Safety-II is moving beyond the conceptual, with practical applications emerging from the fog of models and theory. But critics still point to a lack of evidence and limited real-world proof that the promise is justified.
A BMJ article entitled The Problem With Making Safety-II Work in Healthcare looked into whether Safety-II can help us to better understand and make improvements to patient safety. One of the author’s, Mark Sujan, recently joined our webinar on Safety-II: A Critical Look at the Promise and Potential for Healthcare to contribute to the debate.
Safety-I & Safety-II: together in harmony
Mark talked about the place of Safety-II within healthcare quality and patient safety. Safety-II is often perceived to be a significant (and recent) shift in thinking that is the antithesis of Safety-I, focussing on proactivity to Safety-I’s alleged reactivity.
Mark suggests that there really is no conceptual “Safety-I” and that instead there is a rich diversity of thinking in safety science, which might be characterised by a gradual shift in the models and the methods towards a systems focus.
He challenges the assertion that Safety-I is purely reactive, highlighting tools such as Failure Mode and Effect Analysis, which has been used for decades in the design process of products and processes, and which seeks to proactively identify and manage risk before any harm or incident occurs. Safety-I can sit in harmony with Safety-II, he says, because they provide different and complementary perspectives on patient safety. A diversity in safety thinking should be regarded as an asset rather than a threat.
However, the increased complexity of the healthcare system does require us to think differently about safety and how we manage it.
Safety-II helps us to think of safety as the presence of abilities that enable things to go right, not simply as the absence of adverse outcomes.
We must accept that safety is achieved by flexibility of action and adaptation rather than purely through the success of risk barriers and control measures. We should seek to learn from everyday activity rather than focus only on investigating incidents. And finally we should embrace human variability rather than seek to constrain and standardise it as a source of both success and failure.
Using an example of research he has undertaken in the management of patient deterioration, Mark outlined how work-as-done deviates from the predictable, is often complex and variable, and that through the lens of Erik Hollnagel’s “resilience potentials” (Anticipating, Monitoring, Responding and Learning) we can better understand our systems and make potentially more effective recommendations for change.
This shift isn’t simple and the outcome won’t be easy to implement, but the result will be worth the effort.
Using anticipatory practice to reduce serious harm from falls in an emergency department
Q member Bianca Viegas from East and North Hertfordshire NHS Trust outlined an improvement initiative aimed at using Safety-II to reduce serious harms related to falls in the Trust’s emergency department.
Ms Viegas shadowed the ward nurse manager and her team, asking questions about everyday work. This exercise revealed specific adaptations and workarounds for patients, including anticipatory practices. For example, if ward capacity was low, high risk falls patients were relocated within sight of the nursing staff.
By surfacing this and other anticipatory practices, the ward nurses were able to spread the practices across the whole care team at the daily nursing huddle.
Not only have there been no falls in twelve months since the implementation, but the team felt listened to and are more engaged with other improvement initiatives.
Towards a non-hierarchical clinical leadership
Along with examples of Appreciative Inquiry, Q member Prof Rob Cunney of Children’s Health Ireland talked about applying Safety-II in a health care setting. When the Intensive Care Unit team explored a problem with the equipment used to scan blood samples, a junior nurse shared a work-as-done practical insight that solved the problem.
Although Prof Cunney was the most senior member present, and regarded as a knowledgeable in this area, the team had sufficient levels of trust in themselves and each other to respect the clinical leadership of a junior nurse.
Prof Cunney pointed to this as an example of a Safety-II cultural shift that made it safe for clinicians at any level to assert themselves in the interests of patients, regardless of their post or professional status.
Prof Cunney also shared an initiative to develop psychological safety through the use of ‘positive question’ cards. At team huddles, one card is picked at random to facilitate the sharing of stories.
This demonstrates how Safety-II can be used to cultivate opportunities for the sharing of professional insight in a learning culture driven by collaboration rather than hierarchy.
Challenges to adopting Safety-II principles
During the webinar, we ran a survey about the challenges of implementing a Safety-II approach. The survey responses fell into four broad themes:
- Proliferation of Safety-I thinking – examples of this are a fixation with error, the need to standardise behaviour, and a lack of familiarity with Safety-II concepts amongst front line staff leading to a prioritising of Safety-I
- Cultural barriers – examples of this are the lack of an evolved safety culture, a change-resistant culture and the NHS not having identified a framework for trusts to use to adopt Safety-II
- Lack of capacity / resource – examples of this are that clinicians do not have structured time to implement a Safety-II approach, along with the challenges of staff fatigue and juggling multiple priorities
- Stakeholder engagement – this was cited as a significant challenge to adopting the Safety-II approach
Evaluation of Safety-II: how do you measure a non-event?
One participant questioned how it was possible to measure outputs of non-events. As part of a discussion about the wider challenge of how to implement, evaluate and measure Safety-II in practice, participants talked through range of evaluation tools for doing this including:
- prospective audits
- embedding a safety culture
- data on adverse events, and
- surveys of stakeholder satisfaction.
Safety-II: showing encouraging progress
From the webinar and the survey findings, we learned that 39% of respondents (40 of 102) have partially implemented Safety-II principles in their organisation. Sixteen types of Safety-II interventions were shared including Appreciative Enquiry and Learning from Excellence, with more in development. Twenty-two examples examples of problems and issues addressed by using Safety-II were shared, ranging from clinical issues to organisational challenges to policy.
National initiatives such as the Patient Safety-Incident Response Framework, our survey results, and the intervention examples shared on the webinar illustrate that Safety-II is moving beyond a purely academic context. It is starting to have a positive impact on patient safety and health care work culture.
Challenges remain but this community is committed to realising the promise of Safety-II and sharing our insights along the way.
If you would like to explore this more deeply and see the slide presentations, view a recording of this session.
Join our Organisational Resilience & Safety-II Special Interest Group to connect with colleagues, share your experiences with Safety II, and find out more about upcoming events.
If you have any ideas on future events please contact Simon.