What is a safety culture?

I remember when I first started as a nurse and learning about the intricacies of caring for patients when one of the nurses who was supervising me said about a particular task; ‘this is the way we do it round here, you might go to the ward next door and they do it slightly differently but ‘this is the way we do it round here’.  This phrase has been used time and time again during my training and beyond.  When I moved into intensive care, when I moved to another hospital … ‘this is the way we do it round here’.

People who study safety culture often say that it is ‘the way we behave when no one is watching’ – the things we do as routine, the things we do without thinking, the way we behave to one another because that’s how it is.

The definition of culture is ‘the ideas, beliefs, customs, and social behaviour of a particular people, ethnic group or age group in society’.

Anthropologists describe it as the sum total of ways of living built up by a group of human beings and transmitted from one generation to another’ i.e. the way we do things round here.

Within the NHS there are multiple groups of people, multiple teams, multiple cultures; people who work in organisations with thousands of staff through to isolated individuals working in remote communities.  Professions, teams and departments with formal customs and hierarchies that prevent people from challenging others.  Professions, teams and departments that go out of their way to gather people together to hear from everyone no matter how disparate their views.  Professions, teams and departments that all have their own ideas, beliefs, customs and behaviours.

If culture is a combination of ideas, beliefs, customs, and social behaviour of a particular people, ethnic or age group in society’ and ‘the way we do it round here… when no one is watching’ – what is a safety culture?

If safety is both a state where as few things as possible go wrong and a state where as much as possible goes right (Ref: Eric Hollnagel) then a safety culture is the mixture of the behaviours, decisions, beliefs, the way we do it found here, in order to make this happen.

A safety culture is therefore:

  • one that is mindful for the potential for getting it wrong, for risk and harm, one that takes steps to prevent that and to minimise its effects if it does
  • one that seeks to learn when things do go wrong or nearly go wrong; learn so that things can be changed to the system to the designs of what we do to intuitively help us get it right
  • one that seeks to learn from the day to day and seeks to learn from when we get it right in order to replicate it, and seeks a way of optimising what we know we do well

This beautiful combination will as Eric Hollnagel and others suggest help us move the language from ‘one person’s job’ or a topic of ‘patient safety’ to helping people work safely.  This is the task of policy makers, leaders, managers, clinicians – all of us.

At Sign up to Safety we believe that in order to do this we need a different way of working together.  One where we are kind and respectful of each other.  That we need to help people connect and create the relationships that are vital for safety; where people are able to speak out, and are listened to when they do.  This culture needs to be fair and consistent both when things have gone wrong and when things have gone right; a ‘just culture’.

At Sign up to Safety we are therefore seeking to help everyone grow and nurture and achieve the ultimate safety culture:

a mind-set and a set of behaviours that become the very essence of what we do so that working safely is embedded into our beliefs, customs, social behaviour, ‘the way we do it round here’

 

 

The way we work

In order to develop a more proactive approach to preventing harm and improving the safety of patient care there is a need to understand how people actually work.  Steven Shorrock writes eloquently on the subject and describes the different ways people work (Shorrock 2016, Shorrock 2017).

Shorrock proposes that there is a difference or a gap in relation to how people think that work is done and how work is actually done. He suggests that there are four basic varieties that can be considered: work-as-imagined; work-as-prescribed; work-as-disclosed; and work-as-done. These varieties, he says, usually overlap, but not completely, leaving areas of commonality and areas of difference.  It is important to know how work is actually done because with only with this knowledge can we start to think about how it can be replicated or improved.

Let us look at this a little more…

Work as imagined

With a complex organisation such as the National Health Service (NHS) it would be virtually impossible for anyone to truly understand how all of the work is actually carried out everywhere.  However, if people are responsible for developing guidelines or standards or policies and procedures then relying on what you imagine someone does rather than what they actually do could mean that the policy is either incomplete, unworkable or fundamentally wrong.

Even if you have past experience of that area, the moment you step away from the frontline you start to become removed from it. Change in healthcare happens quickly and people’s memories become distorted.  Also even if you go out and about and talk to people who work there you may only be getting a partial story; if the culture is inhibitory then people  may say what they think people want to hear not what is actually happening.

Work as prescribed

Sometimes it is important that the work we do is prescribed. Apart from the obvious in terms of medications there is a need for prescribed laws and regulations to ensure care is being provided safely for example in radiotherapy or chemotherapy.  These are the ‘islands of reliability’ that Vincent and Amalberti (2016) refer to.

In healthcare we have an abundance of prescribed work; targets, checklists, guidelines, requirements and standards and so on. But do we have ‘work as prescribed’. Similar to work as imagined the work that is prescribed is often done so by those with some distance from the frontline.

The problem as Erik Hollnagel would say is that in healthcare it is usually impossible to prescribe all aspects of what we do, even when that work is well-understood.  Healthcare constantly requires people to adjust what they do to match the conditions they work in and the patients they are treating.  No two days are the same so there are many ways in which the work can be done.

