Never/Zero Thinking

“God save us from people who mean well.”
― Vikram Seth, A Suitable Boy

There has been much talk in recent years about ‘never events’ and ‘zero harm’, similar to talk in the safety community about ‘zero accidents’. ‘Never events’, as defined by NHS England, are “serious incidents that are wholly preventable as guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers”. The zero accident vision, on the other hand, is a philosophy that states that nobody should be injured due to an accident, that all accidents can be prevented (OSHA). It sounds obvious: no one would want an accident. And we all wish that serious harm would not result from accidents. But as expressed and implemented top-down, never/zero is problematic for many reasons. In this post, I shall outline just a few, as I see them.

1. Never/zero is not SMART

We all know that objectives should be SMART :

  • Specific – target a specific area for improvement.
  • Measurable – quantify or at least suggest an indicator of progress.
  • Assignable – specify who will do it.
  • Realistic – state what results can realistically be achieved, given available resources.
  • Time-related – specify when the result(s) can be achieved. (Wikipedia)

Never/zero fails on more that one SMART criteria. You could say that ‘harm’ and ‘accidents’ are specific. ‘Never events’ are so specific that there are lists – long and ever-changing lists (in NHS England, apparently beginning at eight, growing to 25, and recently shrinking to 14, with an original target of two or three). This in itself may become a problem. Someone can always think of another. So what about the ones not on the list? When thinking about zero harm, what about the harm that professionals might need to do in the short term to improve outcomes in the longer term?

You could say that ‘harm’ or ‘accidents’ are measurable, and that never/zero is the target.  There are of course problems with measures that become goals. One problem is expressed in Goodhart’s Law: “When a measure becomes a target, it ceases to be a good measure.” A measure-as-goal ceases to become a good measure for a variety of reasons, explained elsewhere, but (among other factors) targets encourage blame and bullying, distort reporting and encourage under-reporting, and sub-optimise the system, introducing competition and conflict within a system. There is much evidence for each of these claims. Even if never/zero is seen by some as a way of thinking, it is inevitably treated as a numerical goal, and inevitably generates a bureaucratic burden.

As for assignability, well, you could assign the never/zero goal to a safety/quality department, or the CEO, or the front-line staff…or everyone (but it that really assigning?).  But what are we assigning exactly? Are we assigning not having an accident to individuals, or never/zero to the organisation as a whole? Or perhaps the putting in place of specified safeguards? (And if so, can they always be implemented as specified?) What are the consequences for those to whom never/zero is assigned when an accident does occur, aside from the immediate physical and emotional consequences (see Point 6)?

By now we can see that zero/never is not realistic given available resources (having probably never been achieved in any safety-related industry), but probably given any resources, unless all activity were to stop (e.g., no flying, no surgical procedures). But then other harms result, as we saw following 9/11 with increased road deaths associated with reduced flying. If never/zero is unrealistic, then the time factor is neither here nor there, but knowing that it is unrealistic, people usually avoid specifying when never/zero must be achieved. And if they do, it is demotivating when it does not happen (see point 8 below).

2. Never/zero is unachievable

This is obvious from the above but it is worth repeating because it is not all that obvious to those removed from the front-line. There will never be never. There are, at present, several ‘never events’ a week in English hospitals. The chance of zero harm is zero. It is a dream, a wish. For some, it is a utopia, but perhaps it is lost on those people that utopia comes from the Greek: οὐ (“not”) and τόπος (“place”) and means “no-place”. Never/zero is nowhere. In no place does it exist.

3. Never/zero is avoidant

Leaving aside the counterfactual inherent in never/zero definitions, never/zero focuses our attention on an anti-goal (harm, accidents, ‘avoidable deaths’). We may wish for a never/zero utopia, but with a focus on anti-goals the strategy obviously becomes avoidance. The anti-goal itself gives no information on how to go about this, and a focus on avoidance may, paradoxically, lead you into the path of another anti-goal as you run up against another constraint or complication with a limited focus of attention.

There are many potential ways to avoid an anti-goal, which may take you in slightly different directions and perhaps toward different things, which may or may not be desirable. In air traffic control, controllers do not train primarily by thinking of all the things not to do, and do not work by practising avoiding all the things that should be avoided. The focus of training is to learn to think about what to do (goal), and how to do it (strategy and tactics). It is well known, for instance, that thinking of a flight level (e.g. FL270 – 27,000ft) that is occupied by another aircraft or otherwise unavailable can lead you to issue that very flight level in an instruction. Thoughts lead to actions, even thoughts about what not to do. To part-quote Gandhi: “Your thoughts become your words, Your words become your actions”. It does not necessarily follow that focusing on not doing something will result in that thing not being done.

