Kitchen Tables.. why?

Its Kitchen table week from next Monday!!!

How exciting is that.  Here are some quick key points for you to think about what you are trying to achieve.

‘Your kitchen table could help you……

  • Find out from your staff how your organisation could be better at listening
  • Bring people together from different parts of the organisation working on different things to share experiences and insight
  • Bring people together to share what they think works really well when they care for patients so that we can start to make the transition from Safety I to Safety II a reality
  • Reach out to people who may not normally be included in the conversation like porters and catering staff to find out what they know about keeping people safer
  • Talk to each other about how you think your corporate objectives relate to working safely
  • Take a moment to reflect together on what you are doing now in your safety work and what you wish for the future
  • Share ideas for steps you can all take that are free and don’t need permission but can make all the difference in building positive relationships and a strong safety culture; our website is full of them!
  • Reach those who find it difficult to take time to connect by going to them. Many of last year’s kitchen tables were really kitchen trolleys!

What matters is helping people feel welcomed, heard, listened to and understood.


Just Culture

I was recently told a story about a nurse.  He had given the wrong patient a drug which was supposed to be given to another patient.  He immediately knew that he had done this and instantly checked the patient, called 111 (this was in the community), informed the family, went with the patient to hospital and stayed with them for the next 16 hours or so.  Also at the same time informed his line manager and even referred himself to the Nursing and Midwifery Council.

If I was this person’s line manager I would clearly want to understand what happened but I would also console the nurse and ask him what I can do for him and applaud him for his actions following the error.  Instead the nurse is being disciplined.  That to me is not applying the Just Culture.

What do we mean by applying the Just Culture?

I recently shared an adapted definition of a just culture from the Skybrary website  at a presentation.  It was:  ‘A just culture is one in which people are not punished for actions omissions/decisions which are commensurate with their experience and training but where wilful and intentional actions are not tolerated’.

Definitions, and trying to bring clarity to a complicated subject, rightly leads to others saying things like ‘well there is a hell of a lot more to it than that!’.

Yes there is.

There are a number of different views on the Just Culture and a fair few myths and misconceptions.

David Marx describes how we should try to distinguish between different behaviours and respond appropriately and proportionately to these behaviours.  His books (Whack a mole and Dave’s Subs) try to help us understand the differences between error, (some refer to is as human error), risky behaviour, reckless behaviour, negligence and criminal intent or wilful acts.  He and others such as Prof James Reason would describe the big three as:

  1. Human error:  inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake
  2. Risky behaviour:  choices that increase risk, where risk is not recognised or is mistakenly believed to be justified – includes violations and negligence
  3. Reckless behaviour:  behavioural choice, intentional acts, conscious disregard to a substantial and unjustifiable risk

There are a number of toolkits, guides, decision trees that try to help with these distinctions. One of them is found at the Skybrary Just Culture Toolkit Just culture section.  Developed by Job Bruggen a safety manager at Air Traffic Control the Netherlands and Patrick Kools of GoGen – Beyond Rules.  A summary of the toolkit is below.

You might want to think of the nurses story at the beginning and ask where the case fits and what the response should have been.

Level – (the behaviour – the response)

  • Level 1 – Exceptionally skilled handling of a safety situation – recognise and reward exceptional behaviour as an important element of a just culture
  • Level 2 – A person suggests an improvement to the system – recognise and reward as a way to motivate others to do the same
  • Level 3 – People helped others to understand and operate the system better – sharing lessons learnt is a major milestone and significant contribution to safety, recognise and reward
  • Level 4 – Day to day good practice – working well on a day to day should not be trivialised, recognise and reward the desirable state to continue to motivate
  • Level 5 – Someone made an error (slips, lapses, omissions, commissions including wrong procedure applied), the actions are unintentional – there are some detailed notes here on what to do in response, I would sum up as understand and find out why, console and support
  • Level 6 – A rule or procedure was not followed – either the rule was not known or the rule was too ambiguous or complicated to understand properly – again there are some detailed notes here and again I would sum up as understand and find out why and coach the person about what they could do differently in the future
  • Level 7 – Although the person knew about the rule and the rule was in principle workable, he or she decided it was not applicable, this could have been to optimise the situation or to be helpful – again there are some detailed notes here and again I would sum up as understand and find out why and coach the person about what they could do differently in the future
  • Level 8 – Person knew the rule and person knew it was not followed but that suited him or her, they were acting recklessly – this needs to be dealt with promptly and may involve sanction although always apply the principle of first understanding and finding out why

Sidney Dekker suggests it is perhaps impossible to draw neat lines around behaviours and that there are blurred boundaries between them; that someone can be both erroneous and risky and what really is the difference between risky and reckless behaviour?  Who gets to draw the line?  He says that an organisation’s journey to a just culture will never be finished.

