Fail safe, learn fast – our motto for great route to improvement

Fail safe, learn fast – our motto for great route to improvement

Why do we say this?

quality improvment clinic article - fail safe learn fastWell you can learn in an unsafe environment – it may be scary and not of your choosing, but its OK. You can learn why its unsafe and maybe think about how to make things safer next time around.

Failing in an unsafe environment is however a problem. It’s the territory of the deep sea fisherman, thrill seekers and danger mouse. In healthcare we really need to avoid it if at all possible.

And most of the time, high risk surgery aside, it’s possible – IF you approach it in the right way.

Why do we need to embrace failure?

Well, we learn the most through failure. Yes, I know it can hurt – but its more often than not its just a matter of pride. Once we’ve mastered our chosen profession – you know, we don’t really put ourselves out there to fail, but when we were learning – well it happened probably quite a lot, in the class room, no one got hurt. And with our supervisor – well they were on hand to catch and make good if it looked like we were heading for the point of no return.

When do we need to fail safe?

So even though we are now good at our day job the fact remains that we will often learn more from from failure than we will from success. When we have problems we’ve tried to fix time and time again, we should know that we need to take a different approach to get a different outcome. Now this might be risky: it may upset the routine, it might upset people, it might unsettle us. But the fact remains that our previous efforts are not making the difference we need – and so more drastic action is needed. So we need a way of doing this ‘failure and learn thing’ safely.

How do we do this?

quality improvement clinic article - fail safe learn fastWe generate a bucket full of ideas that we can test.

We look in the bucket for ideas where logic suggests it might deliver the outcome we seek.

We pick ONE idea and we PLAN our test.

We keep our test VERY small, AND our PLAN very detailed: We anticipate what might go wrong and we include steps to minimise this.

We predict in advance what success would look like, and we agree what measure we will use.

We ask ourselves if it is safe to do in our work setting, and if its not we think about how we can set up a simulation, in an office, in a corridor, in a classroom.

We work with a colleague, rather than a patient and we make sure there is someone to put things right if something goes wrong.

AND we make records whilst we DO the test. We record what happens, expected and unexpected.

And then we STUDY our record with colleagues and wring out all the learning we can.

And with our quickly acquired knowledge and no harm, we decide on our next ACTION

  • ABANDON the idea – and try another one
  • Try the idea AGAIN – to see if it can work a second time, maybe with a patient if you’ve learnt that the risk of failure was imagined.
  • ADAPT the idea – to see if you can make it work better
  • ADOPT the idea – build into business as usual
  • EXTEND the idea – share with others so they can gain too

 

We love to meet like minded people. So if you live by this motto too – why not connect with us?