Monday, October 29, 2018

Safety Culture: What are the Contributors to “Bad” Outcomes Versus “Good” Outcomes and Why Don’t Some Interventions Lead to Improved Safety Performance?

Sidney Dekker recently revisited* some interesting research he led at a large health care authority.  The authority’s track record was not atypical for health care: 1 out of 13 (7%) patients was hurt in the process of receiving care.  The authority investigated the problem cases and identified a familiar cluster of negative factors, including workarounds, shortcuts, violations, guidelines not followed, errors and miscalculations—the list goes on.  The interventions will also be familiar to you—identify who did what wrong, add more rules, try harder and get rid of bad apples—but were not reducing the adverse event rate.

Dekker’s team took a different perspective and looked at the 93% of patients who were not harmed.  What was going on in their cases?  To their surprise, the team found the same factors: workarounds, shortcuts, violations, guidelines not followed, errors and miscalculations, etc.** 

Dekker uses this research to highlight a key difference between the traditional view of safety management, Safety I, and the more contemporary view, Safety II.  At its heart, Safety I believes the source of problems lies with the individual so interventions focus on ways to make the individual’s work behavior more reliable, i.e., less likely to deviate from the idealized form specified by work designers.  Safety I ignores the fact that the same imperfections exist in work with both successful and problematic outcomes.

In contrast, Safety II sees the source of problems in the system, the dynamic combination of technology, environmental factors, organizational aspects, and individual cognition and choices.  Referencing the work of Diane Vaughan, Dekker says “the interior life of organizations is always messy, only partially well-coordinated and full of adaptations, nuances, sacrifices and work that is done in ways that is quite different from any idealized image of it.”

Revisiting the data revealed that the work with good outcomes was different.  This work had more positive characteristics, including diversity of professional opinion and the possibility to voice dissent, keeping the discussion on risk alive and not taking past success as a guarantee for safety, deference to proven expertise, widely held authority to say “stop,” and pride of workmanship.  As you know, these are important characteristics of a strong safety culture.

Our Perspective

Dekker’s essay is a good introduction to the differences between Safety I and Safety II thinking, most importantly their differing mental models of the way work is actually performed in organizations.  In Safety I, the root cause of imperfect results is the individual and constant efforts are necessary (e.g., training, monitoring, leadership, discipline) to create and maintain the individual’s compliance with work as designed.  In  Safety II, normal system functioning leads to mostly good and occasionally bad results.  The focus of Safety II interventions should be on activities that increase individual capacity to affect system performance and/or increase system robustness, i.e., error tolerance and an increased chance of recovery when errors occur.

If one applies Safety I thinking to a “bad” outcome then the most likely result from an effective intervention is that the exact same problem will not happen again.  This thinking sustains a robust cottage industry in root-cause analysis because new problems will always arise and no changes are made to the system itself.

We like Dekker’s (and Vaughan’s) work and have reported on it several times in Safetymatters (click on the Dekker and Vaughan labels to bring up related posts).  We have been emphasizing some of the same points, especially the need for a systems view, since we started Safetymatters almost ten years ago.

Individual Exercise: Again drawing on Vaughan, Dekker says “there is often no discernable difference between the organization that is about to have an accident or adverse event, and the one that won’t, or the one that just had one.”  Look around your organization and review your career experience; is that true?

*  S. Dekker, “Why Do Things Go Right?,” SafetyDifferently website (Sept. 28, 2018).  Retrieved Oct. 25, 2018.

**  This is actually rational.  People operate on feedback and if the shortcuts, workarounds and disregarding the guidelines did not lead to acceptable (or at least tolerable) results most of the time, folks would stop using them.

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