Organisational Learning & Tools
Overview
• Organisational Learning (OL) in Health Care (hospitals)
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Floor Koornneef
TU Delft / Safety Science Group
f.koornneef@tudelft.nl
ETPS09 – Warwick Medical School
key issue in SMS, but OL is hardly structured, organised & embedded
some basics & principles: theory-of-action, verbs, loops, actors, SOL
what there is to learn…: operational readiness, (re-)design issues
some work forms & levels & outputs of OL
• Tools
18 Nov ember 2009
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supporting OL functions: detect, notify, inquire, adjust
supporting Organisational Memory: compare, retrieve, adapt, update
tool box
tool selection
 Check out presentations @ 1st ETPS Workshop 2008
www2.warwick.ac.uk/fac/med/staff/sujan/ws_hfet2008
091118
Organisational Learning
Concepts & Principles in OL
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from operational Surprises (after Argyris & Schön ´96)
Principles of Organisational Learning (Argyris & Schön, Ashby,
Bateson, Dewey) & Organisational Memory (OM): theory of action
+ learning loops OSLL/ODLL/DeuteroLearning : organisations do not
OL Basics & Principles (1)
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learn… intelligence system that needs to be organised  SMS
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etps09-2
Language is a modelling tool – words come with assumptions
Humans are operational experts with much knowledge
To Err is Human…
Concept of Operational Readiness (Nertney)
Concept of Mindful Organisations & Resilience (Weick & Sutcliffe)
Concept of Viable Systems (S. Beer)
Action Research (methodology)
Life Cycle thinking: medical devices, health care system…
Murphy's Law and GIGO principle…
Evidence-based rule sets
091118
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theory-of-action = espoused theory & (tacit!) theory-in-use
verbs: detect – notify – inquire – adjust
loops: Individual Single Loop Learning – Organisational Single Loop
Learning – Organisational Double Loop Learning - Deuterolearning
actors: work process workers – learning agent & learning agency – higher
management – first line management
organisation
match
organisational unit
Gov erning Variables (values,
norms, means)
adjust
pe ople & means
make product
(work process)
surprise:
mismatch !
detect
adjust
individual single-loop l earning
notify
OL system
etps09-3
Learning =
CHANGE !
091118
etps09-4
organisational single-l oop learning
Agency
inquire
organisational doubl e-loop learning
Organisational Learning & ~ Memory (OM)
Tools supporting Organisational Learning
OL Basics & Principles (2)
supporting OL functions: detect, notify, inquire, adjust
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SOL: System of Organisational Learning
- also see ETPS 2008
Do the
people
match the
plant and
hardw are?
Plant and
hardware
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People
Do these
procedures
match the
people w ho
use them?
Operational
Readiness
Procedures and
Management
•
relevant
management
Do the
Controls
procedures
match the
plant and
hardw are?
learning agency
Lessons to learn:
work process
learning agent
1) OR of work process
2) supply chain processes: MeD, drugs, food
compensation of loss3) technology
requirements,
incl. DOs/DON'Ts
of-context / elicitation
Learning Scopes:
OL memory
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of tacit contextual
knowledge
- tactical
- strategic
- evaluative
- explorative
artefacts: reporting or notification forms (notify),
training (memory),
- time critical
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storage
protocols (adjust; memory), safe reporting…needs
culture
to be (policy)…
organised
WHAT there is TO LEARN…: operational readiness, (re-)design issues
some work forms & levels & outputs of OL – outputs also stored into OM:
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OL work forms & levels: learning agency supported by learning agent(s): departmental +
interdepartmental + inter-organisational; focus: review of single incidents, review of PKIs
or trend differences; review and sharing of lessons learned & best practices
outputs: process modification, protocol update; procurement process input, training
programme revision, organisational change, policy change, regulation, etc.
work process level: OR + identification of issues beyond span of control + device surprise
detect: logs, person experiencing operational surprise (e.g. weak signal), trend analysis
(SPIs, KPIs), forecasting (e.g. EVP)
notify: incident notification form, log review, alerting responsible management, process
modelling (BPM)
inquire: perform problem analysis by an appropriate Learning Agency with objective to learn
from it for the organisation using in-depth analytical tools and mobilising in-house expert
knowledge. Appropriate AI tools include ECFA+, 3CA, MORT. Retrieval of known precedents
with CBR. Note that explanation of changes in KPIs may be readily available at shop floor!
adjust: protocol update & communication & implementation; resource reallocation decision
making & translation into work process adaptations, change of training requirements, etc.
Feedback to relevant - primary as well as supporting - work floor processes is crucial.
supporting Organisational Memory: compare, retrieve, adapt, update
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e.g. Case-Based Reasoning, training programme, observation (e.g. guild system), regulation
tool box: all of the above, and more…
tool selection: appropriate to task, user & context - see also
nri.eu.com/Tools~final.pdf
091118
etps09-6
1
BPM: business process modelling
Voor...
Tijdens...
HC
IC
Na...
transport
heropname
transport
IC-elders
IC-box
(isolatie)
Chirurgie
elders
transport
IC
Tool Examples
?
transport
ecmo
infectie
doorverwijzen
bevaling op
OK
IC-voor
transport
OK
IC
IC
zorgverlening
klaar
op IC?
operatie
op IC-zaal
IC
IC-HC?
hartcatheterisatie
transport
transport
biopsiekamer
IC
IC
IC
IC/HC
na
HC
HC
?
transport
operatie
IC
overloop uit
uit regio/land
kinder-IC
(open hart)
transport
IC
ja
bevaling op
VK
HC-voor
HC
HC
zorgverlening
klaar
op HC?
transport
HC-elders
?
MC
?
overplaatsing
vanaf MC
091118
etps09-7
ja
Neonathology dept.
ECFA+ Incident Reconstruction
report
nri.eu.com/NRI4.pdf
Structured
approaches
& formats
Minor
Analytical tools for
low-to-moderate
scale investigations
Level of abstraction
Data
Collection
Analysis of
Immediate
Cause
Analysis of
Underlying
Cause
• Accommodate
diversity: in
people, tasks
and context
• Identify OM
resources
• Mobilise context
expertise
091118
ol
• Lessons to
learn in
different
dimensions…
To
NND tools
structured
root cause
methods
Tools
• Organisational
Learning must
be organised
People
Task
xt
Sequencing
Tools for
methods
forming &
testing
hypotheses
Rigorous
root cause
methods
Concluding Remarks
OL & OM
nte
Co
Moderate
Interviewing
Major
Forensic
Photography
Very Serious
Scale of Investigation
Context: skills and tools map
• Flexible tools
and/or flexible
toolkit
• Tools as
servants, not
masters
etps09-12
nri.eu.com/Tools~final.pdf
2
Cultural change…
and now, Dirk will explain to
us his blunder of last
week…!
More notifications, better understanding…
better care!
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