Using serious success reviews

Learning from errors is crucial to enhancing practice and implementing change. Nonetheless, while it is natural to wish to hide any embarrassment or anxiety associated with failure, mistakes can be a stepping-stone to better things.

Enquiries and inquests, such as serious case reviews, are key mechanisms for learning how to improve health and social care practice, both individually and collectively. Reflective leadership is crucial to this process.

Leaders must recognise that mistakes are both inevitable and a learning opportunity and should try not to react defensively or by attributing blame.

Developing a learning culture is not just about learning from errors, but what enables better outcomes for people accessing services. Organisations are more effective when they can recognise, learn from, and build on good practice. We need to identify what ‘good looks like’ so it can guide us when things go wrong.

Research by Forrester and colleagues (2019) explored the relationship between key social work skills and outcomes in child and family work. They asked social workers how they recognise what ‘good’ looks like. Responses highlighted the importance of effective authority and relationship-building skills, as well as having the space to reflect on how they might be enhanced.

The health and social care sectors also recognise the importance of a strengths-based approach, which has a focus on relationship-building. Good practice is seen as collaborative, facilitating maximum independence for people accessing services (Department of Health and Social Care, 2017). Practitioners work in a person-centred way to help people identify their individual skills and assets that can inform the way in which care is accessed.

Bexley Council have introduced the idea of Serious Success Reviews to identify the features of good social work practice (as well as what works less well) – see Stevenson (2017) available here. Although designed for social workers, this approach will be useful for leaders across the health and social care sectors. Leaders could use Appreciative Inquiry (see KFP2 Sense of Appreciation) and other consultative approaches to explore what constitutes good practice in their organisation.