National Kitchen Table Week will be from 18 March until the 24 March 2019. The week will also be a wonderful way to celebrate the ending of our work.  The team have run the Sign up to Safety campaign, funded by the Department of Health and Social Care (DHSC), for the last five years.  Our work was to create a shared purpose; all of us focused on helping people think and act differently about patient safety.

Our roles will be ending in March 2019 but this doesn’t mean that the work should not carry on. As you know two of our principles of the campaign were local ownership of the campaign and for you all to work on things that matter to you.  So Sign up to Safety still belongs to you to carry on the great work you have been doing so far.  To help you do this, to thank you all for joining and for working so hard to help people work safely we are going to share everything we have learnt, from how we have worked to what we have done and why and perhaps what we think people could do after we have gone.

Around 98% of the NHS in England joined the campaign and we have learnt tons. However, we don’t want to write the usual report that has a list of sweeping recommendations about how we should all make safety our top priority or how leaders need to pay attention to safety.  In our humble view that would not help particularly and let’s face it, it has been said many times before.  Instead we want to ‘do as we tell others to do’ and have a conversation.  We will produce some podcasts of us talking about our learning and back these up with links to evidence, stories and blogs.  We will focus on what has worked but also share our challenges and where we went wrong a few times.

The way we think about patient safety in healthcare needs to change. Achieving patient safety is not about short term projects to reduce individual harms it is much much more than that.  There are emerging theories (safety II), the world of behavioural insights, positivity and positive deviance, learning from excellence and addressing behaviours such as incivility.  There is also a deeper understanding developing of the learning and restorative just culture that healthcare needs.  This is a wonderful time to be working in safety.

To add to these, in our view, caring about people working in health care is the key to helping people work safely.  In fact we believe it should be the central driver to improving the safety of patient care.  How can staff work safely if they have not eaten anything for 12 hours, how can they make safe decisions when they have not had a good night’s sleep for weeks, how can they be helped to safely carry out complex tasks when they are frightened to ask for help.

We started thinking about this when we concentrated on helping people talk to each other, and provided the opportunities for people to listen to one another in a kind and respectful way via our ‘kitchen tables’. We will continue over the coming months to provide the evidence that underpins all of these ideas, some practical ideas for you address them but we also hope to stimulate a wider conversation about what we should do differently.

Caring about people working in health care is the key to helping people work safely

We would like to thank all of you for being a part of the campaign and in particular we are grateful to the Quality, CQC and Investigations Policy Team at the DHSC who have supported us throughout the last five years and importantly commissioned us for those extra two years which have made all the difference to our learning.

I would like to thank Amanda Oates [ @amandajoyoates ]  Joe Rafferty [ @JR_MerseyCare ] and Beatrice Fraenkel [@BFraenkel ] together with large swathes of staff at Mersey Care NHS FT whose names I may never know for providing those of us who have been working in patient safety with hope.

I have just watched the film about their work in growing a just and learning culture across their organisation.  This work has been in partnership with Sidney Dekker [ @sidneydekkercom ].  The film can be found here.

Complex systems like healthcare and hospitals are filled with hundreds of moving parts, scores of players and varied expertise. The moving parts and people are ever-changing with constant adaptations in action.  Even though there is an attempt to create mechanisms of ‘command and control’ it is impossible for the senior leadership of a hospital to be able to control everyone’s behaviours and actions.  However, despite this the prevailing view is that people should be controlled in some way with targets, policies, standards and guidelines and that when people inevitably deviate from these or fail to achieve them that they (the individuals involved) should be punished or sanctioned in some way.

The leadership at Mersey Care think differently.  They are doing their best to think and act differently about how to respond when things go wrong.

The film shares snippets of the individual stories of staff who have been hurt by the traditional way in which people are dealt with when an incident happens or a complaint is made.  This is not isolated at Mersey Care, it is in fact the default position across a lot of the NHS.  Sadly I have numerous stories from staff from all professions and all care settings who have been treated badly.  They have been suspended, investigated, banned from practising, moved, shifted, sacked.  They have felt ashamed and in some cases have taken their own lives as a result.   There is a moral imperative to support staff not blame them when things go wrong.

