Introduction 

In the last edition of The Human Stream, we noted that the modern pursuit of safety and quality has been framed as a top-down, ‘at-arms-length’ (and highly codified) endeavour, which tends to view governance as the exertion of control on healthcare systems (to assure or to improve) by setting objective standards of performance and then monitoring adherence and deviations.

We also explored why this way of thinking, at minimum, is deficient in complex healthcare settings. How deficient exactly? That can be debated at length. Irrespective, most experienced practitioners and leaders will agree that the mountain of manufactured objectivity - the data trends, the forest of indicators and quality dashboards - is no guarantee of useful insights nor does the rigorous enforcement of compliance measures guarantee perfect performance in the areas that matter.

Ironically, efforts to impose increasingly ordered systems of governance over messy work often just produces more messiness. We certainly aren’t governing with any more certainty because of these efforts….but might well be drowning as a result of it.

Those looking for more substance around these arguments (as in the unintended deleterious effects of the current paradigm) might wish to look beyond recent issues, as this has been a somewhat consistent theme across many editions of The Human Stream.

However, the current issue is all about practical ways to break out of this conventional paradigm and its patterns of unending circularity. I must emphasise that pragmatic suggestions offered here do not represent some sort of compromise, at least not in my book. I don’t see them as some homely alternative to a “proper crack” at change via a multi-year strategic transformation initiative. Far from it.

Unlike the high-investment, low-yield transformation programs that many of us have been witness to over the years, this more subtle approach is all about entraining a set of core practices that will (over time) help you gradually escape the unsettling holding pattern of the '1000-foot-view' and bring you into a paradigm that is much richer, more connected to the myriad complex risks that in live in the nooks of everyday clinical service delivery and with the means to do something about them.

It actually works, albeit slowly. This is much more about systems change that might be immediately apparent at first glance, but what these steps lack in grand claims of turning patient safety on its head, it will make up in small scaffolded wins that will get you there in time.

Change the Task to Change the Thinking

As someone reasonably well-versed in the emerging thinking (from complexity through to safety science) and the challenges of on-the-ground translation efforts, I am starting to see many early adopters in healthcare run into some predictable barriers.

Much like the parable of the seed that fell on shallow ground, the excitement surrounding Safety II and other new view perspectives often leads to hasty implementation. Organisations rush to adopt new models of practice while still using familiar but outmoded ideas of change management. This is an exercise in futility.

It's easy enough to update safety and quality strategic plans with the latest catchphrases: repealing old exhortations and injecting new buzzwords: "a focus on what goes well," "the principles of restorative justice," or "a systems-based approach." These updates often come with a flurry of activity - exciting workshops with rakish ex-pilots, invited talks from superstar academics, private book signings and the celebratory tones that accompany all new things.

While these efforts do have some value in rallying the troops and to enthuse leadership for a short time, disillusionment can quickly set in once the shine comes off. Thankfully, most are not there yet, but I do see the early signs. I would suggest there are better approaches than rolling out the rationalist playbook - the very one that new thinking implicitly critiques.

My friend and colleague Dr. David White Jr, a cognitive anthropologist and possibly the most down-to-earth change leadership expert on the planet, emphasises that if leaders are serious about transformation, organisations need to grow out of this aspirational adventurism (my sentiment, not his) and settle into the grunt work of reshaping the everyday task environment.

The task environment and the shared knowledge held by groups (what David calls 'dominant logics') exist in a symbiotic relationship. You cannot change these shared logics by simply exposing your system to alternative ideas because the everyday tasks naturally resist changes to their underlying logic.

So if Safety II demands changes in how we think about safety, then we must first think about the task environment within which Safety I embeds - namely the routine activities, orientations and structures of clinical governance. This comes much before we think about changing the system ‘out there’.

Practically, what this means is setting up the everyday meaning-making practices that will exert a consistent but gentle pull on the underlying shared logic. If it offers some adaptive benefit to a governance team or to your safety leadership, it will weaken the dominance of one set of logics, allowing another to grow in its place. If it does not, it will not. This is a key insight to retain along any journey of complex change.

