Working Safely

It turns out that if you change how people talk, that changes how they think’

Lena Boroditsky, Professor of Psychology, Stanford University

Over the last twenty years the subject of patient safety has grown and we have achieved a number of changes in terms of raising awareness of the issues and quantifying the problem.  However we all know that this is not quite working as we imagined.

As has been mentioned by us in previous blogs we are big fans of the work of Erik Hollnagel and his colleagues and their thoughts in relation to Safety I and Safety II.

To remind you…

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

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

With this definition, safety (and patient safety) changes from studying why things go wrong to studying why things go right. Hollnagel suggests that means studying and understanding everyday activities which are ‘actual events’ that show how a system functions.  The purpose is no longer to ‘avoid that things go wrong’ but instead ‘ensure that things go right’.

Hollnagel challenges us to think about our definitions and language when talking about ‘safety’, that we should move away from these titles or easily boxed in headings to talking about ‘working safely’.  We could not agree more.  This completely changes the mind-set.  It moves Patient Safety from a thing one person does or a workshop or a strategy to about everything we do, every action we take and every decision we make.

Helping people work safely means we help them adjust what they do to match the conditions of actual work, help them learn to identify and overcome the flaws in the system, and help them interpret and apply policies and procedures to match those conditions.

So in that respect ‘Patient Safety’– should be redefined as ‘working safely’ and should be defined as:

working safely (in relation to patient care) is ensuring that that the number of intended and acceptable outcomes is as high as possible and people adjusting what they do to match the conditions of actual work, learning to identify and overcome the flaws in the system, and interpreting and applying policies and procedures to match those conditions

Those that work in patient safety should study what is working, rather than what doesn’t and should study how people work, individually and collectively and how the organisation functions when things are going well.


There are a few things we can do to help people work safely.

Connect people up to work together

We need to connect up the people who are working separately on particular problems in isolation. When people and their isolated projects come together learning increases and instead of improving one process at a time they improve aspects of care (and problems) that thread throughout all of these different harms.

We have tended to focus on problems in isolation, one harm at a time, and our efforts have been simplistic and myopic. If we are to save more lives and significantly reduce patient harm, we need to adopt a holistic, systematic approach that extends across cultural, technological and procedural boundaries – one that is based on the evidence of what works”

Professor the Lord Ara Darzi

Working on harms in isolation can have the risk of creating competition in a way that people don’t know which ‘interest’ or area of harm deserves more or less effort, time and resource.  These competing interests create competing prioritisation and confusion.

Instead organisations could hold ‘cross harm’ conversations where people talk about the common set of causal or contributory factors. These conversations could help discover new ways of sharing information, or designing new pathways to pick up issues more quickly, what could be standardised and what cant.

Stop assuming that healthcare fits into a neat linear model

Erik Hollnagel suggests that simple linear accident models were appropriate for the work environments of the 1920s (when they were first conceived) but not for the current work environments. Also that ‘composite’ liner models such as the ‘swiss cheese’ model by Jim Reason from the 1980s also worked for a different operating model than today.

The reality is that working in healthcare is muddled and unpredictable.  However, Liz Wiggins and Harriet Hunter talk about organisations as…

complex responsive processes with the focus on local, unpredictable interactions between people

They assert that there are multiple, non-linear relationships and interactions between people that are taking place all of the time.  That what is really happening is different from what people think ought to be happening.

Working safely is not a nice neat linear, step by step process that is underpinned by nice neat linear protocols or procedures.  That would be reliant on everyone agreeing with what is needed, that it is known by all and achievable and that nothing unexpected will happen along the way.

Zero harm is impossible

We have to accept that a system can never be ‘safe’ it can only be as safe as possible. Too often, people work in systems that are not well designed or not designed to help people work safely.  What we can do is drive down error and design systems to minimise its effect as much as we can.

Narrow the gap between ‘work as imagined and work as done’

There is an assumption that everything we do can be written down in procedures and guidelines and people will simply follow them.  Wiggins and Hunter suggest:

the key to a relational approach to change is paying attention to what is actually happening in practice as a result of people working with each other, rather than being enslaved to beliefs about what you think ought to happen and what is inscribed in the protocol

This is also the view of those who believe in Safety II concepts and the science of Human Factors.  Steven Shorrock and others talk eloquently about the issues associated with ‘work as imagined as opposed to work as done’.  Steve is the Editor of a fantastic resource titled the Hindsight Magazine which devoted a whole journal to the subject (Hindsight 25).

Sidney Dekker says:

“Sure, we can imagine work in a particular way. We can believe that people will use the technologies we provide them in the way they were intended. Or that they will apply the procedure every time it is applicable. Or that the checklist will be used.

These assumptions (hopes, dreams, imaginings), are of course at quite a distance from how that work actually gets done on the front line, at the sharp end. Work gets done because of people’s effective informal understandings, their interpretations, their innovations and improvisations outside those rules”

Extreme adherence to the plan or directives or rules can be problematic. The way work is imagined by policy makers, board members, leaders, managers and planners is the way they want it to be done not necessarily how it can be done. What these people need to do is:

“Pay attention to what is really happening, rather than what you think ought to be happening; be facilitative and focus on working with people, rather than ‘doing to’ them and see relationships as the source of insight, creativity and energy”

Liz Wiggins and Harriet Hunter (2016)

Sidney Dekker goes on to say;

To learn how work is actually done – as opposed to how we think it is done – our leaders need to take their time. They need to use their ears more than their mouths. They need to ask us what we need; not tell us what to do. Ultimately, to understand how work actually gets done, they need an open mind, and a big heart

At Sign up to Safety we would add:

In order to learn how work is actually done go and talk to people, sit down with them and listen with intent, listen to understand. Then think about what you can do to help people with their reality

Talking and listening to staff on the frontline provides a rich source of intelligence of what works well, especially those that move around the system frequently such as doctors in training.