People make countless adjustments during their work. Most of these lead to success.  Some lead to failure.  There is no error.  There is just work, which we can try to understand.  Takes the blame out of failure (Adrian Plunkett via twitter @adrianplunkett )

We could fire everybody who makes a mistake, punish everyone who makes an error and put in an entirely new workforce but it would be far more useful to learn about why the mistakes and errors happen, together with learning about what actually goes ok or even well.  This balanced view means we stop defining an individual by the single mistake they make and instead understand the context of the thousands of times they got the same thing right.  People are not the problem.

Mersey Care are doing just that, working out how they can learn from when things go wrong, hearing from the people involved and what happened and not simply get rid of the people.  The film describes how they are doing this beautifully so I don’t need to repeat that, but the film would not have happened, the work would not have happened and the chance of hope would not be there if it wasn’t for the inspired leadership at Mersey Care and the fact that people want to follow.

They themselves say they have not yet got to where they want to be.  As I always say safety is not a 3-5 month project its a lifetime of work.  I for one cant wait to follow their progress.

In the third of my trilogy on ‘joy’ I will explore the things that everyone can do.  As it says in the title, role modelling isn’t just for leaders.  Firstly, everyone has the ability to be a leader no matter where your role sits within the hierarchy or structure.  Secondly we can all role model the behaviours we want to see in others including joy. Similar to our @signuptosafety twitter campaign #kind2018, there are some really simple things you can do today to bring joy to others.

Say thank you

Saying thank you is a powerful act of civility

(Kumar and Epley 2018)

We never thank people enough.  I don’t mean just the generic ‘thank you’ at the end of the shift or clinic or session.  It has to be authentic and genuine – you have got to mean it.  Research* shows that we underestimate the positive impact on others and ourselves when we say thank you.

What can you do today? Send someone a thank you message; write a text, a tweet, an email or a letter telling someone how they had helped you.  Do this in a meaningful way by being personal and detailed, explaining what they did and how it had affected you, how it had made you feel.

Be kind

What’s not to like or to lose by being kind to people?

What you can do today? Follow the people who inspire me everyday with their efforts to mainstream kindness, fairness, learning from excellence, joy in work, appreciation, and civility…:

• Gemma Crossingham – Consultant Anaesthetist in Plymouth.  Tweet: @gemolio
• Adrian Plunkett – Consultant Paediatric Intensivist at Birmingham Children’s Hospital.   Tweet: @adrianplunkett
• Emma Plunkett –  Consultant anaesthetist at University Hospitals Birmingham and Birmingham Women’s Hospital. Tweet: @emmaplunkett
• Neil Spenceley – Head of Paediatric Intensive Care in Glasgow and the Scottish Paediatric Patient Safety Lead. Tweet: @Neilspenceley
• Chris Turner – Consultant in Emergency Medicine. Tweet: @orangedis and more via http://www.civilitysaveslives
• Steven Shorrock – Psychologist – Human Factors and Ergonomics Blog at http://www.humanisticsystems.com and Tweet: @StevenShorrock
• Richard Taunt – Tweet: @RichardTaunt and @kscopehealth
• and of course – the team @signuptosafety

Keep a gratitude journal

Its hard being positive all of the time, in fact I would suggest impossible.  But there is a human trait which is to doubt ourselves or to feel like nothing seems to go right.  To help, some people have found it works to keep a gratitude journal. It has helped them feel more positive about their life or their work.  Those that keep one have said it is really easy and over time the things that they feel grateful for become smaller and smaller, as in they recognise more and more the things they feel grateful for.  Some people have given blank notebooks to staff when they start a new job or a new rotation or for attendees of courses to use to keep a gratitude journal.

What can you do today? Simply jot down the things you are grateful for at the end of the day or the end of the week. Write about what you feel is great, what you are proud of, who you might want to thank, what kind act you mind want to do, as well as things you might want to do differently.

Share stories

Lisa Rosenbaum** wrote an article ‘Twitter tailwinds – little capsules of gratitude’ about the Twitter campaign #ShareAStoryInOneTweet – this as she says ‘briefly transformed twitter’ into the most wonderful collection of stories from healthcare practitioners. It describes how an emergency doctor in Oregon US – Esther Choo – shared a story and used the hashtag. This role modelling of storytelling was picked up and briefly twitter ‘lit up with stories’.

