The awkward body shaming tendency of safety science

In September 2017, the major fashion houses of Gucci, Dior and Louis Vuitton officially banned size zero models. The pressure of unrealistic expectations on the models exacted a tragic human cost. The wider societal burden of role modelling those modelling the clothes can quickly become toxic.

It is not just the catwalks of Paris that has a difficult relationship with the idea of zero. Safety does too. This should not be a huge surprise. Safety has for the most part been considered to be a binary function. The presences of 1s and 0s is implicit in our understanding. It was not until Erik Hollnagel introduced the number 2 that this relationship was challenged.

Even with emerging new views of safety, the notion of zero remains dominant. At the recent Maternity Safety Conference, Sir Liam Donaldson, the World Health Organisations Envoy for Patient Safety, explained how zero harm was to be understood within “Global Action for Patient Safety”. The first draft suggested an objective of zero harm, which drew criticism from some circles (including myself). The latest version, shared with the conference delegates, was to make “zero avoidable harm to patients a mind set and rule of engagement”.  The vision of the future for patient safety therefore owes more than a nod to Hippocrates over 2000 years ago; “first do no harm”.

It would of course be churlish to argue against this sentiment. Also, the new formulation of language offered by the WHO is entirely understandable. Old safety dogmas need to be placated whilst progressive views given some intellectual space. The language expertly stitches these dramatically different views of safety into a coat all can wear. Despite this and no matter how expert the tailor, I wonder how long it is before there is a person in the crowd that points out that the emperor isn’t wearing anything at all.

There is also a section of people interested in organisational safety and performance that may not be anchored to the notion of zero, but are just as wedded to the principle of being lean. Much like Root Cause Analysis, Lean Thinking originated within the manufacturing industry. It can be a valuable approach to improve efficiency and costs of operations. Whilst there are some in healthcare that apply lean methodology to good effect, its relationship with patient safety is less clear cut.

Lean Thinking desires to reduce, even eradicate, variation within a system. Safety systems in healthcare need to have a more nuanced relationship with variation than an arbitrary and immediate judgment. Emergency departments, trauma situations, psychiatry, for example, all operate in environments that necessitate a degree of adaptation within the system. Lean thinking can consequently make the system less safe. We need variation to allow people to operate safely.

This view was shared by someone during a recent Twitter exchange. @SystemsNinja suggested

to counteract “Lean” I am releasing an improvement called “Chubby” which helps organisations understand the need for some excess to allow them to remain adaptable to changing environments.

Systems thinking that considers deeply the role of variation and the need for adaptation is to be welcomed. By adopting a similar language to the orthodoxy one is trying to challenge, however, can result in similar structural limitations.

Recognising that not all systems should be lean is an important observation. Should we though accept a layer of excess spread through all systems as a result? For example, how much adaptive capacity should we welcome for the blood transfusion teams? And if so, how much additional fat do we need?

It is time to elevate our language in line with our finest thoughts. We need a moratorium on any approach that anchors upon a model of zero, especially if the best vision of the future adds nothing to a thought that is more than two millennia old. We need to challenge the dangers of systems that starve people of the ability to think. Even progressive ideas of accepting a system that is just plump enough require a critical eye. It is time for safety to cease the body shaming of systems. The pressure and judgements that follow quickly become toxic. Instead, we should consider simply ‘how healthy is this system, and how can we help people succeed more within it?’