Building a learning culture: how quality improvement can help

In our second guest commentary, Catherine Oxtoby of The Veterinary Defence Society (VDS) tells us about the importance of asking ‘what’ is responsible for outcomes rather than ‘who’, and how quality improvement can help us achieve it. 

The Veterinary Defence Society

‘The more you react to failure, the less you will understand it.’ So says Sidney Dekker, one of the world’s most vocal advocates of ‘Just Culture’ in relation to human error in multiple industries.

The emotional response to failure is completely natural but it also often obscures important truths. It focuses on the person, blaming the individual and using words like sloppy, careless and inattentive. Just Culture is about understanding why someone made a mistake; seeing past the person, to the system which shaped their behaviour. It’s about learning from failure. The more we react, the less we learn.

But hold on. Sometimes people really are just careless – there must be some culpability. We’re professionals and we must take responsibility for our mistakes.

Just Culture is Learning Culture with accountability thrown in. It does not absolve responsibility for errors, but ensures that responsibility is fair and realistic, by examining the systems in which people work before examining the person. It asks what is responsible for outcomes, not who.

Culture is shaped by our behaviours and attitudes. It is reinforced by our systems and structures, by the reactions of our superiors and peers. Most high-performing companies and organisations espouse a just and learning culture. The psychological safety such a culture promotes enables people to speak up, voice concerns and analyse their actions for development and improvement. Those behaviours are also driven by professional values. Improvement efforts in most industries rely on the inherent desire of professionals to progress in the pursuit of excellence. Improving the quality of what we do is built into our professional DNA.

And that’s important, because the opposite of Just and Learning Culture is blame and shame. For centuries we have learnt through storytelling. A culture of blame and shame stifles that conversation.

It is easy to talk about our success stories, but don’t we all remember our mistakes in horrible, granular detail? The name of the animal, the reaction of the client, that awful sinking feeling when we realise something’s gone wrong. All the things we did, the things we didn’t do, the things we’d change; what a rich and valuable source of information to carry forward and use to teach ourselves and our colleagues, to make a change which just might stop the next person from making exactly the same mistake. Our motivation for telling that story is quality improvement (QI).

Learning cultures begin with the desire to improve, and conversations about mistakes. Efforts in medicine to combat entrenched blame and shame begin with stories, through the discussion of mistakes in a supportive, non-judgemental environment. Proper facilitation of mortality and morbidity rounds and a structured discussion which focuses on systems, not people, can facilitate organisational learning and safeguard clinicians against the emotional distress caused by medical errors.

So how does a culture of learning relate to quality improvement?

It is fundamental to it. QI is about more than clinical audit, data gathering, analysis and action planning; it is about understanding that what you have done can always be done better, that the cycle of continuous improvement never stops and that no matter how good the performance, there is always room to learn.

Ultimately, culture is the responsibility of leadership, from the regulatory responsibilities of the RCVS, to the policies within organisations, to the attitudes and behaviours displayed by senior colleagues.

Just and learning cultures must be built by vocalising and enacting a commitment to openness and understanding, by ensuring that the system of accountability creates learning not retribution.

Successful quality improvement therefore both relies on a learning culture, and helps to promote one.

QI initiatives are often triggered by poor results; increased wound infections (the nurse didn’t prep the site properly), a retained abdominal swab (the surgeon must have been careless), an anaesthetic death (the assistant was inexperienced).  It is a scientific discipline which relies on data, not emotions. It does not propagate the ‘bad apple’ theory that poor performance is the result of people who don’t take care.

When feelings are running high, QI assesses systems. It remains cool and focused and provides us as scientists with the evidence to change.

Done well, it is hard to argue with.

Want to know more about what QI can do for you? Come to Skills Day.