Work as disclosed

Work as disclosed is how people describe what they do either in writing or when they talk to each other. However this may not always be what is actually done.  For many reasons, it may be the partial truth.  This may be because explaining every little detail would be too tedious or that because we do things automatically we may forget some of the details.  We also often explain things differently depending upon the audience.

Explanations may be too simple because we want to help make it understood or we say what we want people to hear.  This could be the case when we are being scrutinised or audited; ‘just tell people what should happen not what does happen’.  One fascinating aspect that Dan Ariely (author of The (honest) truth about dishonesty 2012) says is that you may not get the truth because as humans we lie to ourselves and others every 10 minutes.

Work as done

Work-as-done is actual activity – what people do. Shorrock emphasises that work-as-done is the most important and yet most neglected variety of human work.  Both he and Hollnagel say that work-as-done is mostly impossible to prescribe precisely.  Safety II describes how safer healthcare is achieved by adjustments, variations, and trade-offs.  These compromises are necessary to meet the conditions within which we work. These adaptations are based on our day to day experience.

Work-as-done can be observed but like all ethnographic study it is challenging. People may behave differently when they are being observed, (the Hawthorne effect) it may also be really hard to understand just from observation alone.

Shorrock (2017) updates these four activities with his recent posts about seven archetypes (with his own summaries in brackets):

  1. The Messy Reality (Much work-as-done is not as prescribed (either different to procedures, guidelines, etc., or where there are no procedures), and is usually not known to others who are not at the sharp end of the work. The focus of The Messy Reality is the actual work and the messy details).
  2. Congruence (Much human work is done ‘by the book’ – at least in general terms if not the fine detail – and is done much in line with how people who are more removed from the actual work imagine. Such work is often even disclosed, since there is no reason not to. However, prescribed work can have unintended consequences. These, of course, were not imagined, at least by those who designed the work.)
  3. Taboo (This is activity that people don’t want to talk about outside of one or more groups. It is often not in accordance with official policy, procedures, etc., or there is no relevant policy, procedures, or if it is described in procedures, others would find the activity unacceptable. As such, the activity is often not widely known outside of specific groups. The main defining feature is that it is not openly discussed)
  4. Ignorance and Fantasy (This is what people don’t know about real work and what they imagine happens. The imagination relates to official policy, procedure, standards, guidelines, etc. that people assume are in force, or there may just be a general impression of how things work and should work. The primary focus of Ignorance and Fantasy is the imagination of those removed from the actual work)
  5. Projection (We are prone to imagine that things will work according to a plan, and prone to wishful thinking, ignoring the potential for problems. The focus of Projection is the imagination of the future, as we think it will be, or would like it to be)
  6. P.R. and Subterfuge (This is what people say happens or has happened, when this does not reflect the reality of what happens or happened. What is disclosed will often relate to what ‘should’ happen according to policies, procedures, standards, guidelines, or expected norms, or else will shift blame for problems elsewhere. What is disclosed may be based on deliberate deceit (by commission or omission), or on Ignorance and Fantasy, or something in between… The focus of P.R. and Subterfuge is therefore on disclosure, to influence what others think)
  7. Defunct (Some forms of prescribed work are not enacted, or else drift into disuse, but are still officially in place. Some will imagine that these are in place, while others know or think they are not. However, the existence of the Defunct work may be used to judge actual activity)

Steve Shorrock (2016 and 2017) explains in much further detail so I would head to his blog at:  https://humanisticsystems.com/2017/01/13/the-archetypes-of-human-work/

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?

References:

 

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

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

Skybrary – website https://www.skybrary.aero/index.php/Toolkit:Safety_and_Justice

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.

Refs:

(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.  http://www.behaviouralinsights.co.uk

 

 

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.

Kitchen Tables

In the 1960s my Uncle was a scientific officer at the Radar Research Establishment in Malvern. There were a number of divisions within the establishment who had a tendency to stick together in their different groups.  My uncle decided that every day the different groups should be invited to come together for coffee and conversation.  They had one main rule which was to ban any conversation which concerned things beginning with C.  This was to rule out computing, which was their main work related activity and therefore encourage people to broaden the conversations to help learn more from and about each other.

He would pose questions that may have been triggered by the latest New Scientist or the latest news but more often than not they were stimulated by some obscure question or fact. For example one time they talked about Puccini’s opera Turandot.  The opera was unfinished at the time of Puccini’s death in 1924, and was completed by Franco Alfano in 1926. The question posed was; ‘should an opera lover walk out at the point that Puccini stopped and before Alfano started or stay to the end?’  This to my uncle was a bit of fun but he was fascinated in how it stimulated conversation and improved the conversational skills between divisions.

My uncle is not the only person to think about helping people talk to each other.

For example, a lot of people have used conversational methods such as ‘The World Café’. One such example is that of Bob Veazie, a senior engineer at Hewlett-Packard.  Bob’s role was to improve organisational performance.  He experienced a World Café event where he realised that the boxes in his traditional hierarchical organisation chart would be better depicted as webs of conversations.  That managing these conversations might not be the best way to achieve results.  He described how every day his teams were engaged in conversations about different questions.  He sensed the power and potential for networks of conversations and how the connections among them could produce real value.  He wondered if conversations and personal relationships are at the heart of our work.  He questioned his role as the leader and whether he was contributing to or taking energy away from this natural process.  He questioned why we are using the intelligence of just a few people when we could gain the intelligence of hundreds or thousands of people.