What can you do today? Share your own stories with others.  Share what brings you joy and what you are proud of or grateful for.

Don’t use incident reporting systems as threats

Sadly so many people tell me that incident reporting systems have lost their purpose.  Rather than being used to learn they are being used to threat.  This keeps the negative culture alive.  It is a significant symptom of the culture of your organisation if it is used to blame people, target individuals, prod people to prioritise your issue above others.  It is a significant symptom of the culture of your organisation if it is used to replace a simple conversation between one human being and another.

What can you do today?  Completely rethink the way incident reporting is implemented in your organisation so that it is purely about learning.  If you need to tell someone that you are not happy with their attitude or behaviour then think of a different way and if possible sit down and talk it through with them.  And Be kind to people when things go wrong….  Ask the 3 questions Sidney Dekker suggests; who is hurt, what do they need and whose obligation is it to meet those needs.

Learn from what works

Shift the emphasis from just looking at things that go wrong and move towards learning from things that go right.  Try it out. When you are in a room full of people talking about what works you can almost touch the joy.  Appreciative inquiry is a great method for shifting the tone of a conversation from relentlessly focusing on the negative.  Carrie Biddle shared a blog*** on how she used appreciative inquiry in culture survey debriefings to keep a positive focus on what people wanted to do for a better future.

What can you do today? Ask positive questions.  Ask – even when things have gone wrong, – what worked.  Ask – even when you are investigating a complaint or incident or claim, – what worked.

When you are opening a meeting or receiving a report from others or carrying out a debrief or huddle, ask what worked first.  Asking what works first sets the tone for the rest of the conversation.

References

*Amit Kumar and Nicholas Epley (2018) Undervaluing Gratitude: Expressers Misunderstand the Consequences of Showing Appreciation, Psychological Science

**Lisa Rosenbaum (2018) Twitter Tailwinds – Little Capsules of Gratitude N Engl J Med 379: 209-211 DOI: 10.1056/NEJMp1806737

*** Blog: Carrie Biddle (2018) Improving team culture to deliver safe sustainable services for patients – The South West Academic Health Science Network – http://www.swahsn.com/blog

Every profession including healthcare has its great leaders; charismatic, high profile, some even adored. But they are not the only great leaders.  Some great leaders are humble, kind, respectful and quietly making the world a better place.

Most people, most of the time are neither saving the world nor exploiting it. [Badaracco]

The NHS is filled with leaders at all levels of the service making decisions every single moment of the day – the sum of which are a hundred times stronger than the acts of those that receive the public recognition.  These people are trying to solve important and sometimes what feels like impossible problems.  The every day problems that are messy and complicated; not having the time to do a good job, not having time to talk to patients, not having the time to reflect and think about what is working and what is not, and not enough time to sort out the staffing and resource issues everyone faces.

The every day problems are not solved by quick, decisive directives from the top, they take time in themselves.  They are addressed by leaders who build a shared purpose, engage with others and listen to their staff and patients.  Because the every day problems may not go away quickly then there is an imperative to make the day to day as joyful as it can be.  It calls for perhaps a kind of ‘joyful leadership’.

What does joyful leadership mean? 

These leaders pays attention to creating ‘joy at work’.  They also pay attention to the way they behave and how they want others to behave.  This includes being humble, kind, positive and respectful.  Many may assume that positive leadership is ‘nice’ and weak, rather than necessary and courageous.  That it might get in the way of getting the job done.

People had this lazy opinion that he’s too nice and they see kindness as weakness, but it’s the most unbelievable strength if you use it in the right way

This quote is about Gareth Southgate in a recent article in the Guardian found here. (I know I am picking up on the much talked about world cup here but its too good a quote to not share it).

Creating ‘joy at work’ is not just about having fun as the term suggests, although it doesn’t preclude having fun it is far more than that.  For me it is about really caring about your staff, taking the time to find out about them and helping them build on and make the best use of their strengths.  It is about helping people work well together and working things through together, respecting everyone’s views as equal.  Successful leaders do not just think they should be caring and kind they intuitively are.  It is crucially about how to help people find the precious resource of time.  To make dedicated time for people to work on things they enjoy together.  It is also about saying thank you and creating a culture of positivity in the workplace.

