Thanks to Richard Taunt of the UKIA (http://www.ukimprovement.co.uk/) I am reading Team of Teams: New rules of engagement for a complex world.
There are so many similarities with our own learning at Sign up to Safety that I will share as the weeks go by. However I was struck by a section on intelligence that harked back to the talk I did for the James Reason Lecture (you can find in an earlier blog).
The quotes are from the book.
Like ripe fruit left in the sun intelligence spoils quickly
We like a metaphor at sign up! But think of this in terms of data related to Safety. If an incident reporting system was about fixing things quickly then by the time incident reports reach an analyst most of the information is worthless.
Note I used the term analyst. Our risk managers (or equivalent) as I have said before are seen as removed and bureaucratic- not the forensic analysts that they should be or the safety intelligence of an organisation.
To many the intel teams were simply a black box that gobbled up their hard won data and spat out belated and disappointing analyses.
We have all heard that one in relation to incident reporting. Our current catch all approach actually creates this problem. Of course with a mass of data every single day anything learnt is going to be belated and disappointing. What this sadly means is that it is often ignored and frankly because of this, time would be better spent doing other things. But that’s a dilemma- we can’t ignore the data but how can all the data be tackled in a timely manner.
On the intel side, analysts were frustrated by the poor quality of materials and the delays in receiving them and without exposure to the gritty details of raids they had little sense of what the operators needed.
This reminded me so much of the way in which we inappropriately compartmentalise safety into neat boxes with people working independently in an interdependent environment. Safety people need to be exposed to day to day experiences and at the same time appreciated and valued for what they bring.
This I would suggest is symptomatic of a larger problem; the way the whole organisation works and dare I say it the overarching system that is there to support them.
It always boils down to people and relationships in the end.
Patient Safety Now 