So, without further ado, here are a selection of catalytic activities that I have tried and found useful to advance these priorities with governance teams and board committees. Not all of them work all the time or in every situation, nor is this an exhaustive playbook by any means. My hope in sharing these examples is that it makes the abstract a little more tangible, and if it sparks enough of a connection with your unique local context, that it would stimulate a different conversation and alert you to the possibilities of incremental transformation in your own systems.

Map often - map deep

A feature that I observe in many governance teams and board committees is a type of ritual observance that creeps into governance activity over time. The longer something has been going or how widely it is adopted across a sector, the more sacrosanct it is. Sometimes this is overt, where queries about the ongoing utility of activities are rapidly shut down. More often, challenges to the status quo get enveloped in appeals to authority and circular reasoning. Whatever the case may be, governance teams lose a lot of self-agency, time and effectiveness as result.

In these types of situations, I find facilitating a simple mapping activity to be very helpful. One version of this involves drawing two intersecting axes on a whiteboard (or using mentimeter like I often do). On one axis you look at estimate how ‘mandatory’ something is (Whether you have to do it or not) and on the other how prescriptive it is in nature (Exactly how it must be done). You then collaboratively work out which activities draw the top 80% of your resources and attention and where they go across the four quadrants that have been created. If something is flagged as mandatory & prescribed then there should be clear line of sight to the current sources of that requirement. If it checks out, don’t mess with it.

The other three quadrants provide interesting food for thought. If an activity is mandatory and not prescriptive, how could it be done in away that is either more useful to the organisation or in a way that that reduces the burden of that work (perhaps in a way that integrates it more meaningfully with other activities)? If something is clearly not mandatory then it should prompt deeper reflections on how it creates value for the organisation (which can often be of greater worth than activities that solely exist to meet compliance requirements). If it does not, then it is worth discussing whether it’s time to disinvest and redirect resources elsewhere.

Not only is this a great way of shedding unnecessary ‘clutter’ and legacy requirements that no longer apply, it’s can also gently counter any default resistance to the weighing up of effort versus value. More importantly, it provides governance functions with the shared experience of looking that their work in a markedly different way.

Depending on the maturity of the conversation, you could even adapt this approach to consider more challenging questions. Try mapping ‘organisational risks’ versus ‘applied resources’. The options are quite endless.

What this does is that it gradually shifts the task environment in way that allows in a more systemic orientation to seep into the discourse of governance. In my experience, governance functions that periodically create space to collectively engage in these types of activities tend to become better thinking through issues rather than just ‘actioning’ issues, and also at sifting out the high priority stuff from the cacophony of demands that pull at them.

Devote time for ‘working systems out’

In 1995, Don Berwick wrote a canonical piece (A primer on leading the improvement of systems) and his second principle was that one must changing systems rather than changing within them. I agree that a systems focus is up there, but to work on systems in order to change them, you first need to know how they work and often they work quite differently to how higher ups in the organisational hierarchy would wish them to. As a result, I think working systems out (or working out how they work) should be the first step of any change - but it is also at the heart of effective governance.

Fundamentally, you are trying to cultivate a good enough but evolving understanding of how outcomes are created within your organisation. This means identifying:

• Pressure points and tipping points

• Protective features and points of excellence

• Unique processes, peculiarities, how they operate and their relative influences

• How these elements interact dynamically

There are many formal systems tools available for this purpose, from causal loop diagrams to work domains analysis, FRAM, and Accimap. However, the specific method you choose is less important than developing a repeated practice of exploring categories of risk with the aim of updating your collective understanding about the issues at play. The best tools are the ones you know how to use.

In a governance context this would mean bringing other voices to the table (clinicians, support staff and consumers), and converging multiple lines of hard and soft data to build a more coherent story of how those outcomes are created (positive or negative).

Coming together like this engenders a couple of key shifts. First, it pokes at our assumptions of stability in service delivery systems and the risks that they harbour. Explore the same adverse event class twelve months apart, and it becomes more instinctively obvious that we cannot presume that the same set of risks will combine in the same ways perpetually.

