Now is the time to turn theory into reality. Over the last five years I have been studying and writing about new approaches to safety. I have set that out in both my books and in particular my second book below. It has also been reiterated and explored by a growing number of patient safety specialists. The conclusion is that we have still not built the optimum approach to safety in healthcare. We are still focusing on failure but not on the day to day to understand why sometimes it fails and why most of the time it goes ok. We must reject the notion, however well-intentioned, that the primary path to improved patient safety is to learn from failure. As Steven Shorrock (2013) says it is a bit like ‘trying to understand happiness by focusing only on rare episodes of misery’.
The emerging theories and concepts of safety II, psychological safety, just culture, learning from excellence and compassionate leadership are growing in their sophistication and in popularity but what we are struggling with is their application. However, for me it has always been much more of a mindset than a set of interventions. That what we should be doing is thinking differently, and applying a different way of doing things to our current approach together with building on that with the new concepts. Rather than looking at either or both tails of a normal distribution of outcomes, we should look at the broad area in the middle, at the things that happen frequently or always, in the daily activities of the everyday clinical work that just functions and unfolds regularly as it should.
One of the questions people ask me about safety II is how do we do this when we are snowed under doing safety I. If we are already drowning in data why would we want to add more? That is where the myth comes in that it is all about rejecting safety I and moving to safety II. To ‘do’ safety II we do not have to move away from the approaches we have used to date but we do need to be much better at using our current strategies. We do need to rethink how we capture safety I data and how much effort we spend on safety I and then think about how we can free up that time to focus on safety II data.
Safety differently is not blindly following a stepping stone path but taking the time to turn over each stone and challenging why is the stone here in the first place, what was the intent, it is still valid and useful.
Gary Wong 2015
There is often this dilemma which is ‘please don’t instruct me or tell me what to do’ but ‘tell me what to do’. As Sidney Dekker says this is ‘literally taking a safety I mind-set to a safety II world’ (2018). His view is that providing a step by step guide to safety II would negate what this new thinking is all about because it isn’t a checklist or a downloadable solution. Safety II is a whole new way of thinking that needs to be experienced and lived. It is a way of being curious about how the system functions and how people adapt and adjust, it is a series of questions and conversations, it is a look at people’s worlds in a very different way. This is a change in behaviour far more than a new tool or technique.
What we need are stories and examples of what people are doing to bring these to life. I have been having a few of those conversations recently which you can also enjoy….
The West Midlands AHSN set of webinars provides us with some real case studies of people using appreciative inquiry as a way to bring safety II to life. These can be found at:
The Q community webinar also explored the adjustments people have been making, a key component of safety II, over the last few months. This can be found at:
Gary Wong (2018) asks ‘do we need a recipe follower or a chef? He says anyone can follow a recipe if they are well written and easily followed and practice and expertise will increase success. He says there a lot of recipes in safety I. What happens however if you don’t have all the recipe ingredients or someone demands that you must cut the baking time in half or that the recipe follower is tired, confused and pressured? If you keep trying to following the recipe with these changes in dynamics and conditions then you may fail. A chef however adapts to the unexpected conditions, doesn’t always follow the cookbook but knows the art and principles of cooking (Wong 2018). Safety II enables people to become chefs rather than simply following the recipe.
Safety II means we can seek to understand how things mostly go right as an explanation for how things sometimes go wrong. It helps us understand that all performance ultimately flows from the same underlying processes and systems with the same behaviours and practices. It provides us with a way to hear stories of success and to appreciate the times when nothing went wrong. This is a much more proactive approach to safety that has emerged from a substantial theoretical foundation; decades of research in safety, human factors, sociology, psychology, cognitive systems engineering, organization complexity and resilience engineering (Hollnagel et al 2013).
Dekker S (2018) I am not a policy wonk blog via www.safetydifferently.com
Hollnagel, E, Braithwaite, J, Wears, R L (2013) Resilient Health Care. Ashgate Publishing Limited Surrey England
Shorrock S (2013) Why do we resist new thinking about safety and systems – Blog via humanisticsystems.com
Wong G (2015) Blog – And now for something completely different via www.gswong.com
Wong G (2018) Blog – Safety Differently: Recipe follower and or chef? Via www.gswong.com
Also see – my rolling take 5 slide on twitter