Thursday, 26 June 2014

Fear and Learning

An interesting news story emerged this week: A fifth of hospitals are under-reporting mistakes that lead to avoidable patient deaths. To address this the government has launched a microsite on Patient safety in the NHS ranking hospitals by their safety data. It includes a category of 'Open and honest reporting'.

Increased openness - A great idea?

In 2005 Martin Bromley's wife died in hospital following a routine minor operation. Drawing on his experience in the airline industry, Mr Bromley managed to instigate an investigation with a focus on learning rather than blame. As a result, the investigation uncovered 'communication problems' that initially appeared to be within team, but were in fact a systemic issue across the healthcare system (sounds like they did a great job of popping the why stack).

Mr Bromley went on to found the Clinical Human Factors Group, a charity campaigning to prevent exactly the kind of avoidable deaths that are being under-reported. The BBC's Today programme interviewed him (go to 01:09 - available in the UK until Tuesday 1 July), and Mr Bromley's thoughts on the new website are worth quoting at some length:

My concern is that what we're trying to a culture of learning...where you balance learning and accountability. My concern here is that we might be naming, shaming and by implication blaming. What we really see is in organisations that do have a strong learning culture is a genuine desire to hear the bad news, a genuine desire to learn and I'm not convinced at the moment that simply naming, shaming is going to bring out the best.

Opening yourself to criticism makes you vulnerable. You have to overcome an emotional cost, and there's a risk of losing face in the organisation. Even critiquing a colleague can feel risky. In the NHS it can only be harder, where simple errors can have grave consequences. Mr Bromley fears that this new site raises the stakes, so makes open internal reporting less rather than more likely.

However taking and giving criticism are also some of the most powerful skills you can learn.

And so to Agile

A learning culture isn't directly part of the Agile Manifesto but it is a very congruent value. Of course it's embodied in Scrum's retrospectives. Retrospectives endeavour to create a safe environment for continuous improvement by focusing on the team rather than individuals. Scheduling retrospectives at fixed intervals, not in reaction to a crisis, makes them a routine learning opportunity rather than an investigation (with inevitable overtones of blame), and creates an opportunity to address small weaknesses before they become big problems.

The issue of vulnerability as a blocker to learning is also highlighted by Liz Keogh in her blog entry on How to run Safety Checks. If you don't know the technique it's worth a read. The bottom line: people can only open themselves up to this kind of learning if they feel safe.

Do we feel good about this?

Agile development is better at fostering a learning culture than healthcare? Yay us!

Wait a minute. That's 20% of hospitals under-reporting errors, ie 80% doing a faithful job. When we get to figures like that in IT, we can start thinking about feeling smug...


  1. Scrum is an agile methodology which is different than the traditional project management. It is an iterative approach which is appropriate for projects which are changing and have more emerging requirements. Here the project is worked on iterations wherein the team works with customer to outline the deliverable in each iterations and the whole team is responsible for the delivery of the project. This methodology is more popular in development of projects.

    1. Indeed Kylie. In this post I've assumed a certain familiarity with Scrum.

      It emphasises a point I made earlier in Bruce Lee and the Agile Spectrum. We should consider the tools offered by various Agile methods (and legacy methods) beyond the confines of by-the-book 'Methodologies'.