The human factor in organisational cultures of safety and improvement

06 April 2016

Quality and patient safety are the highest priorities of provider boards. NHS providers will have noticed a renewed national focus on building cultures of safety and improvement across NHS organisations, and greater proficiency at learning from mistakes and spreading good practice. 

Despite a strong reporting culture in trusts, evidenced by over 1.8 million entries into the National Reporting and Learning System (NRLS) last year, widespread translation of reporting into routine learning and demonstrable improvement has yet to happen. 

The reasons why error persists despite evidence of causality are myriad and complex. Experts such as Professor Don Berwick and others have convincingly argued that the barriers to shared learning and improvement in the NHS are as much a consequence of system and regulatory factors as they are of variation in local skill and capability. But local leadership remains key: provider boards must drive their own organisations towards cultures of greater learning and improvement.

‘human factors’ recognises that error is inherent in complex systems such as healthcare and offers powerful insights to drive cultures of safety and learning


Amongst trusts that are recognised for their strong safety culture, there are clear commonalities: stable, strong and visible leadership; robust governance and internal assurance processes around quality and safety; and high levels of staff engagement are among them. These hallmarks of excellence are underpinned by a board level understanding of how people operate, and that they will sometimes inevitably make mistakes, given the context and environment in which they work.  Known as ‘human factors’, this science recognises that error is inherent in complex systems such as healthcare and, by exploring the interaction between human and non-human parts of a system, it offers powerful insights to drive cultures of safety and learning. 

The clinical case for a human factors approach in healthcare is well-established and recognised by growing numbers of providers, as well as in national policy, through the National Quality Board’s Human Factors in Healthcare Concordat, the new independent Healthcare Safety Investigation Branch, and the recommendations from Health Education England’s Commission on Education and Training for Patient Safety. However, there’s an equally strong cultural case for human factors in healthcare that goes beyond safety to all aspects of care quality. The cultural case hasn’t resonated as loudly yet, but it is perhaps the more immediately compelling, because it can help shift the locus of control away from centralised regulation and performance management to where it needs to be, with boards.

Improving quality is never finished

Boards must signal to their staff that quality is a dynamic process that is never ‘finished’, and that each member of the organisation can make a positive contribution to improving quality and safety.  Human factors supports boards to develop a more open and enquiring approach to quality by challenging entrenched assumptions and seeking a diversity of feedback and performance information, which is essential for countering group-think and confirmation bias. It also drives the development of tailored, timely, proactive in-house assurance processes that focus less on retrospective regulatory processes and compliance, in favour of a more predictive, preventative and solutions-focused view of risk and mitigating out potential for harm. This engenders collective responsibility and accountability for quality, helping to avoid a ‘blame culture’. High-performing trusts that openly credit the contribution of human factors to their strong board leadership on quality include Nottingham University Hospitals, Cheshire and Wirral Partnership and Salford Royal.

local leadership remains key: provider boards must drive their own organisations towards cultures of greater learning and improvement


Staff experience, so closely correlated to patient experience, is the most powerful antecedent to improved organisational culture and care quality. Research shows that staff are most productive and happy when they feel a high degree of control at work, are involved in local decision-making and perceive strong support from colleagues and managers. Human factors helps achieve this, as it gives staff the tools and insight to reflect on their performance, both individually and as part of teams, in the context of their work environment, and to consider how resourcing, management support and operational systems could be improved.  This approach has contributed significantly to Wrightington, Wigan and Leigh NHS Foundation Trust’s improved staff engagement and reductions in avoidable harm, and also to east London’s organisation-wide training in continuous quality improvement, where there have been remarkable gains in staff engagement, wellbeing, patient outcomes and experience. 

Co-designing treatment 

For patients, human factors approaches offer the solution to most effectively designing care around their needs. By co-designing care and treatment, patients are more effectively incorporated into the process of care. This in turn engenders ownership of treatment and outcomes, and a greater sense of control and capacity to contribute to their own recovery and ability to remain well. Mersey Care designed its new mental health facility Clock View hospital using human factors science, learning and understanding how people interact with the environment in their workplace in a positive way and the way in which patients and staff benefit from an internal and external therapeutic setting using landscaping, spaces and art to improve their  experience. 

These are just snapshots of how human factors offers a highly useful framework for boards to develop more just, open and positive organisational cultures and improve the experience, efficacy, productivity and efficiency of giving care. Culture change only succeeds when it is locally-led.  The growing application of human factors, drawing on peers’ good practice and ample supporting guidance, can deliver greater insights for boards into their own behaviour and of their staff and patients, to help cultivate more highly performing organisations and better care.

This blog was published by National Health Executive 

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