers from an unintended or undesirable outcome of treatment, often referred to as complications. Organizations in healthcare need to learn from these events to prevent recurrences and improve patient safety. However, the methods used to learn from these complications do not appear to have the desired effect, evident from the absence of a decrease in complications. To improve learning processes, it is necessary to know which steps hamper the learning process, thereby hindering optimal learning. For this pilot study the theoretical framework ‘Learning from Incidents Process’ (LFIP) (Drupsteen et al., 2013) is introduced in the healthcare domain. Originally the framework was developed for the (non-healthcare) industry to identify bottlenecks that inhibit learning processes and to get an indication of the use of learning potential throughout the process. The model is renamed as ‘Learning from Complications Process’ (LFCP) to fit the healthcare...Show moreOne in every ten hospitalized patients suffers from an unintended or undesirable outcome of treatment, often referred to as complications. Organizations in healthcare need to learn from these events to prevent recurrences and improve patient safety. However, the methods used to learn from these complications do not appear to have the desired effect, evident from the absence of a decrease in complications. To improve learning processes, it is necessary to know which steps hamper the learning process, thereby hindering optimal learning. For this pilot study the theoretical framework ‘Learning from Incidents Process’ (LFIP) (Drupsteen et al., 2013) is introduced in the healthcare domain. Originally the framework was developed for the (non-healthcare) industry to identify bottlenecks that inhibit learning processes and to get an indication of the use of learning potential throughout the process. The model is renamed as ‘Learning from Complications Process’ (LFCP) to fit the healthcare context. With this study the LFCP-model is introduced and applied in a hospital setting, aiming to answer the following research questions (1) Are the steps in the LFCP formally arranged and executed at Hospital X and how well do they work according to the medical staff? (2) At what steps in the LFCP does the medical staff experience bottlenecks, that hamper the learning process and its outcomes? (3) To what extent does psychological safety influence this learning process? The internal consistency of the LFCP-questionnaire was tested on an M-Turk sample of healthcare employees, to justify use within a healthcare setting. To answer the hypotheses, a mixed-methods design is applied. The data for this study were gathered by use of online questionnaires (N = 6), semi-structured interviews (N = 3) and online observations (N = 13). It is expected to find results indicating sub-optimal use of learning potential, and a diversity of bottlenecks throughout the LFCP. Results showed a significant decline in formally arranged, executed and quality of executed steps throughout the LFCP. Consequently, the use of learning potential followed this line of decline, with the biggest loss of learning potential at the evaluation stage. Bottlenecks were identified after stage 1 ‘Understanding causation’. However, no correlation was found between psychological safety and the LFCP. These results indicate that there is ample room to improve the quality of the learning processes, implying that patient safety can be further enhanced by improving the quality of total learning processes. For the future the LFCP-model can be used as a tool to quantify results of interventions to improve the quality of learning processes. Because of the small sample size this pilot study is a proof of concept. Therefore, no hard inferences can be drawn, and results should be treated with the utmost caution.Show less

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Learning from Complications: a pilot study on the quality of learning strategies in a hospital.