Safety conversations 

Getting beneath the surface

Tuesday 27 October 2015 was a fairly momentous day for me.
The Sign up to Safety campaign has a small but very select team of specialists; in campaigning, in patient safety, in large scale change and importantly in learning. Everyone in the team makes a unique individual contribution to the whole.  One of our team (guest blogger) David Naylor – has significantly contributed to our approach to learning. He is helping us think about how we can enhance people’s capacity to talk and think more deeply together about the critical issues facing patient safety and what lies beneath the surface of things to get to what really matters and what is really going on.

Together we designed an approach which we tested on 27 October. We developed a day for 33 people to have a conversation about safety – we chose the problem of the implementation gap, but we quickly learned that we could have chosen any aspect of safety.  The day was a carefully structured and facilitated process – which started with recruiting a diverse group of staff from the NHS across England; diverse in profession and status, equal in terms of gender.  Nothing was not thought through.  The pre-event communications, the event handbook, the facilitation, recording and venue.  The welcome was warm and embracing.  Our enthusiasm to see everyone very genuine.  Individuals were connected to their ‘trio-mate’ and introduced by name only; again trying to move away from the usual associations of role, organisation and status.

The method uses a process of trios – three people who have three consecutive rounds of dialogue; a conversation with three very particular roles; a speaker, an active listener and an observer.  We had eleven trios.  Some readers may have experienced this type of approach in other guises (such as coaching, co-consultancy and appreciative enquiry). Each member of the trio takes it in turn to experience each of the three roles.  A structured conversation.

A novel aspect of the conversations was the use of metaphors to help build and connect from one story to another.  This seemed to be a stroke of genius – the use of metaphors seems to transcend or at least help with the language barrier and the potential for things being ‘lost in translation’ between the individual participants.

The individual people in the trios met together in small groups; again another neat trick – with all the original speakers, original active listeners and observers meeting together.  This was to spread their insights and then meet and feedback into a larger group to continue to carry the conversations into collective knowledge.  To be honest we need to get better at the feedback stage but that didn’t stop us seeing the potential.

Conversation is a core human skill but we still need help to speak, and given time to speak, we need help to listen actively and ask the right clarifying and open questions and we need skills to observe in such a way that we start to see meaning that wasn’t there before.  The culture of conversation is a different culture.  These are the skills we wanted to enhance.

The reason why it was momentous was that we found that for most of the 33 participants we seemed to provide them with something very special. The method seemed to create what some describe as ‘psychological safety’ and lessen inappropriate grandstanding and peoples attachment to their own points of view.  Words like ‘novel, different, enhancing’ – were often used during the day. They told us that we had provided a safe, comforting and comfortable space, the time to talk, time to listen, and time to observe.  They felt valued, respected, cared for.  One person said we had provided them with ‘the ability to feel human again‘.

It felt that this was at the very heart of what a safety culture should be

The potential for immediate and practical implications for patient safety seemed to shine very bright for us.  Why attend a conference and passively be spoken to when you could have a meaningful conversation about safety. I am probably getting ahead of myself – we have yet to properly evaluate the day but structured conversations using this method could help with learning from error and harm, a collective approach to creating new knowledge, creating  shared understanding of contributory and causal factors associated with patient safety investigations, addressing the implementation gap and helping with large scale change.

Change is a natural result of constructing meaning and knowledge together.  If we pose the right questions and convene the conversations, one good conversation that matters could shift the direction of change forever. If we combine conversations that really matter with the reach of the campaign and the desire of the frontline we have a powerful force for change from the ground up.  We believe that we have the potential for something great.

There is the possibility for a transformation of the nature of the conversation about safety, both individually and collectively and that is what we are exploring.

So what next.

  • We will continue to test and evolve the methodology
  • We will continue to share what we are learning
  • Importantly David will provide his own unique view in his guest blogs over the coming months.
  • and finally…. instead of just telling people about this method and our insights we will probably need to work out how we get some more people to experience it in a way that demonstrates its power and possibility.

A culture of continual learning

I know things move on.

I know that we can’t live in the past.

However when our past holds valuable gems which can help us with our future then I am all for reminding people where we have been.