Justice is one of those categories about which even reasonable people may disagree. What is just to one is unjust to another.

Sidney Dekker suggests having a different mind-set and create a climate of honesty, care, fairness and a willingness to learn, with five key points.  This below is from his excellent editorial in Hindsight.

You might want to think of the nurses story at the beginning and ask whether his treatment is aligned with or misaligned from these points.

Don’t ask who is responsible ask what is responsible.  That people’s actions make sense once we understand the critical features of the world in which they work.  Targeting these features (the what) is an action that contains all the potential for learning, change and improvement.

Link knowledge of the ‘messy details’ with the creation of justice.  What he means here is if someone is going to ‘judge’ another’s actions then they should have all the relevant technical knowledge to do so.  Someone who knows what the work is like, the subtleties of what it takes to get the job done despite the organisation, the rules, the multiple constraints.  So ‘make sure you have the people involved in the aftermath of an incident who know the messy details, and who have credibility in the eyes of other practitioners’.

Explore the potential for ‘restorative justice’. Retributive justice focuses on errors or violations requiring retribution, restorative justice focuses on errors or violations requiring healing.  This acknowledges the multiple truths, each side of the story and point of view about what could have gone wrong and how it normally goes right.  It takes the view that people do not come to work to do a bad job. It fosters dialogue and relationships rather than fostering adversary and create breaks in relationships through sanction and punishment.

Go from backward to forward-looking accountability.  Backward-looking accountability is about blaming people for past events leading to sanction, removal or dismissal of people. This instils a sense of fear and doesn’t help learning, it only leads to reduce reporting and disclosure.  Instead forward-looking accountability sees individual actions as representing organisational, operational, technical, educational and other system issues. People are not a problem to control but a solution to harness.

Put secondary victim support in place.  The practitioners involved in an incident are often referred to as ‘secondary victims’.  This term is not liked by all.  Whatever term we use, Dekker suggests that there should be strong social and organisational support systems for these people.

How about talking about this subject in one of your Sign up to Safety Kitchen Tables?



David Marx.  Books – Whack a Mole and Dave’s Subs

Sidney Dekker.  Book – Just Culture – Balancing Safety and Accountability

Skybrary – website

Violations / risky behaviour

A key part of my job is to explore what it takes to create a safety culture.  I spend a lot of my time thoroughly enjoying reading research, opinion pieces, blogs and books on safety culture and just culture.

No aspect of either a safety culture or just culture is delightfully black or white, one thing or another.  There are blurred boundaries and nuances to every aspect of each.  Some aspects lend themselves to clearer boundaries such as error or criminal intent but its the middle that causes concern or confusion.  What to do with people who take risks or people who are considered reckless but not intentional?  What do we even mean by risky behaviour or reckless behaviour?

In safety II – the experts talk about (healthcare) workers having:

  • The ability for people to adjust what they do to match the conditions of work
  • The ability to succeed under expected and unexpected conditions alike
  • The ability to take actions to help create a state where as much as possible goes right

But in patient safety this behaviour is often described as violating best practice or violations or risky behaviour.  Is it really risky behaviour to do your very best, given the circumstances you are faced, to provide safe and effective care by adapting what you do and even adapting the written policies and procedures?  Even the words violating or violation have strong connotations of ‘disgraceful behaviour’; the tone is already set for those who are found to have not adhered to a set procedure.

However, violation (or risky behaviour) comes in many forms…

  • Erroneous  – an individual did not understand the policy or was not aware of it.  Given the amount of stuff people have to be aware of in this information rich world together with the limited time and pressures in today’s healthcare – its a wonder anyone has time to read a policy or procedure
  • Routine — when the policy or procedure is routinely bypassed or ‘worked around’ – this is the stuff that human factors experts talk about in terms of ‘work as imagined versus work as done’
  • Situational  – usually related to the on-going and insidious circumstances, situation, environment or resources including time, effort, money and people – all of which impact or can make it difficult to take the right steps
  • Exceptional – extreme circumstances which result in the clinician making a purposeful choice to bypass the normal procedure (linked to situational)
  • Optimising —when in fact there is a better way of doing things i.e. people on the ground know better or the policy is out of date, unworkable (linked to routine)

Ken Catchpole (1) sums it all up for me when he wrote in the BMJ Quality and Safety Journal, ‘violations and non-adherence are common, not always conscious, not always planned, are frequently well meaning, and in many cases allow the system to run smoothly’.

