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.



Work as done and work as imagined: a role for LfE?


Much has been written on the concept of work as done (WAD) vs. work as imagined (WAI). Essentially, the idea is that the work done at the sharp-end / on the shop floor (i.e. WAD) differs significantly from that which is documented in standard operating procedures (WAI). Understanding this difference is key to understanding why adverse events occur, yet this approach is often overlooked: the prevailing approach to adverse incident analysis is often based on an assumption that WAI is the reality.

Understanding WAD is not easy and probably requires a completely different approach to commonly used methods like Root Cause Analysis (RCA). WAD depends on variability of performance including improvisation and work-arounds. This variability is essential for socio-technical systems (such as health-care) to function, but this variability can also be the source of failures. Unfortunately, adverse incident analyses tend only to highlight the negative side of human variability, so efforts to make systems safer often result in the imposition of more and more constraints.

How can we understand WAD better? In particular, is it possible to capture the positive side of variable performance?

Capturing WAD necessarily requires real workers describing how real work is done. Hence, the understanding must come from the ‘sharp-end’. Various methodologies exist, but I would advocate the value of excellence reporting. The vast majority of LfE reports describe non-technical skills whereby success has occurred despite difficult conditions.  These non-technical skills (e.g. generosity, kindness, going the extra mile) are not featured in WAI, yet they are assumed.  It is my contention that positive human interactions are a core component of WAD and should be actively noted and appreciated. LfE is designed to do just that.



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.