Patient Safety – a brief history of our time

December is our focused month on the pledge, continually learn – so to get us all ready for this I thought I would create a brief history of patient safety for those new to safety who may not know where we have been and as a way of helping learn about patient safety.

In the NHS in England the patient safety movement started in 1998 with A first Class Service – which described what we know today as clinical governance.  Then in 2000 Sir Liam Donaldson’s advisory group wrote a report ‘an organisation with a memory‘ which described the priority areas for safety, the types of techniques for improving safety and focused people on the findings from Charles Vincent’s work in reviewing case notes for adverse events.  The Vincent pilot study of two organisations led to the overused (and only really applicable to acute care) statistic everyone used on safety… 10% of healthcare results in harm caused by the care the patient receives and not their illness and half of that is avoidable.

Following this, Building a Safer NHS – led to the creation of the National Patient Safety Agency (NPSA) in 2001 (the same years as the first iPOD and 9/11) and the normalisation of the terms patient safety, root cause analysis, systems approach to safety, safety culture and just culture.  These built on lessons from other industries in particular aviation and the groundbreaking work of Professor James Reason – who designed the ‘swiss cheese model‘ and helped develop tools such as the incident decision tree – a vital tool to help create the just culture for safety.  We learnt over time about what it takes to create a safety culture, the role of leadership in safety and how important it is that teams understand their impact on safety, how to report incidents and how to learn from them and how to address the problems they detect.

The NPSA set up the National Reporting and Learning System (NRLS), published the Seven Steps to Patient Safety, ran campaigns to improve hand hygiene (cleanyourhands), reduce infections associated with central lines (matching michigan), rolled out safety tools such as the WHO surgical checklist, and worked with industry to help design infusion pumps, ambulances and medication packages.  Patient Safety Alerts were sent out.  Incident reports came flooding in – over a million a year.

The NPSA was joined by the NHS Institute for Innovation and Improvement (NHSIII), the various iterations of system regulators (now Care Quality Commission) and professional regulators, the Health Foundation, the Institute of Healthcare Improvement, academia and patient groups. The World Health Organisation developed a patient safety centre and created a number of global challenges as well as the patients for patient safety programme.

Over time we learnt about human factors, ergonomics and behavioural change and worked in partnership with others on campaigns such as Patient Safety First.  The NHS has explored the science of improvement, the use of PDSA cycles, LEAN methodology, resilience engineering and high reliability organisations.  Every year the collection of research and books on patient safety and all its component parts grows larger and larger.

At the same time there has been inquiry after inquiry, review after review with recommendation after recommendation.  Notables are; the Bristol Royal Infirmary Inquiry, the organ retention scandal, Winterbourne View, Mid Staffs and Morecambe Bay.  Also we have been shocked by individual cases such as that of nurse Beverley Allitt, GP Harold Shipman and others.

In 2004/5 there was a National Audit Office report on patient safety.  In 2006 the publication of Safety First another review of patient safety and in 2008 the NHS became 60.

In 2012, the Health and Social Care Act led to the abolition of the NPSA and the NHS III.  At the same time as the Olympic Games a small team of patient safety staff transferred from the NPSA to the NHS Commissioning Board (now NHS England) and are now moving from NHS England to NHS Improvement.  In 2013 we had the Keogh Mortality Review, the first NHS Change Day and the Berwick Report.

And finally in 2014 the launch of Sign up to Safety, fifteen patient safety collaboratives and the Q initiative.

I am certain that I have missed much but I did say brief!

All of the above and so much more can be still found in archived sites you will be amazed at how brilliant it all is – happy searching!

Guest Blog – David Naylor

Dr David Naylor

I am part of the Sign Up to Safety campaign team with the responsibility for helping people leading safety improvement work to share their learning. I currently work at The King’s Fund as a senior consultant. My doctoral research was into how people found their voice to speak up and to be ‘constructively awkward’. That is, how to say things that people may not want to hear and survive.  I have trained in consultancy at The Tavistock Institute and facilitation at the University of Surrey.  I have lead a voluntary organisation providing housing and nursing care; and early in my career I was a ward manager in an acute mental health service in London.

