Our throughline

When you talk, you are only repeating what you already know. But if you listen, you may learn something new.

  • Dalai Lama

Everything we do should be about keeping patients as safe as we can and the vast majority of healthcare is provided safely and effectively, however, just like any high risk industry, things can and do go wrong.

The science of patient safety is relatively young. Early pioneers identified aspects of safety in the 1850s but the science as we know it today grew substantially from around the mid-1990s.  What followed has been a cacophony of solutions and interventions and the field of patient safety has accelerated over the last two decades.  But the anticipated fundamental and lasting change has yet to be realised.

Safety is not a task or a set of technical interventions, it is not notices on the wall or a risk register; it is a mind-set, it is in everything we do.  Feeling safe means we need to be constantly vigilant, noticing what happens every moment of every day, noticing when it goes right and noticing when it doesn’t.  With that knowledge we then constantly adapt our behaviour and practice.

Our efforts to date have been a touch random; we give the impression that we don’t quite know where to start or what to focus on when. We have also not consolidated our actions; in that we have moved from one thing to another and then another. We have focused on one off interventions rather than creating a comprehensive, system approach to safety. If we were to make a fresh start what would that look like?

We need to go back to the fundamentals. Ask ourselves some questions, the kind of questions that you can only ask in fact after you have tested out some ideas and assumptions. So while we may be disappointed in our efforts so far, perhaps it is only through these experiences that we can we finally see what we might want to do or where we now should be focusing?

We have been asking these questions over the first two years of our work at Sign up to Safety.  Our conclusions? We need to think and act differently in many ways but at the very heart of safety is people.  Yes the system and environment can help people be safer, it can also set them up to fail – but at the very core are people and relationships.  And at the core of people and relationships are conversations.

So as Margaret Wheatley says:

I believe we can change the world if we start listening to one another again

William Schutlz argued in 1979 (Weick 2009),  that learning and understanding progresses through three stages; superficial simplicity, confused complexity and then profound simplicity.

Profound simplicity is achieved when people doubt the completeness of their assumptions, and through experimenting with a wider variety of possibilities may realise that out of that confusion may come a fuller understanding of what they face. This is only achieved by working through the confused complexity and this needs to be lived; experiential learning is therefore vital. Without the experience (or working it through) people have no idea why the simplifications are profound, why they work, or what lessons there are.  Without the experience the borrowing is superficial and typically fails when implemented.

Only now do I think that we are moving into the era of profound simplicity, where we are starting to realise that there are some fundamental and seemingly simple aspects related to how we work in patient safety that could make a profound difference to the safety of patient care.  What could we do differently?

At Sign up to Safety we have recently worked through what our throughline should be for 2016.  What is a throughline?  Chris Anderson in his book (TED talks, the official TED guide to public speaking 2016) says it is the connecting theme (described in around fifteen words) that ties together each narrative element of a talk.  I really like this idea and thought I would use it to construct our third year strategy.  So we spent a day working through what we wanted our throughline to be. We wanted to construct something so great that it would create a strong thread throughout all the elements of our work.  A way of connecting everything together; connecting the pledges and safety improvement plans people are working on, with our work in creating a safety culture and narrowing the implementation gap.  And those fifteen words needed to inspire our members but also focus them on the precise idea we wanted to work on.

The throughline we came up with was:

We want people to talk to each other about what they know about keeping patients safer

Talking to each other; doing less telling, learning to listen, learning to ask the right questions and acknowledging what is being said and heard.

Listening to another human being starts to create a relationship, starts to help us understand them more.  Listening means we hear someone else’s point of view rather than forcing our own on to others.  We move away from our judgments and assumptions towards curiosity.  This means we start to learn more about what could be safer, what could or should be changed.  The reason why I believe this so fervently is that ‘not listening’ or ‘not being heard’ or ‘not being able to speak out’ has led to harm on so many occasions. Harm to patients, harm to relationships between patients and staff and between colleagues.

Good conversations can help us talk about the things we notice, help us understand and learn about how we can achieve the safest and best possible care for patients. Conversations can help us create the right culture for safety; the just culture.  We want to connect with people in a kind and human way that acknowledges the conditions and to help them work and explore together the possibilities for safer care.   Our throughline will help us explore honestly both people’s lived reality and new possibilities; enquiring more deeply into how to make people safer.

This is, we believe, profoundly simple.   Margaret Wheatley talks about how people band together with their colleagues and friends to create the solutions for real social change.  Such change she argues will not come from governments or organisations, but from the ageless process of thinking together in conversation (Wheatley 2009).

Our solution for change? A culture of kindness and a just culture of safety, one which is based on a very simple premise; that we all need to learn to talk to each other; interactions, relationships and conversations.  That if we get this right we will go a long way to transforming the safety for future patients and those that care for them.

  • Weick KE (2009) Making Sense of the Organisation; the impermanent organisation Chichester: Wiley (John Wiley and Sons Ltd)
  • Anderson C (2016) TED Talks; the official TED guide to Public Speaking London: Headline Publishing Group
  • Wheatley M (2009) Turning to one another; simple conversations to restore hope for the future San Francisco: Berrett-Koehler Publishers inc


1 Comment

  1. This is spot on. The simplicity of the through line is so powerful. It’s hard to argue against talking. Had a good conversation with Philip Boxer yesterday to further refine how we get from stories in the trios to the underlying dilemmas. He would argue that if the same things keep going wrong, the underlying dilemma has not been exposed and the preferences for its management evaluated.

    Anyway great post. D

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