The artist John Constable was interested in everyday life as it was actually lived. Many of his greatest paintings are of the area he knew best, the countryside near his family home in Flatford. Famously, he spent days absorbed by cloud formations, sketching and painting in the open air. Previously, artists had been more concerned with idealised scenes imagined in their studios: mythical landscapes, heroes and villains, triumph or tragedy. Constable’s paintings depict the quotidian world and the people who live in it.

What do you see when you look at Constable’s painting Flatford Mill? Perhaps a sunny summer afternoon in the English countryside. The light shines through the clear waters of the leat, but there’s enough of a breeze to ruffle the river’s surface, to create movement in the trees. In the clouds there’s a foretaste of rain, but the hay has been scythed and gathered safely in. In the foreground a boatman poles his craft under Flatford Bridge; the tow rope is released, his horse is ridden round. An ordinary day in Flatford.

What do you think happened next? How can we possibly say? Perceiving every movement and motive, every material presence, every factor that might act and have impact, we still couldn’t predict the next moment. The chances are that nothing of note happened: the barge passed beneath the bridge, the tow rope was reattached, the horse trudged on its way, the fishermen on the towpath went home with tall tales but without any fish, and later on there was a small shower of rain.

But what if I told you that the next thing to happen was that the boatman’s age-weakened pole broke under the strain. The little boy, desperate to hold the barge on the rope, was pulled into the river and, unable to swim, drowned.

Now you see the whole scene in a different light. Why didn’t the boatman realise that his equipment was faulty and needed replacement? Why was he trying to manoeuvre such a heavy boat alone without even a spare pole? And why, oh why, did he allow the small boys to join in the work? Particularly when nobody had taught them to swim? In short, in hindsight: human error, faulty equipment, failure of planning, a gross deviation from best practice. And yet nothing has changed in this picture. Only our interpretation.

The hindsight approach

In healthcare, hindsight is our usual approach to improving safety. If there is an adverse outcome we believe that something specific must have gone wrong. We believe that we can look back, find it, fix it: the causality credo. We take the system apart. We look for the root causes, asking why, why, why? In our bimodal view, either things were done correctly, according to protocol, or there was a failure to follow and a consequent incident.

Ironically, we try to improve safety solely by analysing situations where it is lacking. And always we find causes – people doing things that they shouldn’t, or not doing things that they should, or who should have known better.

There has been a move to look beyond individual human performance towards the identification of faulty components of the systems in which they practise, surfacing contributory human factors. But still we home in on isolated malfunctions, moments of drama, individual precursors of tragedy.

And humans, alone or in groups, remain the most variable elements of these systems. They continue to be seen as a liability to be managed, constrained, limited. Performance variability is the undisputed enemy.

When we look back at the events that lead to a critical incident, it’s easy to find a direct causal line from actions to outcomes. We can draw out the bones of a story – perhaps as an Ishikawa diagram – and show an inevitable linear path towards failure.

Yet this creates a completely false perspective of the events that preceded the accident. In surgery we speak of the retrospectoscope, a far-seeing instrument that shows what should have been done –clearly, simply and fallaciously.

Yet, complex systems of healthcare are emergent. It is not possible to break them down into meaningful, isolated components, nor to predict outcomes from those constituents. Many of the identified causes will have produced beneficial outcomes innumerable times and, indeed, may on occasion have prevented serious harm.

As a reaction to this focus on negative events there has been interest in exploring particularly good instances of care. Campaigns such as Learning from Excellence¹ try to celebrate examples of best practice. Yet these approaches share a heroes-and-villains view of practice and continue to make rare instances the focus for investigation and learning.

In From Safety-I to Safety-II², Erik Hollnagel and others argue that this is entirely the wrong way to look at improving safety and patient care. Rather than asking why things went wrong on isolated occasions, or indeed why things turned out surprisingly well due to exceptionally good behaviour, we should instead focus on why things go right most of the time. They call this approach ‘Safety-II’, a fundamental change in perspective from the traditional ‘Safety-I’. They are not suggesting that we ignore outlying events, but that our main interest should be in understanding everyday work-as-done.

Standard operating procedures attempt to impose a veneer of order on inherently unstable situations. In the real world of surgery there is uncertainty and ambiguity, and the conditions are often intractable and in flux. Under these circumstances performance variability becomes a key asset rather than a liability.

The power of context

The fluid ability to shift and shape practice depending on context is the oil that keeps the wheels turning. Workers in many industries have found that the quickest way to paralyse a complex system is to work to rule: following, to the letter, the mythical systems of work that managers have imagined and then tried to impose can be as disruptive as a complete withdrawal of labour.

Patient care is diminished if there is blind compliance with protocols, guidelines and standard operating procedures. Patient outcomes are often dependent on surgeons tailoring their management to the context: performance variability is the essence of good care.

Hollnagel argues that the route to improved safety lies in a better understanding of work-as-done rather than attempting to constrain practice into work-as-imagined. We can comprehend failure only through a better appreciation of the landscape of routine, everyday success. Some may say that, in a busy, cash-strapped service, this is an idealistic, unrealistic, head-in-the-clouds approach; Constable and Hollnagel suggest that it is exactly the opposite.