Today the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry was published (a copy of its Executive Summary can be found here).  It appears to be a comprehensive examination of the organisational failings that led to poor standards of care at Mid Staffs NHS Trust between 2005 and 2009.  Therefore there should be much for those of us interested in organisational learning to read, analyse and from which we can all learn.

The report, written by Robert Francis QC, contains many ‘lessons learned’ and makes 290 recommendations for change.  In outline, the following themes are covered:

• Culture
• Patient primacy
• Reduction in regulation
• Monitoring  and enforcement of enhanced quality standards
• Accountability
• Complaint and incident handling
• Caring and compassionate nursing
• Leadership

All good stuff.

A few observations:

We have repeatedly pointed out the incorrect use of the term, ‘lessons learned’ (here and here) and it is disappointing that yet another high profile inquiry makes this same mistake.

To be clear, the Inquiry has not learned any lessons.

However, it has identified many.

If its recommendations are implemented and are seen to have the desired effect then (and only then) can we or anyone else claim to have learned from this.

To repeat, a ‘lesson identified’ is, “…a recommendation or statement, based on analysed experience (positive or negative), from which others can learn in order to improve their performance on a specific task or objective.”[1]

A lesson learned is, “a change in personal or operational behaviour, as a result of learning from experience.”[2]

This distinction matters because in the bad old days, project managers would hastily write an end of project report, add in a ‘lessons learned’ annex and that would be that.

No changes would happen.  No learning would take place.

At best, some months or years later, a newly-appointed project manager might retrieve the report in order to see what his predecessor had done.  However, since the ‘lessons’ had lain dormant for the intervening period, no organisational changes had taken place (i.e. no restructuring, no policy refinements, no process re-engineering, no strategy review) and therefore the new project would begin with the organisation in exactly the same state as at the end of the previous project.

In short, no-one learned anything.

We have already written about the traditional reluctance of the NHS to admit mistakes and the proposed ‘duty of candour’ and welcome the opportunity to see if it works.  Organisations must reward and encourage honesty, whilst punishing and discouraging dishonesty.  However, all too often, they punish honest mistakes and those that seek to report wrongdoing, thereby encouraging only dishonesty.

Of course, accountability is important but let’s not kid ourselves.

If greater emphasis is placed upon “finding and punishing those responsible” than learning from them in order to prevent recurrence then all that will happen is less openness and more defensiveness (which, as we know, is inimical to learning).

Victims’ families and their fair-weather media friends may clamour for a day in court.  Whilst this may be appropriate for those whose actions have been deliberately harmful, it would be wrong to try and ‘punish’ people who were over-worked and missed things through insufficient time or supervision or support.  In these cases, punishment would reduce yet further the pool from which staff are recruited and would send a clear message to others: keep quiet, cover up, lie or you’ll be in trouble as well.

We have also already looked at the need for leadership within organisations that want to develop a learning culture.  My recent post on the ‘dummy incident’ at Mid Staffs suggests that some things have already changed as members of staff feel confident about reporting mistakes or oversights in a way that wasn’t apparent during the period covered by this report.

So, much to learn indeed.