When Bob became the safety leader for Hewlett-Packard’s inkjet operations he was eventually responsible for fifty thousand employees at five sites around the world. When he started there was a high accident rate.  This varied from country to country; in Oregon US 6.2% of the workforce was being harmed each year, 4.1% in Puerto Rico and 2.5% in Ireland.  The initial attempt to address this was to implement a programme called STOP, which is where people give each other feedback about how they are doing against a list of predetermined risks.  Feedback from the test group was that the discussions related to someone else’s list, not their own ideas about what their own risks really were.  He says ‘we started with someone else’s answer rather than a question that should have evoked people’s own curiosity and creativity’.  The second attempt was to pull together a small group of full time internal safety experts, called safety change agents.  The safety change agents defined the set of risks for the whole organisation.  As Bob says this was the second mistake.  He felt that by doing the work internally, they were consistent with the principles of the World Café; that the wisdom lies with the people themselves.  In reality they had created a small group that functioned like outside experts, removing the responsibility from others.

The third attempt was to ask, what are the few key questions that would improve safety results if we were to ask them to people already in conversations about their daily work? What they chose to do was pose key safety questions to the people in the already existing but invisible ‘café’ – the web of relationships – so that they could integrate the questions into conversations they were already having.  Bob and his team began by meeting with people where they normally gathered, in staff meetings, worker assemblies and on the shop floor.  First they shared the local facilities safety record with them.  They showed these people the visual from the world café which shows how one person can then influence a small group, who can then influence a number of groups which can lead to large scale impact.  This shows the powerful pattern of the world café in action.  It helped employees realise that to make a shift, rather than use predetermined training programmes that focused only on solutions.  It demonstrated that they were trusted to hold conversations, develop relationships and mutual intelligence as a way of dealing with critical safety questions.

The first question Bob and his team explored was; if you were to get hurt, how would that happen?’ People began answering the question with risks that they identified from their own work situations. The second question was; do you want to manage these risks before people get hurt or after?’  Of course they all said, ‘before’.  The final question was; ‘what do you want to do about it?’  Bob’s team had invited them into a meaningful conversation called ‘I don’t want to get hurt at work’.  They talked together about different methodologies, and their own ideas for managing risk.  Then they were asked to try out the answers, keep asking the questions and revisit the answers as they learnt more.

Bob used the World Café as a guide to help his safety effort and articulated this as an on-going ‘Safety Café’, a network of conversations across the company connected by key questions. The internal safety experts he had employed were used as the hosts.  Bob and his team travelled across the world sharing the stories, bringing together people from across the product lines to learn with and from each other.  Bob says that as they were leading the safety effort, they were simultaneously learning about how conversations are a core method that really works to enhance performance.  The results of these efforts; the accident rate reduced in Oregon from 6.2% to 1.2%, Puerto Rico went from 4.1% to 0.2%.  The company as a whole was able to reduce the overall accident rate by approximately 33%.

So, thanks to my uncle we have one example of an informal get together to help create relationships with people you wouldn’t necessarily meet or spend time with and thanks to Bob we have another example which is a more structured approach to build knowledge through conversations.

The Sign up to Safety campaign is encouraging conversations to help people work safely and combining these two approaches; bringing people together from different groups to talk to one another but also to focus around what we can all do to help people work safely.

We have called it a ‘kitchen table’ because we wanted to evoke the times when you sit round a table with your family or friends and tell them about your day. We imagine different people from across the organisation or practice coming together to have a conversation about safety.  We don’t want people to over-think it so we suggest that it is not planned like a meeting,  doesn’t need an agenda or minutes taken.  The host could stimulate the conversation with questions and some key insights could be captured as single words or key messages on a scribble sheet in the middle of the table.

It doesn’t have to be as obscure as Puccini’s opera but if that is what it takes to create relationships then why not?! What would be even more wonderful is if the kitchen table then stimulated a network of conversations in the same way Bob achieved for Hewlett-Packard. Imagine that network not only across an organisation but across the country simulated by key questions about how we can help people work safely. This is what we are trying to achieve by our second national kitchen table week starting on 19 March 2018.

We would love it if the conversations were linked to three key topics;

  • Firstly about how everyone across the NHS could implement ‘safety II’ i.e. a way of looking at what works as well as what doesn’t
  • Secondly about how we can instil ‘joy at work’ by building on the initiatives such as ‘learning from excellence’, #kind2018 and saying thank you to the people you work with
  • Thirdly how we can keep building this way of developing relationships and having conversations so that they become part of the everyday fabric of the NHS

If you want to know more about the kitchen table week all you have to do is head to our website or twitter account @signuptosafety. You will see what people did last year and you can see what people are planning for this year.  Any questions can be asked via team@signuptosafety.org.uk

In memory of Dr Philip Woodward DSc – 6.10.1919 to 30.01.2018