This work helps people to become consciously competent. If you notice what you can do you can also explore the gaps between your intentions to keep people safer and what can happen in some situations.

It also works both ways.  Often frontline staff say things like ‘the people at the top don’t understand what we do’ ‘I don’t understand why they cant just fix things’.  So the frontline ‘imagine’ a world where leaders, board members and so on that is not quite as it is ‘done’.

The conversation that will help narrow this gap has to be two way.

What can we all do differently?

  • Change the language
  • Shift ‘patient safety’ from one persons job to everyone’s job
  • Create a consensus of what we mean by a just culture and consistently embed it
  • Learn from when we get it right and replicate good practice
  • Re-design systems and mind-sets across every part of the NHS differently that help the human adapt and adjust their performance safely.  This means across your organisation – finance, procurement, operations, clinical areas and so on to think about working safely as part of what they do – creating an enabling environment to help people work safely
  • Stop doing stuff (prioritise and focus the top down interventions, directives, targets and alerts)
  • Focus on the cross system factors that thread through the individual ‘harms’ such as observation, the factors that lead to deterioration, communication and design
  • Spend as much time on implementation as we do on innovation and improvement
  • Be kind to each other
  • Help people interact and develop relationships through talking to each other and listening


  • 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)
  • Hindsight Journal – via
  • 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
  • Erik Hollnagel, (2013) Is safety a subject for science? Safety Science; Elsevier Ltd


Things that get in the way of talking to each other


How we behave towards each other is the single greatest factor in how well our teams will perform

Chris Turner (2017) at the Learning from Excellence Conference

Having had the chance to observe many conversations we have come to understand that there are multiple dynamics that get in the way of people talking to each other and there is clear evidence that people too often choose silence over speaking up. Cultural rules of what one can say and cannot dominate the safety world and the NHS.

These are just a few:


People fear being judged and blamed, especially fear of being blamed unfairly. People fear being seen as incompetent, stupid and ignorant.  When they feel like this it is far preferable to stay silent that say something that everyone will judge them for.  This fear of embarrassing themselves can go as far as people not pointing out when the wrong body part is about to be operated on or the wrong drug being administered.  The fear pervades at all levels of the organisation from the board to the frontline.  People fail to speak up at boards, in meetings, at the bedside.

As Steve Shorrock says…

What people fear most of all is not the judgement of those who are most distant from the work, whose judgements are relatively rare. What people fear is the judgement of those closest to the work – their co-workers.

People fear raising the issue of judgement and blame by colleagues because they fear being judged and blamed for raising the issue.


There is clear evidence that humans have a strong need to belong within a group which can override the need to speak up. Discussions concerning safety are a mixture of what people will say and what they wont say.  In particular people find it really hard to discuss patient safety issues in a group, but will mention them in private. What this means is that vital information can be omitted unless people are given the space and opportunity to open up in a safe way.  In order to say you feel unsafe in a work situation you need to feel safe enough to point it out.

We are as groups, our own worst enemies. We demand fairness from others but continue unfairly to blame others.

Steve Shorrock (2016)

Power and status

Fear and silence are exacerbated by power.  Power takes multiple forms. There is the power of people, the power or the organisation, the power of the targets and goals. Wiggins and Hunter talk about the different types of power:

  • Position power – the job and status of a role or position in the organisation
  • Reward power – the power to reward some and not others
  • Expert power – the power of having more experience and expertise than others
  • Information power – the power of gaining, holding and using information
  • Personal power – the power of loyalty, friendships and the desire to please
  • Coercive power – the power to punish

Our bias gets in the way

For example, confirmative bias where there is a tendency to see patterns in random events so we come to conclusions that might not be right but we stick rigidly to them or we believe that the knowledge and information we have is the right one so we use this to influence the rest of the group.  We quickly make judgements on people based on very little information. We also tend to listen to only information that confirms our preconceptions or views – which makes it hard to have a conversation with someone else.

Or outcome bias when the same “behaviour produce[s] more ethical condemnation when it happen[s] to produce bad rather than good outcome, even if the outcome is determined by chance.”  For example if a healthcare professional makes an error that causes no harm we consider them to be lucky.  If another person makes the same error resulting in injury to a patient we consider them to be blameworthy and disciplinary action may follow.  The more severe the outcome, the more blameworthy the person becomes.  This is a flawed system based upon the notion that we can totally control our outcomes.

Or hindsight bias – ‘why did you do it like that’ or ‘I would never have done that’ or ‘the knew-it-all-along effect’ usually happens after an event has occurred and sees the event as having been predictable, despite little or no objective basis for predicting it.  It may cause memory distortion, where the recollection and reconstruction of content can lead to false theoretical outcomes.

Over confidence

People can be overconfident which again convinces them they are right. The dominant speakers are often the ones who fail to listen. The dominant voice may not be single individuals but having an unbalanced group in the room.

“are you really listening or are you just waiting your turn to talk”?

Robert Montgomery

Human characteristics

The reluctance to speak up is directly related to the culture of the team, the unit, the practice and the organisation. Human beings differ in the way they interact with each other depending upon their personal characteristics.

For example; introverts versus extroverts, shy people versus confident people, male versus female.

Women and Men are often referred to as from two different tribes, each with a set of rules, beliefs and behavioural expectations. There are also stereotypes attached to how we differ in respect of communication. These are the sort of things that people say about females and males:

  • Females are more empathetic, able to read body language and pick up nonverbal cues
  • Females are better listeners
  • Females are overly emotional, meandering and lack authority


  • Males adopt commanding physical positions and displays of power
  • Males are direct and to the point, blunt and insensitive
  • Males are too confident

Stereotypes exist for a reason, lots of women like to chat about their feelings and lots of men don’t but by saying that all men and all women are like that means we put people in a box and label them. We then expect them to act accordingly.  Our gender impacts on how we communicate but so do a number of different variables.