I have never felt the need to be an aggressive leader, never felt the need to be punitive or to bully people into doing their jobs.  I have concentrated on being me, its much easier being you than trying to be something or someone you are not.  And being me is to be kind, being me is recognising that I don’t know everything and that I need people around me who can talk to me, share their ideas and their concerns and who will know that I will listen to them.

Bringing ‘joy at work’ also fits with ‘Safety II’ which as you know is all about learning from when things go well.  Identifying what works also means that you can see how brilliant the people around you are – which then leads to a lot of saying thank you and celebrating what they are achieving every day.

Safety does not happen if you are negative, shout at people, blame people, keep telling people they must stop making mistakes.

I have come to believe that safety or as we prefer to call it ‘working safely’ is so much more that projects, QI, or safety improvement programmes or even necessarily new ideas, and innovations.  For all (patients and staff) when things go wrong – as Sidney Dekker says – it should be about finding out who was hurt, what they need and whose obligation it is to meet that need.  And as Eric Hollnagel says safety is about finding out what works as much as what doesn’t, replicating and optimising what is already working and removing blame from error.

For us in the Sign up to Safety team, working safely is about:

• good leaders who listen, who care and who set the tone for their organisation
• everyone wanting to learn, wanting to be curious about how things work
• people who can expertly investigate when things go wrong using human factors, behavioural and safety science
• all of us developing the kind of relationships that we all want to have where we are able to speak up, be heard and be listened to

Working safely is ultimately about the way we behave.  It helps if you are kind, respectful and supportive of people.  For me kindness, listening, empathy and creating joy at work will take you further than anything else.

References:

Joseph L Badaracco JR, (2002) Leading Quietly Harvard Business School Press

The Healthcare Safety Investigation Branch has published its first report .  The investigation was triggered by a failure to correctly check hip prostheses for a 62 year old man, Mr John Hampton.

The report is excellent and with this the Healthcare Safety Investigation Branch have set the bar high for the quality of their work.

It is one of the best investigation reports I have ever read.  It is clear, detailed and easy to read and beautifully describes the multiple factors (human, system and cultural) that can lead to an error.  The following are a few things that really hit home for me.

The patient:

From what I can read it appears that the investigators developed a good relationship with the patient and that he was involved in the investigation.  There is a particularly moving point about the on-going effects for Mr Hampton on himself and his family.   Not only will they have a crucial piece of the jigsaw they should be involved , informed and supported throughout.  This should be the minimum.

All investigations should involve the patient and or their family  – they should never be a silent participant of their own story.

Standards, guidelines, policies and procedures:

The report shows that standards, guidelines and procedures are not full proof tools for error prevention.  As Jim Reason says ‘there are not enough trees in the rainforest to write a set of procedures that will guarantee freedom from harm’.  The issue is not that you have a standard but whether people know about it, whether it is easy to read and understand, whether it is short enough to help you make the correct steps but not long enough to drown you in detail.

Standards are worthless if they are not implementable.

Labelling and packaging:

We are reminded of the continuing problems with labelling and packaging (highlighted some time ago by the National Patient Safety Agency (NPSA) in its outstanding ‘design for patient safety’ series).   I urge you to read The Design of Everyday Things if you are interested in this subject.

This has been debated for far too long now and it is crucial that manufacturers use the support of human factors experts, designers and behavioural insight experts to design their products to minimise the errors that can be made with things like poor packaging and labelling.

Understanding human factors:

It is so heartening to see that the report has a wealth of human factors thinking and knowledge thread throughout. Crucially the investigation demonstrates the importance of understanding the environmental conditions, individual and team factors.  For example recognising the role that fatigue plays in performance.   There is a fascinating discourse on team work and relationships and the different error rates between familiar and unfamiliar teams.  There is also an insight to understanding more about our mind-set in relation to error; for example the consultant could recall being brought the wrong size before but not the wrong manufacturer so it ‘was not, therefore, an error experience had taught him to be alert to’.  There are so many things that are applicable for all healthcare, for example the issue of noise in section 5.3 and 5.7, and our cognitive biases in section 5.6.

