Using Appreciative Inquiry in safety investigations

This blog post was published by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

Nichola Crust (biography) — Nichola Crust, Senior Safety Investigator.

Investigations into safety incidents have traditionally focused on accident/incident models, such as some Root Cause Analysis methods. These models identify actions that are outside of normal practice or errors that contribute directly to incidents.

Many newer models are now designed to identify the system level problems and difficulties of organisational life, to help find ways to fix things, for example the Systems Engineering Initiative for Patient Safety (SEIPS). However, HSIB has recognised the benefit of using a range of additional methods to help discover evidence and improve patient safety.

About Appreciative Inquiry

One of the models we use at HSIB is Appreciative Inquiry. Appreciative Inquiry is promoted as an approach to explore and bring about positive change in social and human systems. It encourages people to reframe challenges as opportunities. The emphasis may be quite different to what you have used before while investigating patient safety incidents.

An Appreciative Inquiry approach brings together diverse groups of people to explore and improve upon the best in an organisation. There is a focus on what works rather than what does not work. Appreciative Inquiry is powerfully rooted in the creation of personal relationships. The intention of this approach is to be more like a conversation than a traditional style of interview, taking the time to reflect, think and speculate.

Appreciative Inquiry looks at times when people have seen things working at their best. It helps explore the circumstances surrounding when things work well so that we can identify, highlight, and thereby grow good practices more often and the conditions that enable them. It includes methods for having positive conversations that create a space for people to explore what they do well and how they might do more of it, to improve patient safety in health and care. Appreciative Inquiry asks people to recall those moments in vivid detail and to share their experiences with people they have previously known only in ‘roles’. This does not just build relationships; it also levels the playing field and builds bridges across boundaries of power and authority by allowing everyone to feel heard.

Appreciative Inquiry is a useful model to recognise that although health and care services have many issues, there are always elements of proactive, effective and innovative behaviours. This links with thinking in the field of safety science about the importance of understanding ‘work as done’ by staff and how adaptations are constantly made by staff to overcome challenges to deliver safe care.

Appreciative Inquiry in HSIB national investigations

Below are two examples of HSIB national investigations where we’ve used Appreciative Inquiry, to help understand the patient safety risks we were considering.

Recognition of the acutely ill infant

Our acutely ill infant investigation conducted Appreciative Inquiry conversations with parents of infants, children and young people. This was because the investigation heard that sometimes parents feel powerless when trying to articulate their concerns for their child and that healthcare professionals do not always consider or listen to what parents are telling them.

The aim in using the approach was to explore when parents and/or carers felt they were listened to. The investigation created a set of questions for parents and held focus groups with NHS staff working in paediatrics.

The evidence from this work supported the development of a standalone parental and professional concern section of the national Paediatric Early Warning Score (PEWS) system.

In addition, a safety observation was made for further research and observational studies to examine how listening to parents impacts on clinical decision making and recognition of the sick infant/child.

Harm caused by delays in transferring patients to the right place of care

Our ongoing investigation into delays transferring patients explored NHS staff wellbeing across the urgent and emergency care systems using Appreciative Inquiry.

This has enabled staff to tell us about times they felt proud to work in urgent and emergency care settings. The conversations provided an opportunity for us to hear about the contextual factors that support staff to work at their best and provide safe care, both individually and as part of a wider team of healthcare professionals.

However, the conversations with staff changed as our investigators saw, felt and heard about significant distress. This resulted in a more free-flowing conversation about the emotional impact of their work. A health psychologist with a special interest in moral injury was involved as a subject matter advisor on this investigation. They highlighted the importance of adapting the conversation approach and reflected that it demonstrates the emotionally charged feelings of staff in the system. You can read more about how we adapted our approach in our third interim bulletin for this investigation.

Tips for using Appreciative Inquiry

The best way to learn about this approach is to experience it and stay curious.

If using this methodology with your teams, think about what would help you learn about the area you are investigating and try to follow these basic principles:

Provide a brief background to Appreciative Inquiry and why you are using it.
Provide an example of a personal ‘high point’ story when something worked very well for you.
Thinking of the topic in question, ask when are we at our best in dealing with this issue?
Explore what enables or enabled this to happen?
Ask the ‘miracle question’ - if everything you wished for in the organisation to help you be at your best all the time has happened, what was it that led to this point?
Thank the participants and follow up with them when you have finished your work.

Recognising the benefit to improve patient safety

HSIB has recognised the benefit of using additional methods, like Appreciative Inquiry, to help discover evidence and generate thinking to continuously learn improve patient safety.

Appreciative Inquiry helps understand positive practice, breaks down barriers that may stop staff sharing the positives of how they work and can be used to help staff celebrate success. It can also be useful in improvement projects to discover what already works, while dreaming of what might be and designing effective improvements with creativity.

By not just finding out what goes wrong, but what goes right, we can better understand how the system works. Then we can make more impactful safety recommendations to help improve patient care.