Your governance setup as a whole will become more attuned to the evolving nature of risks and of organisational needs. In turn, these can promote a greater awareness for the need to responsively modulate risk management efforts to signals other than wobbles in a trend line.

The capacity to more confidently navigate signals within you data requires this form of ‘functional literacy’ of your system. Yet, coming to such a realisation cannot be pushed in from the outside, it requires engagement in the shared embodied and enacted experience of doing this stuff together - this is why shifts to practice can be so powerful.

The critical act of system stewardship

A comment that I regularly hear from safety and quality leaders is that they would love to spend more time in system innovation, but that the work of assurance is a relentless task master. Having spent many years myself in the clutches of the same machine, I share a lot empathy for the experience.

However, I will sometimes point out, for safety and quality functions, innovation is not the goal. You are just seeking to realign your profile of activity with the core goals of governance - one of which is to effectively steward the capacities that the safety and quality of services depends on.

That these efforts sound like innovation is an indictment of how far basic governance functions have atrophied. Let’s take for example the familiar issue of inpatient fall prevention. If we start with an agreed position that in order for falls to be effectively managed certain systems must operate within healthy ranges, then how confidently can we tell how those systems are going at any given time? Quick tip, the answer is not in your routine suite of indicators.

During the Great Depression, Frances Perkins who would become America's first female cabinet member as Secretary of Labor, helped balance the emerging labour data by bringing insights from first hand investigations of working conditions to Franklin Roosevelt. Perkins, who championed many significant improvements in workplace safety and women’s rights in the American workplace over her illustrious career, would personally visit factories and speak with workers, bringing back vivid accounts that shaped the New Deal's labour policies. Her detailed descriptions of children working in mills and dangerous factory conditions provided the emotional and factual ammunition needed to push through crucial reforms.

This historical example illustrates a fundamental truth about system stewardship: steady inflows of diverse forms of intel are a vital for effective governance. Yet to keep these streams of information alive over time, listening is not enough. This is where an active forward-leaning stance by governance functions can keep these channels flowing well. By advocating for frontline teams when they detect negative safety impacts from organisational decisions, or by reinforcing and spreading novel practices, governance functions can become trusted partners in frontline risk management - taking on a more fuller role in the stewardship of safety and quality.

Coming back to the falls example, while it’s fairly typical to look at incident rates and at analyses of serious events, how often do we invite managers of high risk wards into committee meetings to add some texture to the narrative? How can governance teams (boards committees even) gain a better appreciation of the nature of everyday challenges, and the meaningful ways in which critical capacities to prevent falls can be supported?

Fundamentally, these cycles of constant learning enable a form of system stewardship that cannot be achieved easily within the more impersonal analysis-detection-intervention model. Again, as highlighted before, discovering deep value in adopting these foci requires the grounding experience that regular immersion in these activities provide.

Conclusions

Admittedly, every organisation is on a different path. Some will take to certain lines of inquiry more easily than others. Yet others will feel so overburdened by compliance and reporting requirements that any thought of carving out time for this work will seem unimaginable.

For all these reasons, the path to doing governance differently must be navigated in context and with sensitivity, mindful of how much of an appetite your colleagues have for such a journey, how much destabilising dialogue your organisation will tolerate and how much trust exists within your networks.

Regardless, whether you start tentatively or with some serious intent, the above should give you some initial ideas to work with. Of course, there are a many more context-specific activities that can help in particular situations. If the ideas above do not resonate to your specific challenges (or if they do!), get in touch.

I wish you all happy start to 2025. We will be skipping a fortnight because of the holidays. See you in a month.

AI Use Declaration: This content is written by a human. A large language model (LLM) was used to support background research and proofing of content. All quotes are verified and directly taken from source documents.

The Human Stream is a fortnightly newsletter for clinician improvers, safety and quality professionals, governance teams and healthcare leaders. The Human Stream compiles insights, topic overviews and practical tips from contemporary safety and systems sciences, all in an easy-to-read, information-rich package, conveniently delivered to your mailbox!