Organisational culture: problem-sensing and comfort-seeking (THIS Institute, 17 April 2023)

Summary

This article forms a section of A guide to good governance in the NHS, published by NHS Providers. Mary Dixon-Woods and Graham Martin contrast problem-sensing with comfort-seeking, confront structural complacency and a lack of eagerness to use hard and soft intelligence, and discuss the crucial importance of openness.

Content

Key messages

• Comfort-seeking is undesirable behaviour characterised by seeking reassurance, by taking undue confidence from the data available, and by the inability or unwillingness to seek out information that might challenge the sense that all is well.
• Problem-sensing involves actively seeking out weaknesses in systems relating to quality and safety, typically using multiple techniques and sources of organisational intelligence.
• Problem-sensing behaviours also involve actively seeking out data or other forms of organisational intelligence that offer challenge, disrupting any incipient risk of complacency.
• Organisations and systems need to be able to distinguish between: quality issues that can be attributed to the individual performance of healthcare staff; what can be achieved through process improvement; and what represents defects in the design and resourcing of systems.
• Culturally, problem-sensing encourages staff to engage in active noticing of where there might be defects, speaking up about them, and ensuring that systems are in place to make improvements.
• As with the collection of 'harder' data, though, it is important not to mistake activity for action. Simply undertaking listening activities or unannounced visits is no substitute for the hard work of analysing and responding to the issues they unearth.
• The willingness of those at the 'sharp end' to speak and of those at the 'blunt end' (senior leadership) to listen exist in a reciprocal relationship.
• We should not overestimate the power of leaders or of 'transformational leadership' in influencing behaviour across complex, disparate and dispersed organisations.
• The most important role of boards and senior leaders in nurturing positive cultures may be in collating knowledge about variations in performance, behaviour and culture across their organisations, and supporting local leaders, located within units with their own subcultures, in their efforts to improve openness.