Finding the words to describe what is really going on

In his recent book, “Landmarks”, Robert Macfarlane (2015, published by Hamish Hamilton) gathers a huge glossary of words that we use and have lost to describe our landscape. He argues that these words focus attention on the features of the terrain that would otherwise not be noticed, even as we walk across them. The language of landscape brings into conscious awareness what would be discluded in our environment if we did not have the words to describe it.

An example is the word ‘smeuse’; a Sussex word for ‘a gap in a hedge made by the regular passage of a small animal’ (p.5). Animals eschew human routes to find their own way across the landscape. This put me in mind of the people, under the auspices of the campaign, who are leading small, local, innovative safety improvement projects.

When you ask people to describe what they do, two things become apparent.

  • Firstly, how adept they are at navigating new ways of working and finding their way around the organisational landscape. They are skilled at helping people, whose first instinct is to resist new ways of working and thinking. It is an irony of good leadership that it will evoke resistance. In fact, you can argue that if people are not trying to counter what you are saying and doing, you are not being taken seriously.
  • Secondly, how people chronically under report what they do. It is as if people’s leadership rests solely upon an unconscious competence. While this modesty is nice, it does not help if you want to critically evaluate what is going on and spread what you know to others.

This habit of modesty reinforces the reluctance to speak to one’s competence. I am not talking about the bombastic assumption of rightness that some people think is leadership. No, what I mean is the realistic assessment of one’s competence that emerges from a fair, supportive and critical process of what one has done. This sort of assessment requires a change, paradoxically in our attitude to failure.

While speaking up and learning from our mistakes is an espoused value in our culture, we know that in reality being candid is not always welcome. As such many of us have learnt to keep our mouths shut. A side effect of this self-silencing is to reinforce the tendency not to talk about what we do well.

In March 2014 Radio 4[1] set out to celebrate failure. Arguably the world’s worst singer, Florence Foster Jenkins was featured. One of the presenters noted dryly that she had freed herself from the need to follow the notes. The singing was magnificent and enthralling in its awfulness; and in freeing herself she was expressing her desire to sing in a way that transcended her obedience to the form. She was freed from the desire to look good.

The people I talk to seem to have access to a limited palette of mostly grey organisational words for change and leadership.

As such, what is said about what works is only ever a partial description of what is really going on when people act to make things safer. What would it be like to speak with more bravado, with less deference to the rules, accessing the sort of glossary for our landscape that Macfarlane has gathered to name things that are interesting and important?

Trying to create a bit of space to talk in colour

When considering this with my Sign up to Safety colleagues we thought about the range of words we used and how we spoke up from the context of a national campaign rooted in the political landscape of the NHS. While we were all experts in our own way and passionate in our desire to make things safer, it was also the case that our preferred ways of walking across this particular landscape led us to recognise the familiar, speak the familiar and to not see, and thus ignore, certain features.

Our question became; how can we ignore less?

Ignoring less means having more words to describe what may be going on. We realised we needed to explore how to channel Macfarlane and Florence Foster Jenkins. To do this we need to unearth new words, recover what may have been discarded and free ourselves to talk in different ways. We have to start probing below the surface of our assumptions to discover more about what is really going on when people act to make things safer. We need to be able talk with some precision and detail about the processes and mechanisms that mediate what goes on, even if we do not fully see them, understand them or have names for them yet.

If we could do this then we would have something useful to spread and inform others’ practice in different contexts. Out of this thinking came the idea of a facilitated conversation; the aim of which is to probe below the surface of the stories people tell about their experiences in implementing safety projects, under the auspices of the campaign.

In my next blog I want to describe how we slowly developed a plan to run an event that could help us probe ‘beneath the surface’.

[1] The value of failure. 2014 [radio] BBC Radio 4. 7th March, 13.45.

The problem with….incident reporting

I have mentioned before the excellent series that the BMJ Quality and Safety journal is publishing titled:

‘The problem with…’.