However, importantly, as Rene Amalberti (2) states, a resilient system requires flexibility to help it become safer, efficient and adaptive to changing circumstances.

It is therefore important to understand why this happens first before simply judging people and disproportionally blaming people when they are considered to have violated a policy or procedure.


(1) Catchpole, K.  BMJ Qual Saf 2013;22:705-709 doi:10.1136/bmjqs-2012-001604

(2) Amalberti, R, Vincent C, Auroy, Y et al BMJ Qual Saf Health Care 2006;15:i66-i71 doi:10.1136/qshc.2005.015982

Six tips for implementation

Recently I have been asked to help provide advice on implementation for a few patient safety projects which made me revisit my previous research in 2008.  Its always interesting to review the knowledge you had at the time and compare with the knowledge you now have.   Mixing the two here are six tips for implementation that might help:

1. Demonstrate that the change is better than status quo

This remains highly relevant.  If all is ok then why change? We can be a bit like that with even our personal stuff.  If the fridge freezer works why change, even though I know there are some amazing super new fridge freezers on the market! So the change has to either replace something that isn’t working or have clear and tangible benefits on the existing way of doing things.

2. Try and make the change as easy as possible to do

This is a bit of a conundrum.  I think it does need to be easy but at the same time, doing something difficult well is incredibly rewarding.  I think the main thing is not to over complicate it.  So don’t produce the 100 page manual that is a nightmare to understand or follow or create something that requires on-going and intense hours of training.  The behavioural insights world has a lot to offer in this respect.



3. Adapt the change to local conditions – use the 80/20 rule



I have slightly changed my thinking on this.  I used to think that organisations or people need to completely adapt something to make it theirs and to own it.  This way they would be invested in it and want it to work more.  However, too much adapting means that simple interventions across the country or similar documentation for things like prescribing are all a bit different as you go round the country.  This is sort of ok if no one moves but with a workforce that is highly transitory then this becomes an issue.  The key is to standardise what you can, stay true to the core of what ever it is you are adopting and then only adapt say 20% of it to fit with your environment. And maybe think again when you want to change the name of something – I came across a team who had decided to call huddles ‘cuddles’ – confused the hell out of everyone who worked there!

4. See who you can get on board to help ‘champion’

If you respect and like someone you pay attention to what they say and what they do.  This is a human trait.  So if someone you like and respect at work thinks the ‘change’ would be a good thing to try and the added bonus is that they have actually done it themselves then you are more likely to do the same.  This is what people refer to as peer to peer influence or the use of opinion leaders or role models.

5. Carefully use intrinsic and extrinsic motivators

Intrinsic motivation is defined as performing an action or behaviour because you enjoy the activity itself. It is an internal form of motivation. People strive towards a goal for personal satisfaction or accomplishment.  The inspiration for acting on intrinsic motivation can be found in the action.  Whereas acting on extrinsic motivation is done for the sake of some external outcome or pressure, itself.  Extrinsic motivation can be another person, or some outside demand, obligation, or even reward that requires the achievement of a particular goal. Think carefully about these when you are developing your implementation plans.

6. Major on reward and recognition

Linked to intrinsic and extrinsic motivators is that of reward and recognition.  If people are recognised for their actions, thanked and valued for their contribution to safer care they will feel great. Others will see that they feel great and want to feel that way too.  This can mean anything from shining a light on someone’s achievement to sharing their work in a journal or a blog, to giving people awards.  But a ‘thank you’ goes a very long way.


Before I go… just a few things that get in the way of success:

  • Relying on training as the way to get people to change
  • Simply sending out stuff – dissemination of alerts or guidance with no support expecting people to notice
  • Punishment for poor compliance
  • Devising the wrong solution that doesn’t actually address the particular problem that needs addressing
  • The sheer number of ‘top down’ articles, policy documents, guidance, interventions  published daily – coming from all different directions including within your own organisation– trying to figure out which are the ones to pay attention to and which are the ones to ignore

As I have said before …. if we do ‘one thing’ it is for the ‘problem of implementation’ to be owned by the guidance developers, solution designers and researchers.  The people tasked with developing something for others to use or to action. This means when planning it all out, spend as much time on implementation as innovation and improvement.

All of this could increase the chances of sustained change.