As a medical director I am routinely required to assess, grade and act on the results of serious adverse events that have occurred in hospital. Often these events have resulted from failures of care through lapses, oversights, errors or neglect. This is often accompanied by a clarion call for some form of disciplinary action and or restitution – usually most insistently from within the organisation rather than by those directly affected, either carers or the patients themselves.

Bad things happen in hospital all the time. Healthcare is the only industry where for a significant minority of users the outcome is death or injury, either expected or unexpected. The overwhelming priority in this situation for both the recipients and providers of the care is learning: learning the truth of events, learning if it was avoidable, learning how it might be avoided in the future, and sharing that learning so it might be avoided elsewhere.

Prerequisites for Organisational Learning

We have, as human beings, an innate gift for learning – it is built into our DNA and, whilst most active in our early years of life, never really leaves us. Individual learning is the most powerful lever of change in human societies, because people love to learn and change as a result. Teams and organisations are made up of people and yet team and organisational learning does not happen by chance as it does for individuals – team learning is an unnatural and deliberate act.

There are three prerequisites needed within organisations in order to promote learning from error and system failure. It is strangely rare to find them all reliably present in healthcare organisations.

  • A Learning Environment
  • A Team Based Learning Infrastructure
  • A Compelling Vision Delivered Through Leadership
  • I will expand on these three prerequisites, but first I want to explore why they are found rarely in our hospitals and healthcare organisations.

    Two Key Barriers to Organisational Learning in Hospitals

    Hospitals are busy places, this is a universal truth – not unique to the NHS. The work processes of nurses and doctors in hospitals rarely run smoothly – they are by their nature characterised by frequent interruptions, unexpected deviations and minor crises. In order to get the job done a large part of the work involves having to create on-the-hoof workarounds and solutions to problems – giving rise to the familiar sense of almost continuous ‘fire fighting’.
    20130120-132457.jpg
    We are actually incredibly successful at doing this, much of our individual innate learning capacity is consumed developing coping strategies for the chaotic environment we find ourselves in. The problem with this ‘first order problem solving’ for ‘low level failure’ is that the learning it generates is of value only to the individual nurse or doctor – they are simply adapting to the flawed environment they find themselves in – just to get the job done. In doing so they are condemning themselves and and their successors to having to learn the same lessons in perpetuity – this grinds you down and drives talent away from ‘the front line’. How do we break the cycle of low level failure that requires constant first order problem solving making every day work flow inefficient and time consuming? The first step is to recognise the problem and then acknowledge that low level failure, whilst common place, is neither inevitable nor acceptable. The next step is to then deliberately and collectively make the time to move first order problem solving into second order problem solving (of which more later).

    The second key barrier to organisational learning in hospitals is a deeper, more cultural one. This is to do with interpersonal attitudes and responses to error. The shameful truth is that the overwhelmingly pervasive culture is a blaming one that inhibits speaking up with questions, concerns and challenges that might otherwise have caught and corrected human error. Moreover there is a culture in medicine that does not encourage admissions of error. Both ourselves and others have high expectations of success in medicine – when we don’t meet those expectations we are as blaming of ourselves as we might expect others to be. What is interesting is that the direction of blame isn’t just top down – in fact top down blame only really materialises when the failures mount up to catastrophic levels. The vast majority of, and undoubtedly more corrosive, blame is that of our colleagues and peers. What is clear is that whilst blame remains the primary response to failure opportunities for learning will be lost and the quality of the lessons learnt will be poor. Overcoming this barrier is a true challenge of leadership at all levels of an organisation as it requires a change in culture – a clear and sustained statement and restatement of values, unwavering adherence to behaviours that follow from those values, even in the face of challenges from within and without the organisation.

    Leading Learning for Patient Safety

    So where should we start with creating a learning culture in our organisations? The answer has to be with leadership, because without leadership on this issue nothing else can follow. The type of leadership and skills required to lead learning, however, are not what are typically viewed as traditional leadership skills. The leadership model for leading learning differs from the traditional leadership model in several important ways:

  • Whilst a ‘burning platform’ undoubtedly exists, the future state can only be guessed at (in an educated way)
  • This makes it hard to articulate
  • The flaws in the current state are hard to spot – there is a deep seated culture of acceptance of low level failure
  • The way forward is not a clear plan with deadlines and critical paths but a process of experimentation, a gradual reduction of uncertainty and regular revision of interim goals and ultimate vision
  • The leadership task is primarily one of engagement and reduction of fear not a promotion of employee effort
  • The task will never be finished
  • If you have read my previous blogs you might guess that I believe these ‘New Model Leaders’ need to come from the rank and file of doctors, nurses and other healthcare professionals that don’t often put themselves forward for such a role.