The journal recently published one on incident reporting; the problem with incident reporting written by Carl Macrae, who provides an outstanding addition to the debate that the problem with incident reporting is that reporting and reporting systems are often misunderstood, misapplied and have left us all with confused and contradictory approaches which have seriously limited their potential impact. He sums it up for me when he says…

‘we collect too much and do too little’

Carl describes our current approach as a filing cabinet.  A cabinet full of past incident reports requiring an army of personnel to do justice to the reports and properly examine and analyse them in search of answers. Our focus has for too long been on collecting more rather than collecting better information.  He provides a really helpful table that shows us the difference between what we could have and what we actually have.  For example:

  • what we could have – ‘avoid swamping the reporting system to ensure thorough review of all reported incidents’
  • what we actually have – ‘celebrate large quantities of incident reports and aim for ever increasing overall reporting rate’

The definition for reporting to the National Reporting and Learning System – ironically created by myself and a group of my colleagues at the National Patient Safety Agency – is

‘any unintended or unexpected incident that could have or did lead to harm’

Carl quite rightly points out that we got this wrong; this is far too broad and misses an opportunity for using reporting criteria to ‘shape attention and set priorities’.  He then goes on to talk about the current emphasis on more reports and that ‘higher levels of overall reporting reflects a better safety culture’.  He states that this is a blunt measure and that we are left with systems which have little new information.  This philosophy can pressure organisations to increase reporting just for the sake of increasing the numbers rather than using them for learning.

‘repeated reports of the same type of event suggest a strong culture of reporting but a poor culture of learning’

One of the most worrying things about the current system is the fact that incident reporting is used as a proxy for measuring safety in an organisation and as Carl points out, this is a particularly poor way of measuring safety performance. Incident reporting systems have never captured all the things that go wrong on a day to day basis; they are biased towards the easy to report and the attitude that different professions have towards reporting, they also capture all sorts of administrative issues that are not safety related and are often highlighting concerns that individuals have about how the organisation is run rather than the safety of the clinical care.  While these may impact on safety they end up by drowning out the important information.  Truly hiding the needle in the haystack.  Also when these biases lead to the reporting of particular types of incidents but not others – this has a knock on effect to prioritising action and activities that may not be as important to address than some issues that only have a handful of reports to their name.  At a national level the numbers and types of incidents reported are then used to shape patient safety policy, create patient safety alerts and other national interventions.

In terms of the quality of information, we now know that in any one event there are multiple truths and facts – that for one person there is their version of the truth, the facts, the event and for another there is a different version of the same incident.  We all know when telling stories about our own lives that we sometimes miss things out or elaborate a fact to make a point.  This natural behaviour distorts the truth very early on.  So to see incident reports as telling the exact truth is wrong. As Carl states ….

‘early reports are often inaccurate and usually entirely wrong’

Carl has a number of suggestions:

  • using current incident reporting systems as simply triggers for further investigation or not and simplifying the data collected
  • reporting to an independent safety team rather than through the line management path
  • drawing on the collective intelligence of staff to build the full picture
  • making incident reporting a more active tool – shifting away from the current passive approach to reporting and relying on others to fix the problem
  • providing feedback and create a two way conversation

Carl concludes with a call to ‘refocus our efforts and develop more sophisticated infrastructures for investigation, learning and sharing to ensure that safety incidents are routinely transformed into system wide improvements’.

I could not agree more.

Communication the 80% factor

Ara Darzi is quoted as saying 80% of adverse events are caused by poor communication. Now I am not sure of the exact stats but having read a fair few incident reports and investigations as well as studied the national reporting and learning data and joint commission (US) reports communication is most definitely a major causal factor for harmful events. 

Understanding the problem is key to finding the solution. 


  • Analyse just a few of your incidents and you will find some patterns emerging. 
  • Ironically talk to your staff and patients – especially those new to your area. They will soon tell you what could be improved. 
  • One interesting tip is to track a piece of communication and see what happens as a result. Did it result in the action intended? 
  • Make the information interesting and relevant. Gossip spreads like wildfire. Guidelines take 17 years to be embedded. 
  • Consider the three main issues below. 

Firstinability to speak out – Human beings differ in the way they interact. Introverts versus extroverts. Shy people versus confident people. Male versus female. Individual versus crowd. One profession versus another. This means some are heard and listened to, others not. 

