“Humble Inquiry is the fine art of drawing someone out, of asking questions to which you do not already know the answer, of building a relationship based on curiosity and interest in the other person”
Edgar H Schein (2013)
Over the last five years there has been a growing conversation about the language of patient safety. If we keep referring to safety or patient safety as a ‘issue’ to be tackled by central teams or vertical programmes rather than talking about ‘working safely’ – patient safety remains a ‘thing’, a side issue or an add on to day to day work. It also remains the responsibility of a few people rather than all.
Working Safely is a phrase suggested by Erik Hollnagel which we feel defines patient safety in a much better way. When we talk about improving patient safety versus improving the way people work safely there is an instant change in mind-set. It changes it from being a project to our everyday actions.
Hollnagel and others describe the latest thinking ‘from Safety-I to Safety-II’.
Safety-I is where safety is defined as a condition where the number of adverse outcomes (accidents, incidents, near misses) is as low as possible. Where there is a simple linear approach to describing and investigating accidents or incidents.
‘Models and methods which require that systems are linear with resultant outcomes cannot and should not be used for non-linear systems where outcomes are emergent rather than resultant’
Hollnagel asserts that the solution is to change the way we look at safety from always looking at what has gone wrong and (potentially punishing the individuals who were involved) to really studying what is going well. This means analysing everyday activities to understand what works with a view to replicating them in addition to analysing single isolated events of things that went wrong.
‘Safety-II is the ability to succeed under expected and unexpected conditions alike, so that the number of intended and acceptable outcomes (in other words everyday activities) is as high as possible’
In ‘Safety II’ humans are seen as an asset rather than a liability and their ability to adjust what they do to match the conditions is a strength rather than a threat. This is a shift from the current focus which views non-compliance with certain procedures as ‘violations’ and as immediately negative and in some cases punishable acts or indicators of poor performance.
What has this got to do with conversations for helping people work safely?
Working in healthcare is rarely about certainty and predictability. Healthcare is complex with decisions that need to be made every moment of every single day and for a variety of reasons some of them will be bad and some good. Often the decisions we make are full of dilemmas where two or more choices can be made and one must be chosen. This can be in so many ways; which procedure to offer, which drug to prescribe, which patient to send home, which patient to keep in and so on. We need to help the people working in healthcare to make these choices.
To help people make choices and work safely means talking to each other.
Often leaders feel that they need to be ‘in control’ and highly directive, that the task of leadership is to ensure that people do as they are told and reliably perform their function. Instead what people really want is to be helped to do their jobs well and as safely as possible through guidance and coaching. They want to be trusted to do the right thing.
To trust people to work safely means talking to each other and listening to what is actually going on and not what you think is going on.
In patient safety we often talk about culture and people can have a tendency to say things like ‘if we just change the culture’… but culture is as invisible as the wind so how do we change it? Within the walls of organisations or practices, there are structures, processes, plans and procedural documents but …none of these are as important as the individuals who work there and the way in which they behave and interact together.
To help people interact with each other means talking to each other and creating those connections and relationships.
Culture change cannot be achieved by a top down mandate. If you want a culture of positivity, respect and kindness you can’t order people to be positive, respectful and kind. What you can do is use more positive approaches to learning about working safely (positive deviance, appreciative inquiry, learning from excellence) and you can be respectful and kind.
To help people be respectful and kind means talking to people with respect and kindness.
You can be a great role model. Role modelling the behaviours you want to see and visibly demonstrating the culture you want is a great way to influence the culture of others. Rewarding and recognising those that also exhibit the behaviours you want to see shines a spotlight for others to see and also want to replicate. Calling out behaviours you don’t want to see (bullying for example) shows people you are genuine.
Rewarding when they exhibit the behaviours you want to see, where people are able to speak out or when they act on something they have heard, starts to build the culture from the ground up.
The culture we want to see is where people are cared for and supported when things go wrong and that others are asked questions first before being judged. The culture we want to see is where we listen to the multiple diverse voices that need to be recognised, heard and engaged.
Sidney Dekker says: If you want to change behaviour, don’t target behaviour. Target the conditions under which it takes place. Those conditions are not likely the worker’s responsibility. Or only in part. Think for a moment about whose responsibility the creation of those conditions is in your organization. And then take your aim there.
The safety culture of a team or organisation or even an entire system is influenced by how people interact, the language, words, writings, and stories they use. However in healthcare a lot of our forms of communication have become one way information sharing or as others might say ‘simply telling’. People are drowning in emails, policies and procedures telling them what to do and what not to do. Conferences are mainly about people sitting being talked at with minimal time for questions and answers. Meetings are the most common way people come together yet most people find meetings boring and unproductive.