People behave and communicate differently depending upon their mood, the circumstances, the stressors, their role, their race and their status.  The tips and tools to communicating effectively apply no matter which gender you are.  It has everything to do with helping people speak out, helping people listen, respond and act.


What can we do differently?

Thankfully there are a lot of people who are also thinking about this conundrum (see references). We and others believe that it is possible for good conversations to be the norm and have a few ideas to think about:

  • Reframe what you say in a positive way; in conversations, emails, texts, tweets, feedback and so on
  • Provide others with positive feedback so that they can learn from when they get it right and want to replicate that behaviour
  • Use a set of ground rules of respect, kindness, humility and civility
  • Slow down and create the opportunity for people to come to you with new information, questions and ideas – like our gathering round the ‘Kitchen Table’ idea which is simply that – an opportunity for a conversation
  • Reflect on your own power balance with others
  • Notice if you interrupt too much
  • Avoid jumping to conclusions before hearing as much as you can. If you suspend your reaction to what someone else has said, instead of blurting out your reaction or even providing what you think is the answer that you can learn something quite different from what you expected
  • Find ways to hear from the people who are too frightened to speak up for example meet with people in a neutral place to diminish the reminders of the power associated with someone’s office or pairing up or buddying to share views
  • Reduce abstract language, acronyms and jargon
  • Deepen individual skills and practice things like asking different questions that are based on genuine curiosity and listening
  • Be bold enough to admit that you don’t have the answer – be honest
  • Use first names only rather than job titles and biographies
  • Develop a culture of psychological safety. Any conversation needs to help people feel safe to talk and to ask questions
  • Pay attention to the way the conversation is restricted or encouraged by the language and the participants themselves
  • Pay attention to who is in the room, how the individuals engage with each other, who dominates and who is silent – if you notice all of these things you will go a long way to creating the right conditions for an effective conversation to take place
  • When you are arranging a meeting or conference, provide less time for the speaker and more time for the audience or participants to discuss
  • One of the hardest bits……. allow for the silence to linger. Silence is often because the people you are with are simply reflecting, have a conversation with themselves in their mind and will respond if you give them time. If there is silence don’t just fill it – wait for thoughts and questions to come

Above all we need to help people engage with each other, participate in meetings, events where they can learn to talk to each other, strengthen relationships, challenge and share ideas and share concerns. It needs to be highly interactive and provided in a positive way that helps people talk in small groups.

When you are genuinely interested in what others are thinking and feeling it gets easier and easier.


  • Nancy Dixon (2017) Building a ‘speaking up’ culture in Teams via
  • Schein E (2013) Humble Inquiry: the gentle art of asking instead of telling
  • Robert Kegan and Lisa Laskow Lahey (2016) An Everyone Culture: Becoming a Deliberately Developmental Organisation – Harvard Business Review Press
  • Amy C Edmondson (2012) Team: How organisations learn, innovate and compete in the knowledge economy – Harvard Business School
  • Amy C Edmondson (1999) Psychological Safety and Learning Behavior in Work Teams – Cornell University Administrative Science Quarterly (44, 350-383)
  • Catherine Turco (2016) The Conversational Firm: Rethinking Bureaucracy in the Age of Social Media – Columbia University Press
  • Sean Stevens (2017) The Fearless Speech Index: Who is afraid to speak and why? Via
  • Liz Wiggins and Harriet Hunter (2016) Relational Change Bloomsbury Publishing
  • Steve Shorrock –


Learning from excellence conference

Every now and then you meet some people who change you

Every now and then you hear a speech or presentation or talk that changes you

Every now and then you talk with others and it changes you

All three of those happened for me yesterday at the wonderful conference ‘Learning from Excellence’.

I was wondering how I would share the learning for others and got stumped at the first hurdle – because this was one of those things you felt and experienced, you just kind of had to be there.  However that’s unfair on anyone who couldn’t go so I shall do my best for you.

The conference was organised by West Midlands Patient Safety Collaborative in conjunction with a group called Appreciating People.  It was billed as the first Learning from Excellence Community Event.  The starting point for it all was in 2014 when Adrian Plunkett and Emma Plunkett (two of the loveliest people you could ever have the pleasure to meet) had an idea that has taken off and spread in just three years to becoming a movement of people who recognise the need to not only learn from when things go well but to be overwhelmingly kind to people who are kind and let them know that they have done something good.

Adrian and Emma have stimulated a whole new way of capturing positive feedback for those that work in healthcare and have two main aims of learning from excellence:

  • Improve quality by learning from what works well
  • Improve morale

If you want to know what good looks like when it comes to organising a conference you need to look no further than this one:

  • Usual comfort things like venue, food, enough toilets for a large audience (believe me that’s important!) space to sit etc.  All sorted.
  • A beautifully crafted agenda that thread its way from why we were there, injected with short presentations and quality time for discussions with the audience sharing experiences and ideas, to what we could all do differently and then finally to what could and will happen next.
  • Every conversation, every presentation, every discussion built upon each other in a way that added value to what came before and enhanced our learning.  They were all connected in a meaningful way to the  theme or thread of learning from excellence.


How has it changed me?

  • Meeting Emma and Adrian has changed my perceptions (in a good way!) of what is possible for a small number of individuals to make a massive impact
  • Hearing from Neil Spenceley, Andy Bradley and Chris Turner enlightened and moved in equal measure.  A master class in presenting and sharing from all three in their unique different ways – (note) Neil has a Risky Business talk which is a must watch –
  • Hearing from and talking with others has made me realise how every part of what we do can be reframed in a way that leads to a much more positive interaction
  • The whole conference has confirmed for me that our work in patient safety and changing the culture of the NHS needs re-thinking and re-framing and has changed the way my next book is evolving

That’s pretty profound.