Generally speaking, extroverts who are confident, male, not influenced by the crowd and in a perceived higher status are heard and listened to. So in order to prevent patient safety incidents provide the conditions for the introverts, shy females. Provide the conditions and tools to hear from everyone. Staff and patients. Importantly hear and listen and act. 

This could lead to someone seeing a potential error and not stopping it because of this ability to say something. 

Solutions include; leaders who seek feedback from all around them, huddles that have no hierarchical structure, give opportunities to those that think before they speak such as pausing before continuing especially at crucial stages e.g before scalpel to skin. Look out for that person who has not spoken, read the body language. Check back and check independently. 

Secondstifling language – Plain and simple language anyone from your grandmother to your child can understand is crucial. That means crafting the information so that it says exactly what you wanted to say in as short amount of words as you can. 

Solutions are as simple as abc. Don’t use acronyms if you can help it and try hard not to get into the specialist language that only a small collection of people know. Acronyms stifle voices who are frightened to admit they have no idea what people are going on about. This has lead to people having the wrong treatment and procedures. 

Thirdtalking to and not with patients– The patient or the person who accompanies them know their own story better than any healthcare professionals- they may not know the answers but they know how they feel. Listen to the mums, the daughters the husbands and the patients themselves.  If they are worried or question an action, listen. Don’t be too proud and too late. 

Solutions include; Making patients (and colleagues) feel their voice is worth listening to – ‘hello my name is’ (the fantastic campaign by Kate Granger) is a great first step. Not hearing those voices can lead to unnecessary delay in picking up deterioration. Checklists that include patients and carers. 

Oh and if you like writing read Stephen Pinker – The sense of style – the thinking persons guide to writing in the 21st century

Through the looking glass

Socrates said that a life un-examined is not worth living. In our re(think) patient safety work which includes ‘getting beneath the surface’ we want to examine patient safety and truly understand how systematic certain mistakes are, how we repeat them again and again and how we could avoid some of them.  And. We really want to understand why certain things are not implemented and others are. 

We need to consider our past actions, things that were considered completely reasonable at the time and ask if they are still reasonable. Once we re(think) these old choices we can open ourselves to new choices, new opportunities.  We may even stop ourselves in our tracks and take a different path. 

For example over the last fifteen years I have witnessed numerous presentations on hand hygiene. Evidence which clearly shows that low hand washing compliance has a strong causal link with transmission of infection. Evidence is some change but I have never seen one that says we have cracked it; say 100% compliance which had been sustained for over 5 years. Imagine that. If you have seen this, then please point them in my direction. Sadly time and time again I witness the eager trying to tackle this problem with similar successful or not quite successful compliance rates. 

Lewis Carroll’s ‘Alice’s Adventures ..’ and ‘Through the looking glass’ have some wonderful quotes that could easily apply to our patient safety challenges. 

‘She generally gave herself very good advice (though she very seldom followed it)’

‘She who saves a single soul saves the universe’ 

‘When she thought it over afterwards it occurred to her that she ought to have wondered at this but it all seemed quite natural at the time’ 

‘It’s a poor sort of memory that only works backwards’ 

‘Finding meaning, like losing meaning, involves pleasure as well as pain’ 

Like Alice we need to get curious- we need to seek to understand more about why things have not worked as well as we had hoped. We may even start to look though a different lens. That of when things go well rather than when they go wrong. If we know what it looks like when patient safety thrives then we could see if can replicate that. 

As Maya Angelou says ‘I think a hero is any person really intent on making this a better place for all people’. 

Put safety first (gender issues)

We talk a lot about the ability or inability to speak out as crucial for a safety culture. However we rarely talk about this in terms of gender. We think we have an increasing equality but it still falls short of ideal. This can have a profound effect on safety. 

Across the many cultures world wide women find it really hard to speak out. Often only giving an opinion if asked. 

I don’t have a solution to this dilemma but I do think it is worth some serious consideration. Gender and the impact on patient safety should be openly acknowledged rather than lurking beneath the surface. 

There is so much fear that speaking up will make the situation worse or be inappropriate or go unheard. All of us, men and women have a role to play. Women need encouragement and respect from both men and other women. We need to act as a cohesive group, working together for a common purpose.

Let’s talk about it.