This study evaluated the use of a Safety-II/Resilience Engineering (RE) inspired safety huddle tool, called the Green Line. The setting was a neonatal care unit in Sweden.
The Green Line draws on prompts of both failure, success and tries to encourage people to engage and learn about the entire spectrum of work. It also frames discussions around the four potentials in RE: anticipate, respond, learn, monitor.
The following questions were evaluated from the intervention:
- Do reflections with a focus on Safety-II in patient safety huddles affect the results of measurements of the patient safety culture conducted using questionnaires?
- What experiences of the Green Line with a Safety-II approach have staff had?
- What experiences of everyday work arise in the patient safety huddles that can be classified according to the potentials defined in resilience engineering; respond, monitor, learn, anticipate?
Providing background, it’s said incident reporting systems historically have too much focus on collecting reports and less on learning, improvement and the social processes around incidents. Further, many other safety management activities focus heavily on retrospective incidents and the like, rather than also exploring actual practices and conditions in-depth.
Huddles therefore are seen as a direct line to the challenges and opportunities faced by people every day.
Results
Overall, the authors conclude that “the Safety-II inspired safety huddles were found sometimes to be worthwhile and sometimes not” (p12).
Further, these results suggested that “it may be difficult to introduce reflections based on learning from everything that happens, including when things go well (Safety-II) into patient safety huddles” (p13).
Covering the four potentials, it’s said:
- Respond: Respondents gave examples of how they adapted to conditions of work, such as redistributing staffing around the ward. Use of safety huddles in one example allowed a staff member to realise that others were also aware of particular issues.
- Monitor: Only one experience reported by respondents could be linked to monitor. This was the importance of staff being with the patients and observing changes in their status.
- Learn: Examples were provided of how respondents go about learning and how the Green Line can facilitate learning potentials.
- Notably, learning during huddles “were mainly from negative events, very few from things that had gone well, when problems were resolved. It seems difficult to get an in-depth reflection on why situations were resolved in a good way” (p8)
- Anticipate: Respondents relayed that everyday work was becoming more and more unpredictable. However, it may be unpredictable but therefore even more important to plan, schedule and anticipate future problems in advance.
- Whether intentional or not, anticipation and preparedness for difficulties in the coming work shifts were central foci during the Green Line safety huddles
The authors then cover some supporting factors and hindering factors of a S-II inspired safety huddle.
Supporting factors
Themes were grouped into “seeing benefits with reflection”, “learning from what happens” and “finding improvements for a rewarding reflection”.
All respondents thought it was valuable to have reflections of previous days work during huddles. The huddles also offer an opportunity for people to speak up who ordinarily have little opportunity to.
Huddles were also seen to support the creation of common values and team cohesion for people working in across different areas. Without the huddle, it may be difficult to reflect on what happened during a shift and to share experiences.
For learning what normally happens – it was again noted that the discussion of negative events outweighed positive ones. This makes sense because negative events tend to be extremely visible and easy to talk about, whereas “positive experiences are taken for granted” (p9).
[** That is, as noted by others, normal work tends to be invisible and “uneventful”. David Woods talks about the law of fluency and how work may appear to be fluent and polished on the surface but this hides all of the difficulties managed underneath.]
People further had difficulty thinking about things that went well without contrasting it with negative things. [** This is a known constraint within RE and one reason why unwanted performance is used as outer boundaries for acceptable performance.]
Nevertheless, people agreed that talking about successful work and good practices to be helpful to “highlight and concretise things that went well so others could learn from them” (p9).
Others suggested that negative comments aren’t always taken seriously, or some topics may be taboo to discuss, so focusing other parts of the normal work distribution is another way to engage with groups while maintaining sufficient levels of interpersonal risk taking.
Respondents gave suggestions for improving the S-II huddle:
- More presence and action from leaders
- A champion/facilitator to direct and enhance the conversations and reflections (which could be cycled through team members each day)
- Occasional involvement from other parties, like the quality and patient safety manager and the like
- Huddles needed to be varied and inspiring – not static and controlling
- Informal and flexible to adapt to current conditions but with enough structure and forward planning to ensure parties like physicians could always attend
- Good clarity on the purpose of the huddles and a system/method to spread lessons from them [** the bane of all formalised learning systems in organisations…]
Difficulties with the safety huddles
The huddle format & agenda could be constraining. Such that sticking to the format was seen as more important than what the goal of the huddle.
Learning and reflection was also challenging, and it was hard to keep the huddles serious and focused. Staff working hours and breaks during the shift tended to dominate huddles and not “creating good care”.
Further, things that needed to be discussed weren’t always discussed and things that were discussed weren’t always carried forward or actioned; which was frustrating. Feedback and reflections often stayed at the local level and didn’t travel.
The atmosphere during huddles wasn’t inviting to raise tough issues and in other cases the conversations were superficial.
It’s said “There was a desire for an open and permissive climate but the experience was that this was not always the case” (p10).
Discussion
Wrapping up the findings, it’s said that while most people were positive towards the huddles and focusing on the full spectrum of work, the format and further foundational work is necessary to realise the benefits.
While learning how things normally go well and the goal tradeoffs resolved, workarounds implemented etc. is a “simple yet compelling concept”, in reality people took to describing failure far more even though both can co-exist.
As mentioned earlier, “We normally “see” when an adverse event takes place, but we do not “see” when an adverse event does not take place, when things go well” (p11).
Therefore, further work in enabling these reflections and building the skillsets needs to be enhanced for the S-II safety huddle to meet its intended goals.
Nevertheless, an earlier study which explored the Green Cross tool (a “conventional” huddle tool which the S-II Green Line was based on) was limited in its ability to elicit quality insights and reflections because it only focused on things that went wrong.
Another point emphasised the role of leaders in supporting huddles and spreading insights. They note “Managers at the clinical level are central to the system’s capacity for expressing resilience but they need more models and training in how to approach their work … [and] Managers need to continuously follow up an intervention to reinforce commitment for a change to be fully accepted and established in the workplace” (p11).
Clear links to psychological safety emerged in this study. Challenges to PS were highlighted by some people not feeling able to speak up about certain topics, nor necessarily getting the right support, tolerance or openness. These factors will limit the success of huddles.
Other reflections is the sparsity of examples from the anticipate and monitor RE potentials. On this the authors speculate there is “possibly a greater propensity for healthcare professionals to act, than to be actively aware of what they can expect from the future and from measurements” (p12).
Authors: Wahl, K., Stenmarker, M. & Ros, A. BMC Health Serv Res 22, 1101 (2022).
Study link: https://doi.org/10.1186/s12913-022-08462-9
Link to the LinkedIn article: https://www.linkedin.com/pulse/experience-learning-from-everyday-work-daily-safety-study-hutchinson
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