Take home quotes:

The bottom line is the frontline (Emma Plunkett)

Move from humiliation to humility (Neil Spenceley)

Incivility is the biggest patient safety concern in healthcare (Neil Spenceley)

When I did a shift as a cleaner I got a superpower – I became invisible (Neil Spenceley)

Would you and could you do someone else’s job for the day (to truly learn about what it is like for others) (Neil Spenceley)

When someone shares with you what you have done well, it makes you want to keep doing that (Adrian Plunkett)

Civility saves lives (Chris Turner)

How we behave towards each other is the single greatest factor in how well our teams will perform (Chris Turner)

Minor incivility has significant impact on performance with 61% reduction in cognitive capacity on recipients, 20% decrease in performance for ‘onlookers’ and 50% reduction in willingness to help others (Chris Turner)

The twitter hashtag #LfEConference will provide you with so much joy and positivity you will be hooked!

Better Culture, Safer Care – Guest Blog by Matt Hill


How we are helping to improve safety culture in the SouthWest

Guest blog by Matt Hill

At the South West Patient Safety Collaborative (SW PSC) hosted by the South West Academic Health Science Network (SW AHSN) we do a lot of work around safety culture. We run a programme called Better Culture, Safer Care which encourages teams to pay attention to and engage with their local safety culture, using different tools such as a survey tool called SCORE which we use in the South West and which measures aspects of teamwork, safety, learning environment and how we improve, local leadership, burnout and work/life balance.  We are also working with NHS Improvement on the national culture work stream, for which I am pleased to be the clinical lead.

Whilst the measurement is the focus of the process, the key to shifting the team culture is the conversations amongst team members that it generates throughout the process. The impact of this programme and those conversations has been really positive and we’ve been sharing its ongoing success in a series of blogs hosted on the SW PSC website.

In this blog we’re going to highlight the stages that facilitate the conversations and do a whistle stop tour of how Better Culture, Safer Care is being used across the region in a wide range of healthcare settings.

Conversation 1

The initial step in the process is to consider who is in the team. We often find that people consider the team to consist of the nurses and doctors but forget about the physios, receptionists and porters who work alongside them to achieve the same goal. It also highlights that we struggle to communicate effectively with all members of the team.

Conversation 2

The explanation to the team of the importance of the safety culture and its links to patient outcomes and staff welfare is a crucial step to motivate the team to complete the questionnaire. Allied to this, it is essential that staff understand that the survey is anonymous and that staff feel psychologically secure enough to answer questions honestly. It is also important that staff know that the results will come back to the staff shortly after they have completed the survey and that they will be used to try to improve aspects of the team culture.

Vicky Romback is from the Glenbourne Unit – a mental health unit which is part of Livewell Southwest.

“The team at Glenbourne were happy to commit to completing the survey…particularly when we described how it was aimed at giving them a picture of how their attitudes, feelings and behaviours might impact on how safely the care was delivered in the unit…my lot take those matters very seriously as you’d expect from an impatient mental health unit rated as ‘Outstanding’ by the CQC.”

Full blog here

Annette Rickard is Consultant in Emergency Medicine at Derriford Hospital, Plymouth.

“We first ran the SCORE Safety in July 2015 and asked everyone in the department to fill it in. We pre-warned staff members and managed to get champions across the tiers – communicating why we were doing the survey; encouraging people ad hoc and getting nurse champions to encourage peers to complete it. We also created a few screensavers explaining what safety culture was.  We were actually really pleased with our response rate, as around 60% of people completed the survey.”

Full blog here

Conversation 3

The Results: this is a non-judgemental process and the results should be used for celebrating strengths and identifying opportunities to improve. They are not about benchmarking or assurance.

Debriefing the results to the local leaders: the results are discussed with the local team leaders first to generate hypotheses about why staff may have answered questions in a particular way. The results should not be justified by the local leaders in any way.

Annette Rickard… “Allan Frankel of IHI talked us through the analysis and the results and put perspective on it. He was able to explain about safety culture and how the SCORE survey tool explores what level of safety culture you have reached within your own organisation – not about comparing with other departments or areas. Once we had received the results we wanted to know more about individuals’ responses.”

Conversation 4

The next step is to debrief the staff to gain the insights into why they have answered questions in particular ways. This is best done using an appreciative inquiry technique and is a crucial step in generating the ideas for the improvement work that this will lead onto. It is essential that the debriefing is carried out in a psychologically secure way so that staff are forthcoming with their views and ideas.

Tina Campbell is Associate Director Medicines Optimisation and Controlled Drugs Accountable Officer at Devon Partnership NHS Trust

“I’m often perplexed why – when it looks like all the ingredients for a great team are there – the reality of ‘being’ in the team is sometimes less than ideal and quite stressful….We are a very productive, effective and efficient team but there had always been something around our ‘team dynamics’ that wasn’t quite right.  We struggled to put our finger on it, but SCORE added another dimension to our conversations and assumptions and forced us all to have a different – and – if I’m honest – a more personally challenging conversation. SCORE has given us a valuable way of delving down into a deeper layer of understanding and insight into how we work together.”

Full blog here

Susanne Smith is Susanne Smith is a Lecturer at Plymouth University Peninsula Schools of Medicine & Dentistry, where she is joint programme lead for the Simulation & Patient Safety MSc, she is also a member of Q.

“Whilst it’s often good to take stock and measure aspects of quality performance, I have been repeatedly struck during the course of SCORE debriefings how the most valuable aspect for staff seems to be the opportunity to talk in a psychologically safe place. I’ve seen amazingly honest conversations, real appreciation of the difficulties of other people s roles, offers of support, and heard tales of how staff have battled austerity, chronic staff shortages, unsupportive systems, physical isolation from key teams/staff, problems with unhelpful professional hierarchies/boundaries, and burnout.”

