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Module 3 – Systems Thinking in Learning from Events

Module 3 – Systems Thinking in Learning from Events

by Professor Paul Bowie

Participation in team-based ‘Learning From Events’ (LFE) is a professional and organisational requirement for medical practitioners in the United Kingdom (UK).


To illustrate how systems thinking principles can be embedded in traditional ‘Mortality and Morbidity’ (M&M) reviews, case conferences, suicide reviews or similar review opportunities.


The processes adopted in these LFE meetings may differ. However, the common thread is the availability of protected time for teams to come together, reflect on, discuss and learn about specific event occurrences.

Typically, these involve a complex clinical or social case, a patient safety incident, a complaint or other quality of care issue.

The goal is to improve working practices to enhance the quality and safety of care and workforce wellbeing.

Effective participation may contribute to improving organisational performance, minimising risks, enhancing professionalism and providing evidence of good care practice and multi-disciplinary team working.

Problems with team based learning

Discussing, analysing and learning from events is a professional expectation for clinicians and others as part of efforts to improve the quality and safety of healthcare worldwide. The topic is often included in undergraduate and postgraduate curricula and evidence of participation and learning from this activity is frequently required to support continuing professional development, medical appraisal and regulatory obligations.

The evidence suggests, however, that related learning and practice can be sub-optimal for multiple reasons including, for example:

  • limited education and training in LFE concepts and methods
  • low engagement in the activity by care teams for fear of ridicule, embarrassment or punishment
  • lack of protected work time to participate in related team-based learning
  • limited feedback on the results of participating in such learning processes
  • failing to implement ‘systems thinking’ to aid analysis, learning and improvement.

What is a healthcare event?

It is important to have a shared understanding of terminology around learning from healthcare events. There are many safety and risk related terms which are often applied arbitrarily and interchangeably in healthcare. This may lead to confusion and misunderstanding.

Untangling these contextual knots and meanings is not the purpose of this guidance. From our diverse professional experiences, event could mean any variant of the following: patient safety incident, critical incident, adverse event, near miss, never event, medical error, serious untoward incident, complaint, good outcome, excellence and so on.

Hence the term “event” will purposely remain “un-defined” in this webinar so that it is left open to develop a localised shared understanding and interpretation (both in terms of its potentially positive and negative connotations) by those engaging with this guidance.

Team learning – aim of the Mortality and Morbidity (M&M) review (or similar) meeting

M&M reviews are important opportunities for peer review, collective learning and quality and safety improvement.

They are also an opportunity to focus on learning from normal everyday clinical work and excellence in care.

successful M&M review meeting relies on the following key factors:

  • Clinical leadership and ownership.
  • A culture of openness, honesty, transparency and professional accountability, based on sound educational principles.
  • Focus should be on learning and improvement of systems and processes of care and not on individual performance.
  • A systems approach to the discussion and analysis of case presentations to ensure in-depth understanding, effective learning, and agreement on appropriate system level improvement actions and recommendations.
  • Performance management and competency issues should be raised by the review meeting chairperson with the relevant senior leader, eg, the clinical director, outside of the forum.
  • Effective links with clinical governance, quality improvement, adverse events management, clinical audit, departmental teaching and training programmes. Outcome data from the M&M forum should be recorded, integrated with and used to inform other organisational safety and improvement initiatives and obligations to maximise collective learning.

Review panel

Consider introducing a M&M review panel to support the meetings and learning process.

The composition of the review panel will depend on the case or cases and specialties involved, for example the panel may include a consultant, charge nurse, trainee and administrator.

The review panel has responsibility for:

  • identifying cases for review
  • identifying if the review requires reporting on to other organisational systems, eg, where adverse events are concerned
  • identifying staff to support and present cases
  • preparing reviews, including use of an agreed system or proforma for case selection
  • undertaking initial analysis of cases selected for discussion and learning in the team meeting review.

Emotional Impact

It is important to consider the emotional impact on some care practitioners involved in safety incidents. Sargeant J et al states:
“For many care practitioners, being involved in a significant event is similar to receiving a form of ‘negative feedback’ on professional performance.”

Dekker S defines these clinicians as:
“Those who suffer emotionally when the care they provide leads to harm”. They are often referred to as “second victims” of patient safety incidents.

The clinician may experience a range of emotional impacts such as guilt, anxiety, depression, increased stress levels, fear of punitive action, professional embarrassment and inability to perform as expected.

This potentially impedes preparedness to highlight related events with colleagues or through incident reporting systems, and may lead to being highly selective in terms of which events are raised and reported. Additionally, there may be a lack of readiness or ability to fully engage in the learning process when events are discussed.

