Latest / Safe As Podcast / E70: Learning Teams: Why Blaming Staff Doesn't Make Workplaces Safer

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E70: Learning Teams: Why Blaming Staff Doesn't Make Workplaces Safer · Safe As Podcast

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  How do learning teams compare to root cause analysis in terms of
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  quality of findings and fixes? Let's find out.
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  Good everyone. Welcome to Safe as I'm Doctor
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  Ben Hutchinson. Today's study is from Robbins ET
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  al, 2021, titled The Evaluation of Learning Teams versus Root
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  Cause Analysis for Instant Investigation in a Large United
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  Kingdom National Health Service Hospital published in Journal of
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  Patient Safety. The study compared 22
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  conventional root cause analysis investigations with 22 learning
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  teams. Learning teams are defined as a
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  facilitated conversation between those that do the work and those
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  that design the work to share operational intelligence between
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  the two groups and improve system design.
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  I couldn't really see much details on what their root cause
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  analysis methods actually entailed, So what do they find?
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  Learning team investigations produced a median 7 1/2 actions
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  versus 3 1/2 actions for root cause analysis. 57% of learning
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  team actions were systems focused versus only 30% for root
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  cause analysis. Learning teams involve all
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  staff, even those not involved in the incident.
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  Learning teams more often focus on systems problems versus the
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  root cause analysis focus on staff performance issues.
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  Learning teams will believe to better empower frontline staff
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  to identify solutions. Next, we'll unpack some of the
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  key themes. So 1.
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  The personnel involved interviewee said learning teams
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  were designed from the outset to be inclusive, involving all
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  people involved within the process, not just those directly
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  involved in the incident. I also believe people lower in
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  the organisational hierarchy were less often invited to the
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  root cause analysis, whereas their expertise is more valued
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  in learning teams. 2 Content of the discussions Learning teams
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  focus more on normal work and less on incident details.
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  Recalls analysis were seen as more focused around a single
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  incident, with significant time spent establishing what went
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  wrong and a tendency to focus on the last barrier to fail.
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  Learning teams were described as more holistic, considering other
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  barriers or factors, and more focused on why events occurred
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  in the setting or this specific context.
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  Learning themes also enabled more flexible discussion, as in
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  complex themes on multiple narratives, whereas root cause
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  analysis were seen to distil many factors into a few root
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  causes, risking oversimplification.
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  This flexibility was seen to improve transferability and
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  support more systems focused actions.
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  Three culture learning teams were described as more
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  supportive and open to learning, with less fear of interpersonal
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  risk. They also favoured less
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  technical themes, enabling people with less technical
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  prowess to contribute. In contrast, Root Cause Analysis
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  were associated with more individual level blame or
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  mistake language. People use words like fear and
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  guilt and describe being less likely with Speaking truth to
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  Power 4 challenges interviewees. We're positive about learning
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  teams but stress they don't suit every occasion.
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  They're just one tool among many others.
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  Root Cause Analysis are well established and familiar.
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  Learning teams face scepticism of the unknown.
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  Staff lower in the hierarchy found it harder to get time to
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  attend learning teams and learning teams can require
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  greater time investment. However, those who attended the
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  first session were often highly engaged and keen to attend the
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  second workshop. Learning teams were also seen to
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  challenge the status quo more often than root cause analysis
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  and seek more innovative solutions.
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  Recourse analysis were seen to reflect more the views of senior
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  management versus the people who are involved in the incident.
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  So what can we make of the findings?
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  In this limited sample, learning teams delivered more systems
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  focused actions and were discussed as high quality and
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  addressed broader issues. Whereas root cause analysis
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  focus more on singular incidents, but they may not be
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  the best tool for all situations.
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  And maybe root cause analysis are more suitable for a specific
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  incident unlikely to recur outside of that events specific
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  context. Also, the authors suggest that a
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  root cause analysis may be more efficient to capture what has
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  changed since the last learning team.
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  They conclude there may not be one right investigative method.
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  Incidents lie on a spectrum and judgement needs to be applied to
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  establish which investigative methods to choose for
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  limitations. Learning teams weren't randomly
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  allocated to events which may bias findings and it used a
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  retrospective design with semi structured interviews.
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  Finally there was no future follow up assessing which method
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  delivered better long term change.
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  That's it on safe as. Thanks everyone.
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  Don't forget to like, subscribe and comment on my channel and
• 4:28
  links in show notes if you'd like to support the channel.