Healthcare Lessons Trend Analysis

At Istidrak we’re focused on solving problems, not selling solutions.

With that in mind, we did some trend analysis on the healthcare sector aggregating the smaller Lessons into some distinct trends. If you face these sorts of problems, get in touch.

1. Loss of Critical Knowledge During Staff Turnover.

·       What’s the problem ? All of a sudden there’s an announcement at the staff meeting that x is leaving at the end of the month. Someone’s leaving. This high turnover of nurses, technicians and doctors often results in the loss of clinical and procedural knowledge.

·       What was the impact ? Mistakes are repeated, onboarding takes longer, continuity of care is disrupted and there is patient frustration / litigation.

·       What can a healthcare provider do ? It needs to retain institutional memory. This can be done by building knowledge repositories (to store the Lessons), create digital pathways that either pull or push the information to the right staff at the right time.

2. Siloed Departmental Knowledge.

·       What’s the problem ?  Lots of us are so focused on our areas, we don’t think about the wider enterprise. Sometimes knowledge is often trapped in specific departments (e.g., radiology, ICU, administration) and not shared with others who could benefit from it.

·       What was the impact ? This results in inefficiencies in the patient flow, a duplication of diagnostic work and delayed decision-making by management making the hospital inefficient. Wasted resource.

·       What can a healthcare provider do ? For not much extra effort, the hospital can facilitate cross-functional knowledge sharing through structured AARs, SOPs, and Communities of Practice (CoPs). It then uses this captured data and ‘pushes’ it to the right department, often enabled by AI.

3. Lack of Structured Lessons Learned from Adverse Events.

·       What’s the problem ?  Departments understand that they need to carry out incident reviews, but the insights are rarely translated into policy or practice improvements. The Department ticks the box, but nobody learns the lesson.

·       What was the impact ? It’s hugely frustrating for the staff. There are lots more near-misses and the hospital missed the opportunity to improve care and, crucially, cut costs.

·       What can a healthcare provider do ? The provider should properly enable a formalised After Action Review process that, automatically, uploads the lessons identified and then produces policy, capability and practice improvements. These are then monitored by the Board. The Lesson is not learned until it stops re-occurring.

4. Inconsistent Use of Clinical Guidelines & Protocols.

·       What’s the problem ? Protocols and SOPs are stored across the providers’ systems, in notebooks, on someone’s laptop or an old form printed off and stuck on the wall. Sound familiar ?

·       What was the impact ? There were variation in care standards, increased clinical risks, and regulatory non-compliance across 1/3 of the providers.

·       What can a healthcare provider do ? They should immediately develop a centralised digital knowledge base where these protocols are stored. AI can then ‘push’ updates out to the deliverers and they can even be integrated into their daily workflows.

5. Fragmented Data from Electronic Medical Records (EMR), Laboratory Reports and Admin Systems.

·       What’s the problem ? Healthcare providers, just like most sectors, procures IT systems at different times for different needs. For those at the delivery end of the spectrum, the data and the knowledge that they need is scattered across electronic systems with poor interoperability. Staff at one location had to print off records off one system and scan them into another.

·       What was the impact ? Staff wasted their time searching multiple systems for the relevant information. The opportunity cost was clear; they spent time extracting information rather than making decisions or treating patients.

·       What can a healthcare provider do ? In most cases, the provider does not need to procure another new and expensive IT system. Data can be integrated into a single knowledge layer with decision support tools and appropriate tagging/taxonomy.

6. No Culture of Capturing Tacit Knowledge.

·       What’s the problem ?  At almost every location, valuable insights from senior clinicians or experienced nurses were not systematically captured or passed on. Only those who knew to ask for an insight or who were on the same shift pattern could access the information. There was little or no appetite for learning from experience mainly due to the pressures of work, but also because there was no top down leadership.

·       What was the impact ? Critical decision-making often had to involve key personnel whatever the time of day and or the physical location of the expert.  This self-induced bottle neck had numerous severe implications.

·       What can a healthcare provider do ? Whilst not easy, it is possible to change cultural norms. It normally requires senior leadership to engage and a series of education and training exercises to make it run smoothly. Mentorship and ‘Lessons Champions’ are key enablers.

7. Lack of Continuous Learning Mechanisms.

·       What’s the problem ? Many locations had sporadic KM / Lessons training and too often focused on ensuring staff adherence rather than any genuine attempt to get better at learning lessons.

·       What was the impact ? Staff felt that this was something they ‘had to do’ as part of their mandatory annual training. There was little engagement and it did nothing to improve emerging clinical practices or operational tools.

·       What can a healthcare provider do ? This was much about culture as policies but providers should build modern learning ecosystems that include microlearning, incident-driven learning, and interactive debriefs. Sitting in front of a slide deck is not learning.