Switching the paradigm: Safety-I to Safety-II
There is no formula to clinical governance. While there are key components that should always be considered, how we consider them requires flexibility and agility to achieve good clinical outcomes.
This is the aim of clinical governance. It is not just about preventing harm, but about ensuring good outcomes. Clinical governance is not just about safety, it is also about quality. While safety is an essential foundation to quality, quality goes above and beyond safety.
This is where the Safety-II culture aligns with clinical governance. Safety-II is a concept that was developed outside of healthcare, yet is equally applicable to it. It concerns ‘the system’s ability to succeed under varying conditions’. On the other hand, the traditional approach (termed ‘Safety-I’) is ‘a state whereas few things as possible go wrong.’ Therefore, while Safety-I tends to be incident-focussed and reactive, Safety-II is responsive and proactive.
Note that a ‘positive patient safety culture’ (discussed in a report by the Victorian Auditor-General’s Office earlier this year, which assessed clinical governance in the state’s health services) is where staff feel safe to voice concerns relating to patient safety, and where a health service is committed to learning from errors and responding to warning signs early. Indeed, it was observed in Targeting Zero that hospitals with a positive safety culture had a robust organisational commitment and investment in safety.
It is considered that health services which instill a positive patient safety culture are more likely to detect clinical risks early, which in turn will prevent avoidable harm to patients. This approach is distinct from a Safety-I culture in that a patient safety culture focuses not on how things go right, but on safety responsiveness.
A paradigm shift from Safety-I culture, or even a ‘positive patient safety culture’, to one which embraces a Safety-II philosophy enables us to support frontline carers and health staff in a more positive way that will capture quality as well as safety. In a Safety-II culture, rather than seeing the workforce as the hazard, we see it as a positive resource to be nurtured and entrusted with the responsibility of care. A Safety-II culture will also engage staff and encourage openness and transparency (including through the reporting of incidents and concerns), in a manner that promotes a patient safety culture as a necessary by-product.
By understanding and promoting how we succeed, we can understand and mitigate the risk of failures. Rather than constantly seeking to prevent incidents - which can at times adversely impact care (for example, through overly cumbersome or complex policies and procedures) - we should be seeking to foster and perpetuate our successes, and continuously improve.
“Look at what goes right, as well as what goes wrong and learn from what succeeds as well as from what fails. Indeed, do not wait for something bad to happen but try to understand what actually takes place in situations where nothing out of the ordinary seems to happen. Things do not go well because people simply follow the procedures and work as imagined. Things go well because people make sensible adjustments according to the demands of the situation. Finding out what these adjustments are and trying to learn from them is at least as important as finding the causes of adverse outcomes!”
- E. Hollnagel et al, ‘From Safety-I to Safety-II: A White Paper (Eurocontrol)
All accessed on 28 November 2021
‘From Safety-1 to Safety-II: A White Paper’. DNM Safety. Accessed at: https://www.researchgate.net/publication/282442036_From_Safety-I_to_Safety-II_A_White_Paper_Eurocontrol
‘Clinical Governance: Health Services: Independent assurance report to Parliament 2020-21:22’. Victorian Auditor-General’s Office, June 2021. Accessed at: https://www.audit.vic.gov.au/search/reports?f%5B0%5D=status%3Acompleted&type%5Breport%5D=report&term=§or=All&status=All&tabled%5Bmin%5D=&tabled%5Bmax%5D=&sort_by=field_tabled_date&sort_order=DESC&page=1
‘Targeting Zero: Supporting the Victorian hospital system to eliminate avoidable harm and strengthen quality of care: Report of the Review of Hospital Safety and Quality Assurance in Victoria’. Victorian Department of Health and Human Services, October 2016.
E. Hollnagel et al. ‘From Safety-I to Safety-II: A White Paper (Eurocontrol), September 2013. DOI: 10.13140/RG.2.1.1626.6961. Accessed at: https://www.researchgate.net/publication/282442036_From_Safety-I_to_Safety-II_A_White_Paper_Eurocontrol