Full blog here

Conversation 5

Whilst there may be benefits from the conversations in the process so far, the next step of bringing all of the ideas together and identifying which aspects team members wish to work on is vital. Staff involvement in improvement work that they believe is important helps to improve staff welfare and adds meaning to work. It also demonstrates that they have permission to make things better and that they have control over their workplace. The on-going discussions about the improvement projects facilitate further discussions about how the team functions.

Annette Rickard….. “One of the key messages that came out of the survey was a really simple thing to fix. It was highlighted that there was an element of poor communication within the department and this was something that we could fix really quickly and easily, simply by improving the way people speak to each other and getting people to think about the way they were speaking to each other…. For some people, key areas of dissatisfaction were the nursing rota, for others printer problems or the interface between wards and work has started on this by our own staff groups who feel passionately about the problem.”


Dr Jillian Denovan is a GP from Pathfields Medical Practice in Plymouth has established team Huddles at the Pathfields Medical Practice, part of a group of four primary care practices.

“Our SCORE results showed us that there was an opportunity to improve teamworking within the practice, so we looked into a variety of options to help support this. We decided on implementing team “Huddles”, which are team-based meetings aimed at providing a forum for highlighting operational and patient safety concerns. Huddles are used widely in the pre-operative hospital setting, and have shown to have a vast improvement in team communication, patient safety and staff satisfaction in primary care. Most importantly, a team with greater cohesiveness produce better clinical outcomes and higher patient satisfaction.”

Full blog on the South West Patient Safety Collaborative website.

Colin Stuckey is CT Lead Radiographer at Plymouth Hospitals NHS Trust and talks about using the SCORE survey in his department.

“We had managed to garner lots of really interesting information from the groups we debriefed and they have made loads of positive suggestions for change for quality improvement. The upshot is that, via the survey, the team have come up with some really great ideas of ways to support me in my role. It was also really useful to show to my manager what the team were feeling– a lot of it was wanting better communication with the senior management teams, which is so easy to achieve with no added cost to the department.”

Full blog here

Summing up

The socialisation within healthcare is a crucial aspect to high quality care and it has become increasingly hard for teams to meet and have conversations about the care that they deliver.

The conversations that happen as a result of using the SCORE culture survey tool allow teams to understand their perceptions, attitudes and behaviours. This allows teams to celebrate the good aspects of their team whilst identifying opportunities to improve, which they can then develop into improvement projects.

It has been a privilege to be involved with so many teams who want to understand their culture and have a desire to get better. The passion that frontline healthcare workers from all disciplines have to deliver high quality care, and the renewed understanding of the crucial role that each of has in looking after other members of the team and shaping the local culture is reassuring at a time of so many other pressures. We need to create the space to care about our team culture.

 Dr Matt Hill


Working safely

I’ve been writing a lot of long blogs lately – here’s one for those that want it short and sweet!

  • Safety is not a task, a set of interventions – it is a mind-set where people are doing their best to work safely
  • Working safely is all about people, relationships and conversations
  • The reality is that working in healthcare is ‘organised chaos’ with everyday people adjusting what they do to the conditions they work in and making difficult decisions every day
  • Not all tasks can be described in detail – the real world is all about adapting not adhering to unworkable manuals
  • People are disconnected by silo working, professional tribes and processes that keep people separate – we need to create ways in which we can connect these people up – in the words of Jo Cox we have ‘more in common with each other than that which divides us’
  • People are confused and conflicted by the endless top down directives, layer upon layer on the ones before generated from outside and within their organisation
  • Implementation is an after thought – it is in fact a science and requires time, skills and effort

What can we all do differently?

  • help people to stop and take time for themselves
  • encourage people to stop doing stuff that doesn’t work or doesn’t add value
  • be consistent in your response when things go wrong
  • role model the behaviours you want to see – kindness, civility, respect, humility and positivity
  • engender a spirit of positive inquiry in work
  • help people create relationships and have conversations that break down barriers, cut across the vertical walls and create new insights
  • help people with the confidence and skills to solve problems together
  • listen to people so that they can talk without being judged – pay attention to what they are saying
  • narrow the gap between ‘work as imagined’ and ‘work as done’ – from what people think others are or should be doing to learning about what they are actually doing and what they actually can do
  • avoid short term answers to long term problems
  • think about purpose before everything… what is the purpose of this meeting? what is the purpose of this intervention? what is the purpose of this task?- if you cant answer then don’t start until you know

Relevant books and websites

  • Dave’s Subs: A novel story about workplace accountability – David Marx
  • Turning to one another – Margaret Wheatley
  • This is Going to Hurt – Adam Kay
  • Your life in my hands – Rachel Clarke
  • Humble Inquiry – Edgar H Schein
  • Relational change – Liz Wiggins and Harriet Hunter
  • Human Factors and Ergonomics in Practice – Steve Shorrock and Claire Williams Eds
  • Team of Teams – General Stanley McChrystal
  • Black Box Thinking – Matthew Syed
  • Safey-I and Safety-II – Erik Hollnagel
  • Rethinking Patient Safety – Suzette Woodward
  • When breath becomes air – Paul Kalanithi
  • Reinventing organizations – Frederic La Loux
  • The (honest) truth about dishonesty – Dan Ariely
  • Do No Harm – Henry Marsh
  • The Checklist – Atul Gawande



Helping people talk to each other – about learning from excellence

The principle type of learning from ‘learning from excellence’ is the same as the learning we experience from any type of feedback.  The main difference is that it is exclusively positive feedback – an extremely rare phenomenon in today’s NHS.