We simply don’t pay enough attention to human factors in the way we design our systems, structures, and organisational processes.

Barriers to error:

The investigation clearly highlights the fallibility of human memory and the importance of the different types and effective use of memory aids and the importance of reading out loud all the details needed and/or independent checks.  Love the comment ‘what’s on the box may not be what’s in your head’ – which tells us all about the strange things our brain can do to convince us that we see things that are not there or don’t see things that are.

The ‘solution’ we are always searching for is the complete inability to make a mistake, ‘designing out the chances of error’ through effective barriers that get in the way of making an error (checklists, verification processes).  These are really rare and if we think we have found them we may have to think again.  Us humans are very clever at thinking of different ways we can get round things that don’t fit naturally with what we are trying to achieve.

As it says in the report ‘team checking processes already in place have not reduced the number of wrong prosthesis incidents, suggesting that more of the same is not the solution’ and ‘double checking requires that one fallible person monitors the work of another imperfect person’. 

Therefore if you are designing barriers, just as for manufacturers, involve human factors experts, designers and behavioural insight experts.

There may never be a neat answer:

There is also a key point that we don’t talk about often enough, ‘the nurse could not understand why she had gone to different cupboards that contained prostheses from different manufacturers’ – ‘the consultant…. could not recall the details of the prosthesis verification during the operation as there was nothing out of the ordinary about it’.  I can think of numerous incidents I investigated when the people involved had no idea why they did what they did.  They could not offer a nice neat explanation.  They could not recall even the steps they took.

There is still a particular pressure to desperately search for a root cause, to find an answer.  We seem to find it impossible to say ‘we simply don’t know’.  Not knowing too often is misinterpreted as ‘covering up’, or ‘hiding something’.

It is therefore great that in this report it clearly states ‘it cannot be known precisely what checks were undertaken or at what point the process failed’  Hopefully this will give other investigators the courage to say this too.  It does not mean that we cannot learn enough in order to make recommendations as this report has done so well.

Carrying out investigations:

The report also recognises the complexities of carrying out investigations, for example noting how the interviews took place six weeks after the incident and that ‘memory recall at this timeframe may be affected by many factors and so have limited accuracy’.  It would be interesting to know whether most incident investigations involve interviews some time after the incident and how much of the truth we are actually finding out because of this.

The only way to truly understand what can be done differently is to study how work is normally done including the actions and habits that have become common place ( Steven Shorrock ).  I particularly like the way in which staff went to observe work in other operating theatres and in another country to see what normal practice was elsewhere.  We all know about the effect observation can have on behaviours but they were clever in that they stated they were observing ‘general theatre practice’.

What I like most about this is the way it demonstrates variation and that this incident was not the problem of one person, one team or even one organisation.

What’s missing:

The two things missing for me:

1. The different slant that looking at all of this through a ‘safety II’ lens may bring.  I think it goes some way to try to explain the every day, what happens in the organisation of review but also what happens elsewhere.  It alludes to what works well elsewhere and what could be replicated but this could be a little stronger for me
2. The cultural issues – was it an environment where people could speak up?  I appreciate that the fact the team were ‘like a family’ and its potential inhibitory factor was bought up but what about the issues of hierarchy or gender or status that may have inhibited people from challenging (even if this was not part of the factors that led up to the error)? Even if there wasn’t a problem it might have been worth discussing more

What to do with this report:

• Read it! and then read it again – it has so many really great learning points throughout
• Give it to your staff to read and use the report as a tool in itself to start the conversation for briefings and debriefings in theatres (it is applicable elsewhere too)
• Use this to show the importance of accessing human factors experts where you can – not only in understanding how things work, how things could be safer and what you can do differently but also in your investigations
• The way the report is written is a lovely ‘good practice’ example for all local investigators to learn from

Link to the report also found here: https://www.hsib.org.uk/investigations-cases/implantation-wrong-prostheses-during-joint-replacement-surgery/final-report/

Norman D (2013) The Design of Everyday Things. London: The MIT Press

There is a lot of talk these days about creating ‘joy at work’.

