Do we need to focus on culture to improve patient safety?

Summary

Recently an enduring discussion evolved on Twitter on why safety culture is important for patient safety. My reaction, of course, was: it isn’t. Let me explain why.

I think it is possible to address safety without addressing safety culture. Or, rather, to focus on actions that will improve both safety performance and safety culture (as a by-product) at the same time. In this blog I propose some of these actions – showing how to create an understanding of how work is (actually) done (rather than what it says on paper), seeing what makes it difficult and identifying what resources are missing. If we address these challenges, then surely we will be able to improve safety and safety culture will follow naturally.

Content

‘Local ingenuity’

What we first need to achieve, is to identify ‘local ingenuity’: examples of ways that people are able to get work done amidst conflicting goals and constrained resources (including time and money), but that have not been formalised. Often these repertoires are not very visible to management. The repertoires might challenge existing rules, guidelines or just the way that management imagined that the work is being done.

When management hears about these repertoires, they often judge them against their idea of how work was intended to be executed. Worst case they will interpret the repertoires as non-compliances and not really want to hear this ‘bad news’. By ‘bad news’ we mean anything that challenges the status quo or the existing belief system. This of course then promotes the need to maintain a sense of secrecy around examples of local ingenuity and, importantly, does not allow these repertoires to be tested for safety or disseminated for learning.

Exception management

Rather, we would hope that by approaching work-as-done in a non-normative, open fashion, that we get to learn about these repertoires and can help people to evaluate them, optimise them and formalise them. That way we know we have a robust and reliable way of working. This requires us to approach rules and guidelines as a resource for people in a dynamic complex world, rather than as an unbending, absolute truth.

We aim to ensure that procedures are fit for purpose, and that effective 'Exception Management' takes place when people feel that rules need to be circumvented. This is quite different to enforcing the rules; rather, it is allowing people some specific, limited, room for autonomy in as much as they are task mature. As we learn about local ingenuity and how work is really done, we are able to work with our team to decide what autonomy they need under which circumstances. And we will feel a collective commitment to these, and an urge to bring exceptions (formerly know as non-compliances) into the open so we can discuss where the rules were not fit for purpose, training was lacking or circumstances were just so exceptional that no intervention is necessary.

As you will gather, all of this will improve trust, transparency, alignment with the rules and a preoccupation with safety – all of which are important components of a safety culture. But in this approach we do not set out to improve the safety culture directly; rather the improvement follows naturally as a by-product of understanding how work is done, identifying local ingenuity and being able to hear ‘bad news’. 

Further reading

Robert J. de Boer. Safety leadership: A different, doable and directed approach to operational improvements. CRC Press, 2021.

About the Author

Robert majored in man-machine systems at Delft University of Technology. After gaining experience in line management and consulting he switched to academia mid-career. Robert is currently the director of SDO University of Applied Sciences in the Netherlands, and also a professor of Safety Management there. He is active as a scientist and consultant in the oil and gas industry, defense, nuclear power, healthcare and aviation. He helped create the successful NHS course on Restorative Just Culture and his book on Safety Leadership was published earlier this year.