Adrian Plunkett (2016)

I’m really looking forward to spending this coming Thursday surrounded by positivity and people like Adrian and Emma Plunkett who are leading an event ‘Learning From Excellence’ in Birmingham this week.

Most of the work to date on helping people working safely (patient safety) is about what went wrong. This causes people to focus on how bad it all is and people as a result feel negative, demoralised, frustrated and isolated.  The more we focus on what went wrong the more the problems and difficulties are all we see or talk about.

Learning from excellence is a ‘call to action’ from a team of clinicians and researchers who have a shared cause; to learn from what goes well in healthcare.  While this is a growing concept the pioneers are Adrian Plunkett, Emma Plunkett, Nicki Kelly, Simon Blake and Gabriella Morley and it also has links to the work of resilience engineers such as Erik Hollnagel.

Adrian says that at the heart of ‘learning from excellence’ is a simple, formal positive feedback tool, which allows peers to show appreciation to each other.  That those that receive the excellence reports are made aware of the positive effects of their actions and gives them the opportunity to reflect and think about why their actions were so well received.  As a result people often go on to make changes in their future behaviours based on the new awareness they have of their positive actions.

In relation to ‘celebration’ Adrian goes on to say that while he is all for celebrating achievements, if we celebrate something (or someone) everyday, we devalue that which we are celebrating. Whenever we create winners, we also create losers. For every award-winner, there are countless colleagues going un-rewarded; under the radar.

Therefore a key feature of learning from excellence is that the positive feedback from each report is privately shared with the staff member who has been reported for excellence. As Adrian says there is no overt celebration. No league-tables or performance charting. Learning from Excellence is a way to show appreciation.

Appreciation is more subtle than celebration. It is not a reward. It is not a prize. It is noticing the good. Showing our colleagues that we have noticed their good work is a powerful motivator, because it shows that they are valued in their work.

Learning from excellence in healthcare: a new approach to incident reporting (2015) by Nicola Kelly, Simon Blake, and Adrian Plunkett

Ref: BMJ Vol 101 Issue 9

In the above article the authors set out how learning from excellence can help improve the way we work safely.  It is so good I have lifted the following for this blog (italics taken directly from the article):

Eliminate the negative

In healthcare, we tend to place greater emphasis on identifying and examining failures of systems or individuals rather than recognising and reflecting on positive processes or outcomes…recent psychological research has revealed that people can learn effectively both from reflecting on failure (negative reinforcement) and success (positive reinforcement). Studies involving front-line healthcare professionals have shown that nurturing positivity in individuals and teams is linked with improved resilience and ability to deal with adversity.

Accentuate the positive

In healthcare, there is innate performance variability within almost all systems, which explains why things sometimes go wrong, but more often why things go well. It is often true that in medicine patients are seldom ‘textbook’ cases and our working environment is rarely perfect, but rather it is risky, unpredictable and challenging. Human performance varies in response to the changing environment. While some of this variation is unsuccessful, leading to error or harm, a great deal of variation in performance leads to success through adaptive adjustment.

These adjustments, or ‘workarounds’, are strategies for overcoming problems or limitations to compensate for variable conditions. This is an example of resilience in the healthcare context, which allows an individual or team to function effectively in a demanding and changeable environment. Although a clinical outcome on such an occasion may not be outstanding or perfect, the adaptability or resilience employed by staff in order to ensure a safe and satisfactory outcome could in itself be viewed as excellent practice.

Noticing everyday examples of good practice, and learning from the adjustments required for successful outcomes in variable conditions, ‘Safety-II’, is an emerging approach to safety. Safety-II originates from the concept of resilience engineering, a new way of considering workplace performance and safety, taking into account ‘work as done’ versus ‘work as imagined’. Resilience in this context refers to the ability of a system to adjust its functioning in response to changes in conditions. The goal of the Safety-II approach is to ensure as many successful outcomes as possible by recognising and learning from good practice and functional adaptations to variation in conditions. The Resilience in Healthcare Initiative, led by Professor Erik Hollnagel, aims to apply resilience engineering practice to healthcare worldwide using Safety-II methodology as a key foundation.

A related, emerging approach in healthcare is the ‘positive deviance’ model, which looks at the variations in performance and process that result in good outcomes rather than harm. The hypothesis behind this model is that by seeking and studying groups or individuals who perform exceptionally well, methods for best practice can be identified and disseminated to improve wider performance.

Safety-II and positive deviance methodologies are not currently highly prevalent in healthcare. Reasons for this may include the lack of clear strategies for defining and measuring excellent and safe practice; our innate negativity bias; or our current regulatory climate, which focuses our attention and resources on harm. We believe that improving resilience in healthcare organisations, through application of concepts such as Safety-II and positive deviance, will benefit patients and staff by optimising safety and by helping to improve service quality and efficacy.

Learning from excellence reporting

Learning from Excellence (LfE), aims to provide a means of identifying and capturing learning from episodes of peer-reported excellence or positive deviance .. the spirit of LfE is to treasure and appreciate our everyday successes, rather than taking them for granted. LfE was developed with the hypothesis that reporting and studying success would augment learning, enhance patient outcomes and experience through quality improvement work and positively impact resilience and culture in the workplace.

LfE began with a pilot project in Birmingham Children’s Hospital’s Paediatric Intensive Care department (PICU) as a system for all staff to voluntarily report episodes of excellent practice. Reports are submitted via an intranet-based ‘IR2’ form, suitably juxtaposed to the adverse incident reporting ‘IR1’ form used within our organisation.

They did not provide guidance or restrictions on which types of episode to report, leaving the reporter to apply their own definition of ‘excellence’. Staff in receipt of an IR2 received an automatic email notification and the reporter received an email acknowledgement. LfE is championed by a small multidisciplinary team of front-line clinical staff, who review all reports, creating weekly summaries with learning points, which are shared with the whole department through an e-bulletin.