Why this growing interest in the study of joy ? What is the difference between joy and happiness? What does it have to do with helping people work safely (patient safety)?

We all talk about happiness and mostly know it when we experience it, but we lack a coherent definition.  Searching the definition of joy the dictionary states ‘a feeling of great pleasure and happiness‘ but when searching for the definition of happiness the dictionary states ‘the state of being happy’.  In fact, the source of the word happiness is the Icelandic word ‘happ‘ which means luck or chance.  What I do know is that during my career I have been very lucky.  Training to be a nurse and the subsequent years working in the NHS has offered me multiple opportunities to experience fulfilment, joy and happiness.

To help us understand more the Institute for Healthcare Improvement (IHI) have created a Framework for improving joy in work (Perlo 2017).  The framework provides four steps for leaders:

1. Ask staff what matters to them
2. Identify unique impediments to joy in work in the local context
3. Commit to a systems approach to making joy in work a shared responsibility at all levels of the organisation
4. Use improvement science to test approaches to improving joy in work in your organisation

Our friends at Kaleidoscope held a day focusing on joy in the NHS earlier in the year (see earlier blog) and have just published their paper which builds on that event together with the associated excellent webinars.  These can be found at:  http://www.kaleidoscope.healthcare/ .  The report is titled Beyond Burnout (Kaleidoscope 2018) and at the end it provides fives ways to bring joy right away:

• Eat together – make dedicated time for colleagues even just five minutes to share a cup of tea or your lunch
• Say thank you – create a culture of positivity at the workplace by normalising thank you and you will start to hear them back
• Seek laughter – laughter brings joy, share jokes and allow yourself to have a laugh even during a tough day (it is ok to feel joy even when things are hard)
• Learn new things – learn things about your work, your patients and each other, discovering something new is invigorating and joyful
• Support flexibility – do your best not to micromanage your colleagues, let their creativity and joy flourish but be available for advice and direction if needed

Psychologists have found that happy people live secure in the knowledge that the activities that bring them enjoyment in the present will also lead to a fulfilling future, rather than enjoying something now that may make them unhappy later.  While we cant be happy all of the time, we can work on becoming happier.  For example, one of the exercises Emmons and McCullough suggest is to keep a ‘daily gratitude journal’, writing down at least five things for which you are grateful every day.  They suggest that doing this regularly can help you appreciate the positives in your life.

Joy comes from so many places; enjoying what you do, liking the team you work with, having pride in your job and your organisation, and your own health and wellbeing. Often joy comes from small moments in the day.  As with so many things at the heart of this are relationships.  Healthcare employees who experience joy in their work and other positive emotion such as contentment may well thrive and build better relationships.  These relationships can be enhanced by the way we talk to each other in a positive and respectful way, our own joy, even the way we smile and show kindness.

Things that get in the way of joy include bullying, racism, sexism, the blame culture and incivility.  There is a need to acknowledge the current problem with incivility, when people are short or rude, which is sadly common in healthcare.   Incivility impacts on people’s cognition, their happiness and quality of work (Riskin et al 2015, Porath et al 2013).  It takes its toll on productivity, morale and relationships. See – https://www.civilitysaveslives.com/.  To shift from incivility to a kinder culture everyone needs to counter the rudeness by role modelling the right behaviour, reward good behaviour and deal with bad behaviour (Porath et al 2013).

In order for a more positive approach to safety to flourish we have studied the psychology of positive emotions, drawing from Barbara Fredrickson’s Broaden and Build theory (Fredrickson 2013). The Broaden and Build theory of positive emotions suggests that positive emotions i.e. enjoyment, happiness and joy, all broaden one’s awareness and encourage new insights, thoughts and actions.

Over time, this broadened behavioural range builds personal skills and resources. This is in contrast to negative emotions, which prompt narrow, immediate survival ‘fight or flight’ behaviours (Fredrickson 2004). Frederickson stresses the importance of positive and authentic feedback to instil pride in the workforce, and the benefits to both the person giving and receiving of saying a simple thank you.

