Learning

Learning practices that reinforce safe behaviors

The Patient Safety Culture “Bundle” is arranged in three main parts with subsections under each; as with other safety bundles, all components (vs. a piecemeal approach) are required to improve patient safety culture. Improving patient safety culture requires sequential, iterative and simultaneous interventions that ENABLE, ENACT and LEARN.

This section specifically examines the LEARNING components of the Bundle.

The table below addresses learning practices that reinforce safe behaviours. The LEARNING section provides tools and resources to help leadership ensure that there are systems in place to support education and capability building, incident reporting/management/analysis, safety/quality measurement/reporting and operational improvements.

Click the hyperlinked text within the categories to access freely available tools and resources to support your work within this leadership area.

Education/capability building

Component	Resource Author	Resource Type	Resource Title
Leaders/staff/physicians trained in safety and improvement science, teamwork, communication	CPSI	Education Program	Advancing Safety for Patients In Residency Education
Leaders/staff/physicians trained in safety and improvement science, teamwork, communication	CPSI	Education Program	TeamSTEPPS Canada™
Team-based training, drills	BMJ Quality and Safety	Article	Team-training in healthcare: a narrative synthesis of the literature
Team-based training, drills	World Health Organization (2018)	Resource	Hearts, Technical package for cardiovascular disease management in primary health care
Team-based training, drills	Midwives magazine (May 2007)	Article	Skills drills training: the way forward
Team-based training, drills	Official Journal of the Society for Academic Emergency Medicine (2008)	Article	Does Team Training Work? Principles for Health Care
Team-based training, drills	The Australian Journal of Nursing Practice, Scholarship & Research (2015)	Article	Effects of team-based learning on perceived teamwork and academic performance in a health assessment subject

Incident reporting/management/analysis

Component	Resource Author	Resource Type	Resource Title
Effective risk/incident reporting system for events related to patients/families and staff/physicians	CPSI	Tools & Resources	Incident Analysis
Structured processes for responding to and learning from safety events/critical incidents	CPSI	Tools & Resources	Communicating After Harm in Healthcare
Structured processes for responding to and learning from safety events/critical incidents	IHI (2011)	Article	Respectful Management of Serious Clinical Adverse Events
Structured processes for responding to and learning from safety events/critical incidents	NHS	Tools & Resources	Learning from patient safety incidents
Structured processes for responding to and learning from safety events/critical incidents	HIROC	Tools & Resources	Applying the Incident Management System (IMS) Framework to Critical Incidents & Multi – Patient Events
Structured processes for responding to and learning from safety events/critical incidents	CPSI	Tools & Resources	Canadian Disclosure Guidelines: Being open with patients and families

Safety/quality measurement/reporting

Component	Resource Author	Resource Type	Resource Title
Regular measurement of safety culture; patient/family complaints; and staff/physician engagement	Qual Saf Health Care (2003)	Article	Safety culture assessment: a tool for improving patient safety in healthcare organizations
Regular measurement of safety culture; patient/family complaints; and staff/physician engagement	University of Adelaide (2007)	Article	Lessons to be learnt: Evaluating aspects of patient safety culture and quality improvement within an intensive care unit
Regular measurement of safety culture; patient/family complaints; and staff/physician engagement	Patient Experience Journal (2014)	Article	Evaluation and measurement of patient experience
Regular measurement of safety culture; patient/family complaints; and staff/physician engagement	OECD (2018)	Report	MEASURING PATIENT SAFETY. Opening the Black Box
Retrospective/prospective safety and quality process and outcome measures	AHRQ (2019)	Article	Measurement of Patient Safety
Retrospective/prospective safety and quality process and outcome measures	Journal of Biomedical Informatics (2003)	Article	Retrospective data collection and analytical techniques for patient safety studies
Retrospective/prospective safety and quality process and outcome measures	Boston University School of Public Health	Webpage	Prospective and Retrospective Cohort Studies
Regular, transparent reporting of safety/quality plan results	National Academy of Medicine (2016)	Article	Fostering Transparency in Outcomes, Quality, Safety, and Costs A Vital Direction for Health and Health Care
Regular, transparent reporting of safety/quality plan results	Health Informational (2011)	Report	Transparency- the most powerful driver of health care improvement

Operational improvements

Component	Link	Resource Author	Resource Type	Resource Title
Structured methods, infrastructure to improve reliability, streamline operations	https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2822834/	BMC Health Serv Res (2010)	Article	Does the process map influence the outcome of quality improvement work? A comparison of a sequential flow diagram and a hierarchical task analysis diagram
Structured methods, infrastructure to improve reliability, streamline operations	https://chfg.org/how-to-guide-to-human-factors-top-tips/	Clinical Human Factors Group (2013)	Guide	Human Factors in Healthcare 'Taking Further Steps'. Case-studies-and-implementation-tips.
Structured methods, infrastructure to improve reliability, streamline operations	https://www.ahrq.gov/sites/default/files/publications/files/leancasestudies.pdf	Agency for Healthcare Research and Quality (2014)	Report	Improving Care Delivery Through Lean:Implementation Case Studies
Structured methods, infrastructure to improve reliability, streamline operations	http://www.eng.cam.ac.uk/uploads/news/files/engineering-better-care-report-web-3mb-20170922.pdf	The Academy of Medical Sciences (2017)	Report	Engineering better care a systems approach to health and care design and continuous improvement
Structured methods, infrastructure to improve reliability, streamline operations	https://innovations.ahrq.gov/qualitytools/plan-do-study-act-pdsa-cycle	AHRQ	Webpage	Plan-Do-Study-Act (PDSA) Cycle
Structured methods, infrastructure to improve reliability, streamline operations	https://www.medicalhumanfactors.net/what-is-human-factors/	MedStar Health National Centre for Human Factors in Healthcare	Video	What is Human Factors in Healthcare?
Structured methods, infrastructure to improve reliability, streamline operations	https://www.cmpa-acpm.ca/serve/docs/ela/goodpracticesguide/pages/human_factors/human_factors-e.html	CMPA	Education Program	Human factors influences on performance.