How learning from excellence can be used to investigate good practice

In order to identify and enhance learning opportunities, reports are given an in-depth consideration at an ‘IRIS’ (Improving Resilience, Inspiring Success) or ‘reverse SIRI’ (Serious Incident Report Investigation) meeting. An IRIS involves a group dialogue between those submitting and receiving the IR2 of interest; facilitated by LfE team members using appreciative inquiry (AI) methodology. These hour-long informal reviews aim to identify how excellence was achieved, including ‘workarounds’ or innovations employed, and to generate ideas for sharing and promoting excellence.AI nurtures a positive mind-set and helps gain new insights into moments of optimal performance. The generative dialogic nature of AI encourages participants to share and reflect upon their ideas for positive change.


  • Learning from excellence is an approach, which redresses the balance between analysing failure and success
  • Excellence reporting can be used as a tool to capture useful workarounds and adaptations at the ‘sharp-end’—essential components of the Safety-II approach
  • The basic principles could be adapted and applied to engage individuals and teams in the process of identifying and sharing excellence in everyday practice
  • The use of appreciative inquiry to investigate excellence has generated new insights into understanding how processes can work optimally
  • Benefits include; improved patient care and staff development, identifying, sharing and modelling excellent practice, supporting staff involved in accidents and incidents, a positive workplace culture and morale, sharing good practice, identify and support innovation and discover new ideas and insights to inspire and facilitate quality improvement
  • Excellence reporting has been shown to identify and promote excellent practice within a front-line clinical environment, it could also be applied effectively to a wider range of healthcare settings including medical training, professional development and healthcare governance
  • This intervention may also help to develop a workplace culture whereby team members feel more appreciated and motivated and their hard work is recognised with positive feedback

The Learning from Excellence philosophy is really closely aligned to our work at Sign up to Safety.  Learning about what works, day to day experiences, good experiences and in deed excellent experiences are vital data to help people work safely.

It is great that we are all striving to redress the balance

At Sign up to Safety we talk a lot about ‘saying thank you’ – but it isn’t about a grand gesture of ‘thank you’ but much more a small act you can do as often as you like to show your thanks to people around you for whatever you feel they need thanks for.

What has this got to do with conversations?

Talking about what is working well changes the whole conversation completely.

Learning from excellence and other concepts such as appreciative inquiry are underpinned by the principles that learning and improvement should come from a place of understanding how things work well. Positive thinking shifts us from what we could have done differently to what would we like to continue to replicate.

A positive inquiry requires all of the aspects of a good conversation. A way of explaining what is working well through storytelling and personal experience, listening to what is being said and asking both clarifying and probing questions to find out more.  It is dependent upon the right set of behaviours, respect, humility, curiosity and kindness for it to work well in itself.

What we have seen from our own experience and then through others such as Adrian and Emma Plunkett is that positive inquiry and positive conversations are energising and uplifting.

What can you do differently?

  • Consider holding a ‘kitchen table’ (for this any other information about our work please go to the sign up to safety website) or any other methodology for bringing people together to talk to each and ask them to share something they are really proud of, or a task, day, shift or act that they felt went really well or simply to talk about what works rather than what doesn’t
  • When investigating incidents, complaints or claims include in the inquiry questions ‘what went well’
  • Forensically investigate care that went well and identify the points that you would like to replicate time and time again for the future
  • Take time to say thank you




Guest Blog – Phil Riddell: Social media and safety – sharing what you know

This blog is the transcript of a speech Phil Riddell was asked to give at Central Manchester FT in May 2017. Since then Phil has graduated and is now a Junior Doctor.

Hi, my name is Phil, I’m a final year student down at Cambridge and I’m interested in patient safety.   I know that medical students, interested and patient safety are not commonly said in the same sentence, but bear with me.  

I know many students who are interested in ‘cool’ things, like being a neurosurgeon or a cardiologist. In Cambridge, we have student societies for pretty much any specialty you can name that advertise careers in these exciting fields.  None of these consider patient safety as part of their remit. This is compounded by more senior staff omitting, albeit subconsciously, that patient safety is part of their work because it may not be as cool as a coronary artery bypass graft.   So, how did I come to be interested in patient safety?  

Well, things were happening on my clinical placements that I just couldn’t get my head around.  In my first week as a clinical student, I was shadowing one of the pharmacists and she found three errors on a single drug chart.  Errors kept happening in my clinical placements, the majority of them were near misses. But that didn’t stop me thinking about what could have happened to that patient, or a future patient.  Some would say I’m a bit of a worrier, but because the consequences of errors can alter the whole patient experience, I feel that it is not worrying- its just trying to learn from every opportunity I can.

So with this interest, I decided that I needed to know more about keeping my patients safer- and my wishes were granted with some teaching from the clinical school.

Patient safety is a topic of teaching that is relatively new in medical education.  From my limited knowledge, it is taught to varying degrees at different medical schools, with even more variation in the impact of that teaching. In Cambridge, we have Professionalism days, where we sit down and have a set of lectures on various topics.  We’ve had a single day on patient safety and human factors- it is a great start, but it was not enough for me. My problem was that it was too didactic- I needed to think about things myself.

So I started to talk to other students about safety, except that when I talked to my colleagues about my interest in patient safety, I was met with looks of bewilderment.  “Why are you interested in that?” “It’s all about finding someone to blame.”  

It’s not hard to see why they say things like this.   Our Patient Safety day turned into an exercise where we were told about big errors that had happened.  As students, we discussed them at length, but ended up laying the blame at someone’s feet.  This just didn’t seem right to me- I knew people who had been involved in near misses before and they weren’t incompetent, they had just made an honest mistake.

