Learning from Nightingale: how to implement a Learning Systems Approach

On July 7 we held the first in our new series of virtual learning sessions, “Doing Things Differently” which looks at how the experience of managing the COVID-19 pandemic can be used to deliver care differently.

Our first session focused on the Nightingale Hospital in London, specifically the learning system that was established to support staff working at all levels in the hospital to make agile changes to practice for the benefit of staff, patients and their families.

Our speakers were drawn from the team who helped to design and deliver this system at the Nightingale, each reflecting on different aspects that ensured it worked well.

Building the system

The system was built on five key components: a rich flow of data, triangulation and analysis, rapid decision making, implementation, and closure.

Jenny Shand from UCLPartners talked about the Bedside Learning Coordinator, a new role that was put in place to gather qualitative insights from staff, observations from the clinical area and communicate any changes to the team.

As Jenny put it, they had two roles: learning fast and acting fast. For me, this role helped to illustrate the shallow hierarchy and the value that was placed on getting insights from all teams. The Bedside Learning Coordinator was not a fixed post, but a role that might be taken on by staff with diverse professional backgrounds. Deliberately rotating the role across different teams ensured that there was a breadth of insight and that everyone felt involved in the changes made.

Comments in the chat section and on Twitter showed similar roles are being considered widely in organisations across the country, and it certainly felt to me like something that could be implemented relatively easily at wide scale, noting the caution that the role needs to be embedded in a learning system rather than implemented in isolation.

The uncertainty of COVID-19 has not gone away. The world will remain uncertain for some time. In response to this: are we set up to learn quickly?

Richard Bohmer, Senior Visiting Fellow, Nuffield Trust

Being more agile

Dominique Allwood (Assistant Director, the Health Foundation and Consultant in Public Health Medicine and Quality Improvement, Imperial College Healthcare NHS Trust) pointed out that COVID-19 taught everyone working in healthcare that we can be more agile – teams across the country were responding to new information and new treatment advice at pace. The same principles around ensuring transparency of decisions, rapid dissemination of data and taking action on learning, can be applied to help organisations be more agile in non-COVID times.

Richard Bohmer, Senior Visiting Fellow, Nuffield Trust, reminded us that the uncertainty of COVID-19 has not gone away. The world is no less uncertain now than it was 6 weeks ago, and will remain uncertain for some time. In response to this: are we set up to learn quickly?

As a new hospital, Nightingale London had the advantage that they were starting from a relatively blank sheet of paper: they could put in place the structures and processes that suited agile working, such as huddles and decision authorities, without having to work around existing academic or medical models. So how can this learning be transferred to existing health care organisations and systems?

“Acting on staff insights can provide voice and agency for staff and deliver tangible improvement as part of a wider system of rapid, reliable learning. 

Jenny Shand, Director, UCLPartners

What would the panel take forward from Nightingale?

At the end of the session, a question on this point was posed in the chat box, asking: “If the panel could take one thing from Nightingale to implement immediately into “normal” organisational practice what would it be?”

I followed up with the panel after the webinar to get their responses, which I’d like to share with you here:

“Acting on staff insights can provide voice and agency for staff and deliver tangible improvement as part of a wider system of rapid, reliable learning. Finding mechanisms to gather those insights (at the Nightingale we used a combination of the Bedside Learning Coordinator and the ImproveWell app), to feed the insights into decision making bodies and to implement changes can be a powerful motivator for staff, and in turn deliver higher quality more efficient care.” – Jenny Shand

“For me, it’s having a lens of learning on all we do. I lead a QI team and Improvement sometimes runs the risk of feeling a bit ‘exclusive’ or separate to the rest of the organisation, but having a lens of learning has felt more inclusive.” – Dominique Allwood

“It’s leaders’ job to help people be absolutely clear about purpose: what they are collectively trying to do. In Nightingale London’s case, protect London by saving lives, and toward that protect staff and reduce the burden on staff on the ward. After that, leaders’ key task is to encourage people to focus on gaining knowledge in areas critical to the purpose. Leaders need to show that they know they don’t have all the answers, and that everyone’s job is to gather data and use to make informed decisions to reduce uncertainty in areas that matter most to the mission.” – James Mountford, Director of Quality, Royal Free NHS Trust

“My take home messages: 1. Link governance team with QI team 2. Make incident reporting easier (try to cut Datix fields) and get exec support for developing a Bedside Learning Coordinator project 3. Many NHS staff don’t fully appreciate role of governance – the flat hierarchy at NHL allowed Governance to get close to all teams and help them realise the importance of policies/ incidents/ risk/ audit. Investing in supporting clinical teams to make better understand and use governance systems.” – Andrew Wragg, Director of Quality and Safety, Barts Heart Centre, Barts Health NHS Trust

If you missed the session, you can watch a recording of the webinar.

And please do join us for future webinars in the series – sign up to our email newsletter if you’d like to hear about upcoming events.

We hope that the series will help shine a light on innovative and excellent work that has been taking place during COVID-19, sharing the learning widely across the UCLPartners region and beyond.