Friday, 17 August 2012

Consultation (3): About the Learning and Improvement Guidance

Here is what I have to say about the Learning and Improvement Guidance

General Comments about Learning and Improvement
This document seems to say some of the right kind of things about improvement, such as referring to "a culture of continuous improvement" and to a "systems approach".

Sadly I don't think the authors have recognised that these approaches require big changes in organisational and professional culture and attitudes. They are approaches that are not compatible with self-protecting, top-down bureaucracies. They involve redistributing power within organisations. They involve leaving the blame culture behind and embracing a "just culture" (see Sidney Dekker's book of that name; Just Culture, Ashgate, 2007).

I was impressed by the thoughts expressed in a letter written by the Right Hon. Michael Gove MP, the Secretary of Sate for Education on the subject of the Edlington tragedy. Concerning Serious Case Reviews he wrote:

I do not want these reports to be used to assign blame where terrible incidents have taken place. People working in these circumstances need to have confidence that they will be backed by their managers when they take difficult decisions with good intent and sound judgement, whatever the outcome. Publishing factual information about serious incidents helps ensure that all the lessons are learned, nationally and locally, to reduce the risk of repeating mistakes. This will not only help people working at the front line; it will also give the public greater confidence. We want an open, confident, self-regulating system where professionals are continually asking how they can improve rather than a system clouded by secrecy and fear.”

I am surprised and saddened that the guidance does not contain a similarly strong statement about the kind of culture and ethos that should be developed both nationally and locally. And, of course, the guidance needs to go beyond statements of intent and offer suggestions about how such a culture could be created. I see nothing in the guidance that addresses that question.

Another deficit of the document is that Serious Case Reviews (SCRs) and Child Death Reviews (CDRs) are only a part of learning and improvement in child protection. Other approaches to learning and improvement get scant mention, if any. I have identified seventeen possible approaches (‘Kaizen’ appears in the list twice) to learning and development and there may be more. Those I have identified are:

1.             Post Failure Analysis
a.    Fatal (or serious) incident enquiries / accident enquiries – SCRs
b.    Complaints
c.     Fault tree analysis. Start with a failure and work backwards to identify all possible causes
d.    Root cause analysis. Similar to fault tree analysis. Traces causes of disaster by repeatedly asking ‘why?”

2.             Pre-Failure Analysis
a.    Critical incident reporting. Reporting of non-fatal/serious critical incidents, or near misses, that would have otherwise been unremarked. Best achieved through anonymous/independent reporting system
b.    Feedback from service users
c.     Individual and Team de-briefings
d.    Safety audits
e.    Feedback from inspection / management
f.      Failure-Mode-Effect Analysis. What is the likelihood that failure will occur? What would the consequences of the failure be? How likely is the failure to be detected before it impacts the service user?
g.    Kaizen – continuous improvement

3.             Designing safer services
a.    Service modelling / design – involving employees and users
b.    Prototyping – trying out service modifications before full implementation
c.     House of quality – ever closer matching of design features of the service with user-requirements. Also known as Quality Function Deployment
d.    Delphi technique
e.    Poka Yoke / Failsafing
f.      Employee suggestion schemes
g.    Kaizen – continuous improvement

I believe that the guidance would be improved if some attention was also given to some, if not all, of these approaches to learning and improvement. Consideration needs to be given to the view that neither SCRs nor CDRs are the most effective ways of learning and that other methods might produce better learning more easily and at lower cost.

What needs to happen to ensure that there are enough people who are trained and qualified to conduct high quality Serious Case Reviews (SCRs)?

There needs to be a recognition that a wide range of skills – practice, professional, management, safety – are required. At the very least I would argue that someone conducting an SCR should have considerable experience of child protection coupled with specific training in human factors approaches to safety. Much of the training available in the area of human factors derives from aviation and medicine and it will be necessary to involve trainers from these fields, especially in the early days.

There needs to be funds, possibly made available through LSCBs, to provide training in human factors approaches to safety.

It is important that the widest pool of talent be drawn on in recruiting people to conduct SCRs. It is not acceptable for a small group of ‘insiders’ to receive the appropriate training and to divide the work up between them. LSCBs should recruit people to conduct SCRs through public advertisement and an open competition.

What arrangements should be put in place to ensure the quality of Serious Case Reviews?

The quality of a Serious Case Review should be located in the benefits it delivers – not in the mode or style of its presentation in a report. Ofsted is no longer involved in assessing the quality of SCRs, but when it was, it contrived to turn what might have been valuable research into the effectiveness (or non-effectiveness) of SCRs into a tick-box, process-focused exercise. Ofsted’s evaluations concentrated on whether reports addressed issues thematically, whether sub-headings were used, whether summaries were clear and whether the reports were well written. The Ofsted studies focused on how to write a good SCR report while forgetting what the purpose of an SCR is – learning and improvement to reduce the risk of a future tragedy.

Anyone trying to assess the quality of a SCR needs to explore the impact that the review has had on practice - on practitioners, professionals and managers. What lessons have been learned and what changes have been implemented as a result? Inevitably some empirical work is required.

Academic research might profitably focus on these issues, but I would suggest that routine business research may be a more valuable tool. In the wake of a Serious Case Review the LSCB should routinely survey local practitioners, professionals and managers to determine their assessment of learning from the SCR and whether recommendations are being put into practice and with what success. 

What arrangements should be put in place to share learning at a regional and national level?

There needs to be an easy to digest summary of the aggregate findings of SCRs. The current system needs to be improved – better circulation of findings should be a high priority.

Peter Sidebotham has argued:

“… with over 100 SCRs conducted each year, it is neither possible nor effective for individual practitioners to read and learn from each one. Rather, the system for national analyses needs to be continued and strengthened, and fresh ways of disseminating knowledge from these analyses need to be developed.”
(“What do serious case reviews achieve?” Arch Dis Child 2011. doi: 10.1136/archdischild-2011- 300401)

I would like to suggest that some brief reporting format be devised to facilitate a simple, but widely distributed, electronic publication summarising all the SCRs conducted in (say) the last six or twelve months. This would not be an academic publication but rather an industry/technical publication, aimed at being available as soon as possible after the SCR reports are published.