Very few of my colleagues seem to acknowledge that safety will be a big part of whatever career we chose as healthcare workers.   Take the recent NPSA alert about medical air valves on wards- that affects every patient that comes into hospital, regardless of which team they are admitted under. As an organisation we are constantly learning about potential, or actual safety incidents and reacting to try and prevent them from happening in the future.  What we learn as an organisation impacts on the experience of so many of our patients.

As you can tell, I still wasn’t satisfied. As a result, I’ve had to look elsewhere for some experience of what it is truly like to work in Patient Safety.  I managed to get a week with the Clinical Governance lead in Papworth hospital, which was a good taster.  More importantly, that’s when I was introduced to Sign Up To Safety.

‘Great’, I thought.  Here is a group of people who are willing to help me get a glimpse of what patient safety is really like.  I had a list of questions ready- what can I read, who should I be listening to and so on.  But then what happened was they asked me to talk about life as a medical student from a safety perspective.  

This time, it was my face that looked bewildered.  Who was going to listen to me? I was just some Graduate-entry medical student who could regurgitate lots of facts under exam pressure. I have thoughts, but no one will be interested in them, because they simply cannot help. 

Regardless of my doubts, Sign Up To Safety were keen to get my views online and out into the wider world.  Cat Harrison worked tirelessly with me to make sure the thoughts that I came up with were distilled into something that was readable.  That in itself was a feat, as my science degree and upbringing in Salford did it’s best to ruin any form of narrative.

My first post centred around the role of medical students in safety.  Cat encouraged me to really think about what I was experiencing, how it made me feel and what that meant for me going forward as a medical student and future doctor.  In essence, she was getting me to narrate my reflections. 

Reflective writing, eurrrghh.  Some of my student friends hate that phrase.  It’s code word for another piece of work that no one is going to read and comment upon. But I had faith in Cat and Sign Up to Safety- they had a vision… “we want to help people to share what they know about keeping people safe”…. and they definitely had more experience than I did. 

Over the next few months, Cat encouraged me to write more.  She read each piece and made comments on how I might further unpick what I had seen. She suggested other things that I might be able read to help me gain some clarity.  Then she put them online.

The first few were simple posts that went out and may or may not have been read by the wider audience that followed the work of Sign Up To Safety.  That suited me- I was only just starting out in the massive world of patient safety.  I think I would have panicked if someone sent me a message. I still felt like I didn’t really belong in the world of safety. 

Then, after a few posts, I got a comment from someone who had read my posts and liked what I had said.  They wanted to share it with their colleagues because something within it had resonated with them. 

Since then I’ve gone on to write about various experiences that I have had.  As I’ve written more, I’ve come to the realisation that we all have something important to contribute to safety, we just need to find a way to distill these experiences into a coherent form.  I’ve managed to do that through my reflective writing.

We all take time to reflect on things that happen to us during the day, I’ve just taken a leap of faith and given others an opportunity to know how my experiences have made me feel and how they will shape my future practice.   You don’t need to be willing to write yourself to help others learn. You just need to be willing to listen and discuss.

The key ingredient in my writing is not me.  It is those who have listened to what I have said and discussed what I’ve written who have enabled me to take my work further.  It’s people like Cat, and later Dane Wiig from Sign Up To Safety, that have taken the time to read what I have to say and offer what I would say is ‘constructive encouragement’.

This key ingredient became clear to me a few weeks ago when I received a notification that feedback is now available on a palliative care essay that I submitted to the clinical school over four months ago.  Usual comments are short and sweet, limited to ‘Good essay’, or “Satisfactory work”.   I was expecting the same sort of comments this time, but I was pleasantly surprised by what I found instead.

The full feedback was no more than a paragraph, but here are the key things for me: 

 “Thank you Philip…”

Wow, someone was grateful that I had made the effort to reflect upon my experiences.   They instantly made me feel that my perspective was valuable to not only myself, but to them as well…

“Have you looked at the…”

My jaw was on the floor again.  Not only was what I said appreciated by my ‘marker’, but they had taken the time to think about how I might be able to develop my ideas further after this essay was consigned to the depths of the medical school archives.  Sufficed to say I have now followed up on each of her suggestions and am grateful that she pointed me in the direction of those resources.

I think this applies across all the work we do.  If you really want to engage someone and help them develop further, you thank them for their current contributions and suggest how they can improve in the future.  We do it all the time in our specialties- we will look at what we are currently doing well and then suggest areas for further reflection.  I don’t think Patient Safety should be any different- we should be thanking people for being confident enough to share their thoughts, and suggesting what they can do to build on that. These discussions will help us all to improve the safety of our patients.

I know that some in the audience will still be sceptical about sharing their thoughts in a public domain as large as the internet.  Once your thoughts are out there, you can’t take them back.  Everyone will be able to see them.  That is something that scares a lot of people, and heavy guidance from the GMC, NMC and other professional bodies can feed this fear.

However, I disagree that this guidance should prevent us from sharing our experiences.  

“The standards expected of doctors do not change because they are communicating through social media rather than face to face or through other traditional media”.  (GMC)

“Use all forms of spoken, written and digital communication (including social media and networking sites), responsibly.  ” (NMC)

Both of these sets of guidance clearly state that any communication online should not bring the profession into disrepute, but this does not stop us sharing what we think, as long as we do this in a responsible way.  I agree with the GMC- our standards do not change, but these standards do not stop us from sharing what we know verbally with our local colleagues.  Why should they stop us from sharing with our colleagues around the world?  Why share and discuss with just a few, when you can do the same with so many? The potential impact could be far greater, for both you and others.

Committed reflection has really helped me to develop my patient safety skills and knowledge, and the discussions I’ve had with people about my reflections, both on- and off-line, have only served to whet my appetite for Patient Safety and my future career.  I hope it can for you and your colleagues too.  Thank you.