Positive emotions are therefore considered a key component in happiness and wellbeing and perhaps even prevent burnout.  It could also help to promote both a positive safety culture and improved patient safety which are both dependent upon good relationships and the ability for people to speak up, listen to each other and learn from each other.

In a positive safety culture workers are seen as the solution rather than the problem. If we change our approach in patient safety, to draw explicit attention to the positive rather than simply look for the negative or even at the absence of the negative, we may in turn help people feel happiness and joy and also develop new insights and ideas.

It is a joyful time that these emerging concepts and theories; positive emotions, positive deviance, appreciative inquiry, safety II, joy at work and learning from excellence are all starting to gain serious traction within the safety world.

References:

Bushe, G R (2013) The appreciative inquiry model. In E.H. Kessler, (ed.) Encyclopedia of Management Theory, (Volume 1, pp. 41-44), Sage Publications, 2013

Cawsey, M.J, Ross, M, Ghafoor, A, Plunkett, A, Singh (2017) Implementation of Learning from Excellence initiative in a neonatal intensive care unit ADC Fetal & Neonatal http://dx.doi.org/10.1136/archdischild-2017-314737

Emmons RA and McCullough ME (2004) The Psychology of Gratitude, Oxford University Press

Fredrickson, B (2013) Positive Emotions Broaden and Build. In Advances in Experimental Social Psychology, Vol 47 Elsevier

Hollnagel, E, Braithwaite, J, Wears, R L (2013) Resilient Health Care. Ashgate Publishing Limited

Kaleidoscope Healthcare (2018) Beyond Burnout found at: http://www.kaleidoscope.healthcare/uploads/8/0/2/1/80213224/beyond_burnout.pdf

Perlo, J, Balik B, Swensen S, Kabcenell A, Landsman J FD (2017) IHI Framework for Improving Joy in Work. Cambridge Massachusetts found at www.ihi.org/resources/pages/IHIWhitePapers/Framework-Improving-Joy-inWork.aspx.

Porath, C, Pearson, C (2013) The price of incivility. Harvard Business Review, Jan-Feb; 91 (1-2): 114-21, 146

Riskin, A, Erez A, Foulk, T A, Kugelman, A, Gover, A, Shoris, I, Riskin, K S, Bamberger, P A (2015) The impact of rudeness on medical team performance: a randomized trial. Pediatrics, Vol 136; issue 3

Design a bad system and it will lead to an increased rate of human error and an increased rate of at risk or risky behaviour

David Marx

What do we mean by risky behaviour?

Risky behaviour is a choice that comes with risks.  It could be a deviation from a rule or procedure, it could be that it is easier to deviate from the required behaviour.  Some refer to this kind of behaviour as violation or simply cutting corners.

Humans make mistakes and they drift into risky behaviours, it is part of being human.  Throughout our day to day lives we take risks, some of us more than others.  We can be placed into various camps; the risk averse, the risk takers, the risk lovers.

The deviation could drift over time towards the risky behaviour becoming simply habit or the new norm and may eventually become such that the level of risk and the new behaviour is accepted.

David Marx suggests that error, risky behaviour and reckless behaviour all have their own defined meanings.  That they are labels that can guide our actions and guide decisions in relation to individual performance and actions.  Being able to differentiate them is important in order to determine what might be done with system design and how we might understand the individuals behaviour within that system.

Is all risky behaviour bad?

Not necessarily.

• Is it risky behaviour for people to adjust what they do to match the conditions of work or the patients they are caring for
• Is it risky behaviour to interpret policies and procedures to make them work
• Is it risky behaviour for people to change what they do so that they succeed under unexpected conditions

What do we do about risky behaviour?

Behind every error and every risky behaviour there is an explanation.  When you see people exhibiting risky behaviour then one step would be to ask them about it, try to understand why they are behaving in that way and provide them with a form of coaching, a conversation about the risk they are taking and whether they see it as a risk to either themselves, their colleagues or their patients.

For healthcare in particular it is imperative that we move away from the punitive approach to risky behaviour and to create a learning culture so that individuals are encouraged to talk about what they are doing and why.  We need to understand that what some may see as risky behaviour for others it may be providing the most optimum service for patients in their care.

Ref: David Marx in Dave’s Subs: a novel about workplace accountability