It is important, therefore, to raise awareness of these potential emotional barriers, and to acknowledge and consider them as a means of supporting colleagues, building psychological safety and contributing to an effective learning culture.

Case selection

Examples of criteria for case selection may include:

  • inpatient deaths, including in emergency departments and theatres
  • delayed discharge due to complications in treatment
  • unplanned ITU admissions
  • unplanned readmissions to hospital
  • post-operative complications
  • learning from:
    • routine care
    • excellent care episodes.

Where possible, events should be prioritised for review based on their learning potential rather than the severity of the outcome. For example, near miss events, also known as free lessons, are often overlooked but may have significant learning potential as they provide an important signal regarding the state of the care system before anyone has suffered harm.

Organisation of the team learning meeting

Review of cases should occur in a timely manner to ensure learning and improvements are identified promptly. Where feasible this should be no longer than six weeks from the event.

Meetings should occur on a regular basis, for example weekly, fortnightly or monthly to provide the opportunity for cases to be discussed. They should be held in a dedicated meeting room which is accessible and large enough for all participants. It should also be well-equipped with audio-visual equipment and other supporting educational aids.

In order to effect change and ensure good system governance, review meetings should be part of the wider organisation’s clinical governance and shared learning arrangements. These should be planned in advance and widely promoted with regular reminders posted using appropriate aids.

Who should attend?

The M&M, or similar meeting, is a highly relevant educational forum. Participation is an integral part of routine education and learning for doctors, nurses and other healthcare professionals.

Attendance should be monitored and used by staff as evidence in appraisals, revalidation and continued professional development.

Clinical leads and management teams are responsible for ensuring attendance at meetings as well as providing protected time to prepare for meetings.

The meeting attendees should be inclusive, multidisciplinary and reflect how frontline patient care is delivered and supported. IT systems or other methods to facilitate shared learning should be made available where it is not feasible to have multi-specialty attendance at the meetings.

Chairing the meeting

The chair of the meeting, ideally a senior clinical lead, is integral to creating a positive learning culture that encourages collaboration and collegiality, and contributes to building a strong safety culture locally.

The role of the chair includes:

  • overseeing the preparation and organisation of mortality and morbidity meetings
  • facilitating meetings, keeping to time, encouraging participants to become involved and to summarise learning and actions
  • managing conflict diplomatically and sensitively when it arises
  • facilitating consensus on any decision-making, and ensuring action points for improvement are captured and implemented.

The chair should be impartial of the case review and be given time to prepare for the meeting. Consideration should also be given to appointing a deputy or rotating chair person.

The chair is required to have the appropriate knowledge, skills and attributes to effectively manage discussions around mortality and morbidity cases, while also ensuring that learning is captured and improvement actions agreed.

The chair should ideally have:

  • an understanding of organisational adverse events management, clinical governance structures and associated policies and procedures, eg, data protection
  • an understanding of the organisational M&M review process and how it aligns with other organisational systems
  • experience of chairing and facilitating multidisciplinary groups to identify learning and improvement
  • working knowledge and application of key principles and theory, for example systems approach, human factors and quality improvement methods
  • an understanding of the evidence base relating to patient safety issues in healthcare.

Managing the meeting

The chair will be required to manage any conflict that arises during discussions. A requisite skill of the chair is the ability to manage these situations decisively, diplomatically and sensitively.

Where there is a fear of blame, judgement and/or perceived negative consequences, participants may become reluctant to engage with the review process and become likely to withhold information about events.

This may affect the effectiveness of the M&M review process. The following tips may be useful.

  • Establish ground rules at the beginning of the meeting. The chair can reiterate that the session should be open, honest but blame free. Participants should be reminded to refrain from attributing direct personal blame or criticism towards colleagues. Feedback should be fair, constructive, sensitively delivered and practically useful.
  • Recognition that colleagues involved may have been emotionally impacted by the event and an understanding that this may not be immediately obvious. If you think someone is affected during a M&M meeting, the chair should make a plan to follow this up.
  • Bullying and overbearing behaviours should not be tolerated by the chair or M&M meeting participants.
  • Monitor team dynamics and interactions to ensure widespread participation.
  • Staff resilience: recognise emotion in the discussion, acknowledge it and allow appropriate expression within the group. Signpost to sources and support for colleagues dealing with death.
  • Remain objective, avoid giving unwarranted opinions or colluding with individuals during discussions.
  • Summarise and share the contributions. Facilitate respectful discussions from other participants to challenge arguments, assumptions and behaviours that are causing conflict.