    Second Order Problem Solving and A Team Based Learning Infrastructure

    Second order problem solving is about creating long term fixes for recurrent problems, it is about analysing root causes and putting in place solutions with ‘traction’, it is often about changing behaviours in ourselves that have consequences for others. There are several reasons why we don’t stop and take the time and effort required to convert first order to second order problem solving. First of all – it does take both time and effort – neither of which we have much left of after a day / week / month / years of fire fighting. Secondly the problems we need to solve are quite often not even perceived as problems, we have been compensating for so long it has just become part of the job – this is where our new model leader has to be insightful. Thirdly second order problem solving requires some quite specific skills such as root cause analysis, process mapping, and change modelling that are not commonly found in healthcare teams. Fourthly – we are quite proud of our first order problem solving, being a coper and thriver in a stressful front line job is associated with significant kudos, particularly in the hospital environment. Finally it does require us to meet as teams for a significant time on a regular basis – which we are astonishingly bad at doing – and when we do for those team meetings to be led in a way that promotes speaking up, learning from others, admissions of failure and a willingness to innovate (and therefore risk failure). This final requirement leads on to the the final pre-requisite for organisational learning – an environment of psychological safety – A Learning Environment

    Blame Free Culture Vs Accountability – A Balance that Creates ‘Psychological Safety’

    Our new model leaders have their work cut out – not only do they have to create time (in an already overloaded time table) to bring together teams (who are singularly reluctant to gather) to discuss both low level and high level failure (failures that may not even be recognised as such) and defend these notions against pressures to use the time ‘more productively’; but also resist the temptation and pressures from above, inside and out to apportion blame for every failure that comes to light. The prize is great if they achieve it – a learning environment in an organisation that continually improves both itself and the people that move through it, one that delivers both on the economic and quality front. A true value adding organisation.

    But – it can’t all be so idyllic surely? People do also make mistakes borne out of stupidity, brazen over confidence, ignorance, stubbornness, laziness, jealousy and – yes – even malice. There is a level of human behaviour for which we all need to be held account. There is also a performance imperative, we all have to be helped to raise our game. Where is the place for accountability in a blame free culture? The diagram below will perhaps help you decide…

    20130120-213610.jpg
    This is the essential difference between ‘blame free’ and ‘psychologically safe’ for the latter comes not just from creating an environment where people feel able to speak up and admit failure but also feel assured that when boundaries are truly crossed that individuals will be held to account. This is the real test of leadership – knowing and communicating expectations and boundaries as well.

    Blameworthy Acts – the Boundaries of a Blame Free Culture

    Where do you draw the boundaries? There are no text books, there are no rules – there is intuition and there are inspirational leaders we can follow. Here is my starter for ten of blameworthy acts:

  • Reckless behaviour
  • Disruptive behaviour
  • Working significantly outside your capability
  • Disrespectful behaviour
  • Knowingly violating standards
  • Failure to learn over time
  • Failure to work as a team
  • Covering up
  • No doubt there are more. Clear boundaries around a learning zone create an environment in which organisations can thrive and patients can feel and be safe.

    I have to acknowledge the source of the ideas for this article. Amy C Edmonson – a truly inspirational teacher at HBS who not only articulates this message with conviction but backs it up with the irrefutable results of research both in healthcare and other settings.

    4 Comments

    1. Hello Dr Steadman
      A nice article . Especially liked the diagrammatic representation of the Psychological safety . It gives a snapshot view of blamefree culture vs accountability.
      Dr Nitish Raut
      ST7
      O-G

    2. Dear Roger,

      I couldn’t agree more: at the level of departments & organisations, healthcare is so busy fire-fighting that it doesn’t plan enough. When you describe the way forward being “a process of experimentation”, I see that you have truely grasped the difference between complicated, complex and chaotic systems. The interplay of our individual & collective decisions is what makes thing happen, not single decisions.

      If you’re interested in identifying root causes/contributory factors in healthcare: I would recommend an evidence based framework that my colleagues and I have been developping. http://qualitysafety.bmj.com/content/early/2012/03/14/bmjqs-2011-000443.full

      When it comes to your closing segment: I agree with many of your blameworthy acts, except perhaps disruptive because occasionally disruptive transformation is necessary to help us notice a different/better way of doing things. I note however that your list of blameworthy behaviours are very much behaviours that are carried out with intent (for example “covering up” is an active decision, as is “knowingly violating standards”). Failures that occur with intent are not errors. James Reason’s classifications of failures is clear: failures can be errors (unintended) or violations (intended). It is only when actual outcomes don’t match desired outcomes that he will use the term error. So to conclude, when I look at your list of ten blameworthy acts, I group these more serious ones in a group labelled “violations”. Unfortunately “Knowingly violating standards” is an interesting one because in some instances, standards have to be violated. For example the duty to report knife crime, which violates patient confidentiality. But that’s another story.

      Thank-you for the stimulating read!
      Pierre

    3. This is such a good article on many levels. It has successfully articulated thoughts I have been wrestling with since becoming a clinical director a few years ago.
      The separating out of learning from mistakes from circumstances meriting performance procedures from redress. Surely we can create a culture where we are open, we learn , we compensate , but where conscientious professionals have nothing to fear. ‘Punishment’ is reserved for blameworthy acts only – in every sector.
      This can only be good for patients – and we are all patients.

    4. Great blog. Your matrix, which shows psychological safety as being a pre-requisite for learning, aligns with Deming’s (usually overlooked) principle 8/14 for continuous improvement – removing the fear of change.

    5. Pingback: From ‘no blame’ to a ‘just culture’

    6. Pingback: Hot air about Just Culture – Alexander's Excavations

    Leave a Reply

    Your email address will not be published. Required fields are marked *