In some cases meetings can be more than unproductive they can be counterproductive. For example, up and down the country there are all day meetings where individuals (mainly nurses) stop what they are doing and nervously trickle into a room clutching mounds of paper and sweaty hands to argue their case for whether the incident they were involved in was avoidable or unavoidable. Judge and jury sit and debate with people desperate to be put in the unavoidable camp. This at best is distracting and at worst perpetuates the blame and fear culture.
People feel that they can’t deliver the bad news or problems without retribution. This approach is too simplistic and stifles people who need to share the problems in order to identify the potential learning and solutions.
It doesn’t have to be like this
Judgement silences things, turns learning into a secret. Empathy enables that secret to be shared. It is everyone’s responsibility to create the conditions for others to come together and talk to each other.
Is there an evidence base?
We have based our thinking on academic theory, research and our own experience. The knowledge we have gained and seeing how others are developing this view of the world has helped build our confidence to explore further.
We recognise that the concepts and ideas we share are not new to many. There are more than forty examples of conversational methods we have come across; appreciative inquiry, organisational learning conversations, polarity management, and world café to name a few. There are all sorts of people who have and are studying how we could tackle this issue. The deliberative democracy movement, the high reliability experts such as Karl Weick, those concerned with creating psychological safety when we make it easy for people to talk to one another, to share, to admit their mistakes and to be supported such as Amy Edmondson. Wiggins and Hunter talk eloquently about how change happens through changing conversations and relationships.
One of the things we have come to realise is that it is not so much the method used to help people talk to each other but the right conditions and mind-set that is needed regardless of what specific approach you choose. In fact we would rather people didn’t turn them into a ‘thing’ or a ‘catchy name’ that gets foisted on frontline staff as the latest trend for helping them talk to each other. What we don’t want to do is perpetuate the view that everything can be solved by a tool kit or neat intervention.
What is the benefit?
Helping people talk to each other – or conversations to help people work safely involves engaging people in things that really matter to them, providing opportunities for people to have effective conversations to connect, build relationships and explore new ideas and opportunities. To explore, to share, to gain more information than we already had.
We believe that helping people talk to each other could significantly impact on the safety culture in the NHS. Whichever way you choose, taking the time to talk to each other can help:
- Bring people together, connecting up the different teams, departments and sites to talk and in particular to focus on working safely
- Talk about what is working well – building on the concepts from the ‘learning from excellence’ research
- Be more positive and help a little with the morale, help people feel valued and acknowledged for the great work they are doing
- Talk about the things that are keeping you away at night
- Discuss the links between working safely, quality of care and productivity, efficiency, effectiveness and reduced cost
- Discuss your CQC inspections (before during and after)
- Bring together from other organisations not just your own
Over the next phase we will continue to share our ideas and insights from people across the NHS and providing practical help and knowledge to continue to demonstrate the importance, build the evidence base and share stories of conversations that have truly helped people work safely.
Schein E (2013) Humble Inquiry: the gentle art of asking instead of telling
Brown J, Isaacs D (2005) The World Café; Shaping our futures through conversations that matter San Francisco: Berrett-Koehler Publishers Inc.
Marx D (2017) Dave’s Subs: A novel Story about workplace accountabilityDekker S (2017) http://www.safetydifferently.com/the-original-hearts-and-minds-campaign-and-the-dereliction-of-behavior-based-safety/
Woodward S (20016) Rethinking Patient Safety via amazon https://www.amazon.co.uk/Rethinking-Patient-Safety-Suzette-Woodward/dp/1498778542
And more here on this blog www.suzettewoodward.org
Wiggins L and Hunter H (2016) Relational Change Bloomsbury Publishing
Wheatley M (2009) Turning to one another; simple conversations to restore hope for the future San Francisco: Berrett-Koehler Publishers inc
Naylor D, Woodward S, Garrett S, Boxer P (2016) What do we need to do to keep people safer? Journal of Social Work Practice – [online] Available via http://www.tandfonline.com/eprint/bVgSRFVSIpjh8cwp2Gka/full
Erik Hollnagel and Rene Amalberti, (2001) The Emperor’s New Clothes or whatever happened to human error? In: 4th International Workshop on Human Error, Safety and System Development, June 11-12, Linkoping, Sweden (keynote)
Erik Hollnagel, (2010) Safer Complex Industrial Environments. CRC Press, Boca Raton, FL
EUROCONTROL (2013) From Safety-I to Safety-II: A White Paper.
Erik Hollnagel, (2012) A Tale of Two Safeties – via