The following questions may be helpful for the chairperson to reflect on during these situations:

  1. What effect is the conflict or behaviour having on you?
  2. How are you responding to this conflict or behaviour?
  3. Is there an explanation for the conflict or behaviour?
  4. How is the conflict or behaviour affecting other participants?
  5. What strategy can be used to encourage consensus and manage conflict?

Engaging participants

A number of tactics can be used to ensure full participant engagement, including:

  • the timing of the meeting to maximise attendance
  • establishing ground rules to encourage inclusive participation
  • providing refreshments and a comfortable learning environment
  • ensuring time is protected
  • asking open and challenging questions to encourage interaction
  • using appropriate aids or systems to demonstrate key points and prompt discussions
  • keeping case presentations concise with adequate time for questions and feedback.

Systems thinking in team learning – a seven step learning process

The following generic ‘7-step framework’ may assist care teams to guide discussion and analysis of a selected event and extract meaningful learning and actions for improvement:

Systems thinking in team learning – a seven step learning process

1. Select a case(s) for review and learning
Select event cases for review based on their priority and learning potential for the care team. Not all events can be reviewed in the time available.

The term ‘event’ could mean the following:

  • patient safety incident
  • adverse event
  • near miss
  • never event
  • good outcome etc.

Care teams should aim to have a shared understanding of related terminology to aid recognition of different types of events when they occur.

2. Summarise in sufficient detail what happened
Provide a written summary of what happened for all participants to refer to, eg, in a slide presentation format, short report or on a flip chart. Using NHS England and NHS Improvement’s SBAR communication tool (situation, background, assessment, recommendation) may be helpful.

3. Explore the impacts on people and organisations
Briefly reflect on, discuss and highlight the consequences, or potential consequences, eg, physical, psychological, reputational, for patients, service users, families, staff groups and organisations of the event.

4. Apply a systems analysis
Identify the system-wide factors contributing to the event using the SEIPS worksheet. Seek out the perspectives of all team members with knowledge. Explore “work-as-done”, why it normally goes well and why decisions and actions made sense at the time (local rationality). In addition, establish if similar events have happened, or could have happened in the recent past.

5. Prioritise interacting contributory factors
You are likely to identify multiple contributory factors related to the event in question and similar past events that you now may know about. Look at them collectively as this gives you a “window on your system”. Think about how the system, as a whole, can be strengthened to minimise future risks of event occurrence.

6. Agree and implement change for improvement
Agree as a team:

  • on practical system changes
  • how you think these changes will lead to improvement
  • who will be responsible for implementing them.

Before implementation, think about how change might create further or different system problems and paths to failure before proceeding.

7. Sustain, monitor and review
To sustain changes in practices they must become accepted and ‘normalised’ as part of everyday work. When you have good evidence of this then you can say that learning and improvement have occurred. To get to this stage you need to monitor and review the impacts of any changes and quickly review them at future LFE meetings and/during normal work, where time permits.

A basic report format

A reporting format would include the following content:

  1. What happened?
  2. What impacts (or potential impacts) on people and organisations occurred?
  3. Why did it happen?
  4. Why does it normally go well?
  5. What have you learned?
  6. What changes are agreed?
  7. How will these be implemented and by whom?
  8. How will you sustain improvements?
  9. Consider how will you monitor improvements?

A template for the report format is provided in Appendix A.

In summary

This series of webinars focused on understanding the need to apply systems thinking in learning from healthcare events.

It is important to know that when things go wrong:

  • Many different factors combine in complex ways, sometimes unexpectedly, that contribute to safety incidents and other problems; there is not a single ‘root cause’.
  • Blaming people does not lead to learning or improvement. The chances are that the incident will happen again to someone else if we continue to do this.
  • We all share responsibility for problems and incidents. This includes supervisors, managers, executive leaders and government policymakers, and not just staff at the ‘frontline’ of care delivery who are often the focus of attention in these situations.
  • To improve things we need to put the spotlight on designing our care processes and systems to better support people doing the work, rather than on individuals.

Useful resources

To learn more we have provided some links to short videos and further guidance which may be of interest to you and your colleagues:

  1. How A System’s Approach Can Change Safety Culture
  2. Systems thinking and incident investigation

The three modules in this webinar series have provided some high level guidance on systems thinking for learning from healthcare events. PMP hopes that you have found them useful and informative. Thank you.

Appendix A: Report template for Mortality and Morbidity (M&M) review (or similar) meeting (PDF).

Information correct at time of publication July 2023

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