There is no error?


I recently attended a FRAM workshop. FRAM is a form of resilience engineering, which allows us to create a model of a complex system. It stands for Functional Resonance Analysis Model; but don’t let that put you off! I spent the first half of the workshop feeling rather confused, but ended up with a basic understanding and an enthusiasm to try the method to create models to better understand my work.

FRAM is underpinned by several principles, the most striking and interesting is: the equivalence of success and failures.

This may not seem intuitive, as we are conditioned to evaluate failure as more significant than success. (E.g. see loss aversion, from Kahneman). But actually, I believe this principle is true for work in complex systems. And it is profoundly important as it provides us with a way to understand our work (and improve it) without having to apportion blame for error. The tendency to apportion blame is, in my opinion, a major hindrance to progress in safety and healthcare in general.

If you make a serious attempt to make rules for every aspect of your work, you will soon realise that is impossible to explain every single action for every possible environment and situation. Thus you will see that in order to go about your work successfully, you will need to continuously make small adjustments. (In FRAM this is called ‘approximate adjustments’). These adjustments are usually successful but occasionally they lead to failure. But whether or not they lead to success or failure, they are essentially the same adjustments.

If we are able to understand this part of our work we will start to have a method for removing blame from error. In fact, this approach removes the idea of error. There is no error; there is only adjustment which may lead to success or failure.



Choice architecture


It’s very easy to focus on the negative aspects of one’s experiences. It’s the path of least resistance – it actually takes more effort to refocus one’s attention onto the vast amount of excellence which occurs everyday. Much has been written on the reasons for this negativity bias, and I won’t explain it here. And I do concede, very willingly, that much of our progress in healthcare (and in society in general) has resulted from our ability to notice the negatives; so I would never say that we should stop doing it.

But there are also many benefits from noticing the good. When you notice what is working, you learn something new. When you show appreciation or gratitude for the good, you improve your mood and that of those around you. Unfortunately, it takes effort to use the lens of positivity. Can we make it easier to access our positive worldview?

I contend that we can use choice architecture to make it easier for us and our colleagues to CHOOSE to see the positive aspects of their work. Providing easy access to an excellence reporting system, and making sure that the system works (i.e. positive feedback is forwarded in a timely manner) are key steps to making it easier to recognise excellence and to show appreciation. Linking the excellence reporting system with the adverse incident reporting system also provides an easy opportunity for staff to balance their observations of their workplace.

We know from 4 years of experience (and thousands of excellence reports) that this does not reduce the amount of adverse incident reports- it simply adds more intelligence to the reported data.  It also  makes it easier for staff to chose to notice what is working, and to show appreciation to colleagues.