Is Learning from Excellence “Safety-II”?


Learning from Excellence is often described as a “Safety-II” initiative.  I can see why this is the case, but the truth is that I implemented LfE before I had even heard of Safety-II.  That’s not to say the Safety-II was an underground movement; I was just a bit slow to find out about it.

The principle aims of LfE are to improve quality (through gaining insight by looking at hitherto under-studied parts of our system) and to improve morale (through formal positive feedback).  Safety-II is a concept based on the idea that safety can be considered a condition where as many things as possible go right; rather than the prevailing approach to safety – Safety-I – where we consider safety a condition where as few things as possible go wrong.  In the history of ideas, Safety-II is a very new one.  Whilst its theoretical principles are increasingly well defined, there is a distinct lack of practical application – particularly in healthcare.  How does one actually “do” Safety-II?  While we wait for the answer to this question, which may take years to come, we are tempted to “fit” initiatives, like LfE, into the Safety-II label.

Does LfE fit into Safety-II?  I think the answer is yes and no.  But a bit more yes than no.  LfE is about identifying success, and viewing it through a learning lens.  The name of the initiative suggests that it tends to identify extremely good (i.e. excellent) examples of work.  Indeed, this was the original idea of the initiative.  However, after looking at over 2000 reports, I have concluded that we are not capturing rare episodes of excellence – we are actually capturing “everyday excellence”.  The vast majority of the reports are a description (or short story) of a small work-around, improvisation, or a generous human touch which allowed success to occur in difficult circumstances.  It turns out that neither difficult circumstances, nor generous human touches are hard to find in healthcare. The success of the initiative is due to the fact that these have been happening since the start of organised healthcare, but have been unrecognised through formal reporting systems.

In the Safety-II construct, we could make our systems safer by understanding day to day work better.  Since success happens most of the time, we should be studying and understanding what happens most of the time, in order to recognise the work-arounds / adaptations / improvisations which create (and underpin) the conditions which allow success to happen.

If most of our LfE reports are about everyday work, I would argue that we have essentially created a system for “doing Safety-II”; at least in part.  What we haven’t created is a system which understands every element of everyday work.  This is someway off.

The fact that LfE is not a perfect practical solution for Safety-II is not a reason to change it. On the contrary, it continues to grow and spread positivity and positive change in healthcare (and beyond), so there is no need to make it fit into anything.

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