Organisational culture: problem-sensing and comfort seeking

Finding out what is going well, what can be improved and what needs urgent attention is not easy, and sometimes organisations can have a tendency to take comfort in data that show that things are going well, rather than seeking out problems and confronting issues that arise.

In a chapter for NHS Providers’ A guide to good governance in the NHS, Mary Dixon-Woods and Graham Martin argue that organisations must avoid viewing compliance as the be-all-and-end-all of monitoring quality. Data collected to this end offer valuable but limited insight into quality and safety. They also contrast ‘problem-sensing’ with ‘comfort-seeking’, confront structural secrecy and the challenges of using hard and soft intelligence, and discuss the importance of openness.

We asked Graham Martin to tell us more.

Problem-sensing and comfort seeking – what are they in lay terms? How do they relate to healthcare improvement?

“Comfort-seeking and problem-sensing are types of behaviour that we identified in NHS organisations in a major study of quality and safety we carried out about a decade ago. What we mean by ‘comfort seeking’ in this context is a kind of behaviour on the part of organisations that’s focused primarily on seeking reassurance – trying to find out that things are OK. When they are comfort-seeking, organisations tend to take confidence from data that they have which presents things in a positive light, and they can also be reluctant to look for any contrasting information that might unsettle them or challenge their belief that everything is fine. Of course, most if not all organisations will have data that they can take comfort in. But if they don’t look beyond those data, they will be limiting their ability to improve – or worse still, they may miss problems that are or could become threats to patient safety.

“In contrast, problem-sensing behaviour involves organisations actively looking for weaknesses in their own quality and safety related systems and making the most of a range of sources and techniques to look for data that might challenge complacency. This might include routinely reported data, for example those presented to audit committees, but it might also include a range of other sources of insight – including things that aren’t routinely monitored, sometimes aren’t easily measured, and often are difficult to hear. Trying to sense these problems actively can be vital in finding problem areas and in detecting potential problems before they take root.

“Of course, few organisations will fall fully into either category. But we think these concepts offer a useful set of principles for what organisations should aspire to be, and a useful set of indicators of the kinds of behaviour to try to avoid.”

What are the pitfalls when it comes to using data and intelligence to help with performance monitoring and improvement?

“A tendency to selectively interpret data and intelligence can lead to an exaggerated sense of optimism – even to organisations deluding themselves as to how well they are doing. This can have severe consequences, for example at Mid Staffordshire, where senior leadership believed the trust was compliant with quality and service standards despite conflicting internal indicators. Similarly in 2022, Bill Kirkup’s report into maternity and neonatal services at East Kent found that “the trust wrongly took comfort from the fact that the great majority of births in East Kent ended with no damage to either mother or baby”.

“Measuring safety is challenging for several reasons. There is disagreement over the validity of indicators of patient safety, particularly at the organisational level, and it can be difficult to identify safety problems prospectively. The way that safety indicators are used can also cause problems: if indicators intended to be used for monitoring and improvement are instead used for performance management and punishment, staff may not engage with them – and that can undermine their usefulness.”

Some cultural issues might lead organisations towards comfort-seeking behaviours. How could the introduction of “learning heath systems” or similar help shift the focus to a more open, problem seeking culture in healthcare?

“Learning health systems are about making continuous use of data collected as part of routine care to monitor outcomes, identify potential improvements, and make change, and very importantly – evaluate the change. In theory at least, they can lead to a positive shift in focus by making the constant integration of monitoring data and improving quality and safety a routine part of an organisation’s work.

“Some organisations are currently better placed to take forward the idea of a learning health system than others, due both to the infrastructures they have available and to the culture of their executives, management, clinicians and other staff. The science of learning health systems is also still developing – for example, it’s clearer how to integrate data from electronic health records than from comments, compliments and complaints from patients. There’s also huge scope to develop learning health systems at levels beyond that of the individual organisation. This can help organisations in learning about and improving the quality of care in pathways that span multiple organisations, in benchmarking their performance, and in learning from each other.”

What else can healthcare leaders do to help encourage openness in their organisations?

“Some past tragedies in healthcare have been blamed in part on a reluctance to raise concerns, and staff feeling unable to speak up about issues they’ve encountered. It’s clear that avoiding these tragedies in the future requires a culture of openness, and people at the ‘sharp end’ need to feel empowered and safe in raising concerns, big and small. But as the idea of problem-sensing suggests, it’s also about work at the ‘blunt end’ to listen to concerns, to make sense of them, and to actively court them.

“Cultures in healthcare organisations are diverse, so the most important thing that boards and senior leaders can do if they are serious about nurturing a positive and open culture is to seek out information and collate knowledge about variations in performance, behaviour, and culture – and to learn where possible from positive deviance (areas that are doing exceptionally well). Different individuals will have different roles here. For example, non-executive directors might have a particularly useful perspective and position, as people outside formal line management hierarchies (of the kind that might inhibit people from speaking up) but with a good understanding of the organisation.

“National bodies, integrated care boards, regulators and improvement agencies also have an important contribution to make. If we want learning health systems to reach their full potential, and to improve patient safety, we also need to avoid creating situations where there are so many priorities to deal with that nobody knows which ones they should be focusing on.”