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

In memory of Dr Philip Woodward DSc – 6.10.1919 to 30.01.2018


Sign up to Safety update

At Sign up to Safety we are constantly reviewing what we have done and what we want to do in the future.  We have assessed the data, looked at what works and what doesn’t, and talked to loads of people who have been involved in our journey over the last 3 years.

We have found that not everyone is aware of how we have significantly evolved from the early days of Sign up to Safety in 2014.  We started out with a fairly traditional aim and approach; help the NHS reduce avoidable harm and save lives through the implementation of a set of safety interventions set out in safety improvement plans.  Now this is a really laudable aim but it was also a very busy playing field with all sorts of national and regional bodies and initiatives trying to do the same thing.

So we worked out where the gaps were; culture, relationship building, networking, kindness, positivity, supporting the learning from excellence initiatives and implementing safety II and we started to relentlessly focus on these gaps.  The thread throughout all of these is our throughline; helping people talk to each other.

So who are we now?

We are a Department of Health and Social Care commissioned team (and not as is often thought part of NHS England).  We help the NHS reduce avoidable harm and save lives by focusing on the following three key objectives.

Our three key objectives for 2018/19

  1. Build on the work of the Sign up to Safety campaign since 2014 and continue to focus on behaviours, attitudes and values that are vital for a safety culture via the mechanism of helping people talk to each other
  2. Support our current membership to build a safety culture, help people work safely and implement a new approach to safety (safety II) and build new membership, particularly in primary care
  3. Support two national priorities (the just culture and implementation of the revised NHS Resolution organisational strategy) with our work on safety culture

How are we doing this?

We started by thinking all we needed was to develop a ‘pack’ that would be a sort of ‘how to guide’ and then quickly realised it needed to be much less a guide and more a conversation in itself.  We wanted to create interactions with our members so that they could find out ideas, connect with others, and feel energised by the new knowledge and thinking.

We were helped by some trusty members who gave us their wise and honest advice. They reflected what we already knew, that asking people to talk to each other is a profoundly simple solution and that people find it difficult to accept simple solutions. What we started to do was almost apologetically turn something simple into something more complex.  To make us feel proactive we tried to turn what we know into a tool or technique or pack. We even started calling it a conversation pack and the methods as ‘Safety Conversations’.  What were we thinking?!

Calling them ‘Safety Conversations’ can be (and has been) misinterpreted and boom another trend is started.

We have enough checklists, policies and procedures to help people work safely.  There is already the confusion around the difference between huddles,  briefings, debriefings, handovers, and Schwartz rounds.  We even added to this list with our ‘kitchen tables’.  Why would we add to this with a ‘new’ thing called Safety Conversations?

So we have chosen not to do this.  Instead we have…

  • Designed a new website which will bring all of our thinking together with ways in which people can interact with us and the new ideas.  It is in the final stages of design but we wanted you to know that it is nearly there
  • Developed videos for you to download and share in your organisation
  • Recorded podcasts for you to listen to about what others are doing
  • Curated the latest thinking on safety and divided them up into 1min, 3 min, 5 min, 10 min, 20 min, 30 min segments depending upon how much time you have
  • Launched #kind2018 – our key hashtag for 2018 to help people share their stories about kindness and being kind to others which includes people saying thank you to each other
  • Designed a ‘Matchmaking‘ initiative being launched this February
  • Continued with sharing our approach to holding conversations about safety through ‘kitchen table’ events and encouraging another national kitchen table week from 19 March
  • Redesigned our newsletters which are issued every other Wednesday which are applicable to everyone no matter where you work
  • Written and commissioned blogs which will continue throughout the year, including the real experiences of our members who are making this a reality where they work

We hope that you will find our new site easy and all of these things, practical and accessible and help you have the conversations you need.

We would love it if the focus of your conversations over the coming year on many of the previous blogs here…such as those on safety I to safety II and helping people work safely.  That you too concentrate on culture, relationship building, networking, kindness, positivity, learning from excellence, and implementing safety II in order to help them work safely.

We truly hope that these conversations will open up new ideas and insights, and enable you to help people to put forward their perspectives, help them be heard without being interrupted or ignored, feeling that their voice can make a difference.

And lastly, try out our ideas, explore the different ways and then if you can share with us what you have learnt and experienced. We would love to show off your work.

We really look forward to hearing from you.


Working Safely

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

Lena Boroditsky, Professor of Psychology, Stanford University

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

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

To remind you…

Safety-I is where safety is defined as a condition where the number of adverse outcomes (accidents, incidents, near misses) is as low as possible

Safety-II is the ability to succeed under expected and unexpected conditions alike, so that the number of intended and acceptable outcomes (in other words everyday activities) is as high as possible

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

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

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

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

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

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


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

Connect people up to work together

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

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

Professor the Lord Ara Darzi

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

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

Stop assuming that healthcare fits into a neat linear model

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

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

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

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

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

Zero harm is impossible

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

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

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

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

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

Sidney Dekker says:

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

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

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

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

Liz Wiggins and Harriet Hunter (2016)

Sidney Dekker goes on to say;

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

At Sign up to Safety we would add:

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

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

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

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

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

What can we all do differently?

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


  • Erik Hollnagel and Rene Amalberti, (2001) The Emperor’s New Clothes or whatever happened to human error? In: 4th International Workshop on Human Error, Safety and System Development, June 11-12, Linkoping, Sweden (keynote)
  • Hindsight Journal – via
  • Erik Hollnagel, (2010) Safer Complex Industrial Environments. CRC Press, Boca Raton, FL
  • EUROCONTROL (2013) From Safety-I to Safety-II: A White Paper.
  • Erik Hollnagel, (2012) A Tale of Two Safeties – via
  • Erik Hollnagel, (2013) Is safety a subject for science? Safety Science; Elsevier Ltd


Things that get in the way of talking to each other


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

Chris Turner (2017) at the Learning from Excellence Conference

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

These are just a few:


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

As Steve Shorrock says…

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

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


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

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

Steve Shorrock (2016)

Power and status

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

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

Our bias gets in the way

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

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

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

Over confidence

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

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

Robert Montgomery

Human characteristics

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

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

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

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


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

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

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


What can we do differently?

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

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

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

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


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


Learning from excellence conference

Every now and then you meet some people who change you

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

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

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

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

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

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

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

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

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


How has it changed me?

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

That’s pretty profound.

Take home quotes:

The bottom line is the frontline (Emma Plunkett)

Move from humiliation to humility (Neil Spenceley)

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

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

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

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

Civility saves lives (Chris Turner)

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

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

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

Better Culture, Safer Care – Guest Blog by Matt Hill


How we are helping to improve safety culture in the SouthWest

Guest blog by Matt Hill

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

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

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

Conversation 1

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

Conversation 2

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

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

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

Full blog here

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

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

Full blog here

Conversation 3

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

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

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

Conversation 4

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

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

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

Full blog here

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

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

Full blog here

Conversation 5

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

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


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

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

Full blog on the South West Patient Safety Collaborative website.

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

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

Full blog here

Summing up

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

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

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

 Dr Matt Hill


Working safely

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

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

What can we all do differently?

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

Relevant books and websites

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