4. Never/zero is someone else’s agenda

No-one wants to have an accident, by definition. If they did, it wouldn’t be an accident. But the sum of individual wishes does not equal consensus on an agenda. Staff have usually not come together and decided on a never/zero agenda. It is usually decided from another place.

There are a variety of goals, there are complications inherent in every goal, and there are difficulties in balancing conflicting goals, especially in real-time, and at the sharp-end of operations. Compromises and trade-offs have to be made, strategically and tactically. None of these can be simplified to never/zero.

5. Never/zero ignores ‘always conditions’

All human work activity is characterised by patterns of interactions between system elements (people, tools, machinery, software, materials, procedures, and so on). These patterns of interactions achieve some purpose under certain conditions in a particular environment over a particular period of time. Most interactions involving human agency are intentional but some are not, or else the consequences are not intended. At the sharp-end, in the minutes or seconds of an adverse event as it unfolds, things do not always go as planned or intended. But nobody ever intended for things to go wrong.

We tend to use labels such as ‘human error‘ (and various synonyms) for these sorts of system interactions, but there is nearly always more to it that just a human. For instance, there may be confusing and incompatible interfaces, similar or hard-to-read labels, unserviceable equipment, missing tools, time pressure, a lack of staff, fatiguing hours of work, high levels of stress, variable levels of competence, different professional cultures, and so on. In other words, operating conditions are nearly always degraded. We ask for never/zero, and yet we ask for this in degraded ‘always conditions‘. Perhaps a new vision of ‘never conditions‘ (never degraded) or ‘always conditions’ (always optimal) would focus the minds of policy-makers closer to home, since it it would bring the trade-offs and compromises closer to their own doorstep.

It makes sense to detect and understand patterns in unwanted events, and to examine, test and implement ways to prevent such events (the basic idea behind never events), with the field experts who do the work. The problem comes with a never/zero expression and all of the implications of that.

6. Never/zero leads to blaming and shaming

It is inevitable. As soon as you label something ‘never/zero’ – as soon as you specify never/zero outcomes that are closely tied in time or space to front-line professionals – those professionals will be blamed and shamed, either directly or indirectly, by individuals, teams, the organisation, the judiciary, the media, or the public. The shame may be systematised; someone will have the bright idea to publish de-contextualised data, create a league table of never/zero failures, ‘out’ individuals, etc. The associated unintended consequences of these sorts of interventions are now well-known. So we have to acknowledge that simultaneous talk of never/zero and ‘just culture’ is naive at best. It is at odds with our understanding of systems thinking, human factors and social science. This understanding is lacking among the public, and this is sadly evident in the language of the media and, for instance, the Patients’ Association’s latest press release, which attached terms such as “disgrace”, “utter carelessness”, “unforgivable” to never events. Never/zero adds to the psychology of fear in organisations (see here for a good overview). Nobody goes to work to have an accident, but never/zero treats people as if they do.

7. Never/zero makes safety language even more negative

These emotive words illustrate how words matter, especially when lives are involved. Never/zero adds to an already negative safety nomenclature, which  limits our thinking about work, and out ability to learn. Inevitably, this language, even if intended in a technical sense, is used in the media and judiciary in a very different sense: ‘human error’ is used, then abused. Error becomes inattention. Inattention becomes carelessness. Carelessness becomes recklessness. Recklessness becomes negligence. Negligence becomes gross negligence. Gross negligence becomes manslaughter. If that sounds dramatic, it is this more or less the semantic sequence that has ensnared Spanish train driver Francisco José Garzón Amo, who – over two years on – is still facing 80 charges of manslaughter by professional recklessness after the accident at Santiago de Compostela, in July 2013.

8. Never/zero cultivates cynicism

It is obvious to those on the front-line of services that never/zero is unachievable, and sadly it inspires cynicism. There are probably a few reasons for this. Aside from ignorance of ‘always conditions’ (Point 5), it illustrates a profound misunderstanding of human motivation. Never/zero is the worst kind of safety poster message (along with ‘Safety is out primary goal‘ ), not only because it is unrealistic or unachievable, but because it assumes that people’s hearts and minds are not in the job, so they need to be reminded to ‘be careful’. Yet any ‘accident’ would almost inevitably harm the front-line workers who were there, at least emotionally, and at least for a time (hence why some organisations have implemented critical incident stress management, CISM).

I know an organisation that set a zero/never goal for a certain type of safety incident. It was widely publicised, and the incident occurred in the first few weeks. So then what? Is the goal null and void, or do we reset the clock? Never/zero can confirm what front-line staff always knew, that never/zero is unachievable (Point 2).

9. Never/zero will probably lead to burnout

It’s tiring, chasing rainbows. And because never/zero is unachievable, because it is a negative, because it cultivates blame, shame and cynicism, because it is someone else’s agenda, it is more likely to lead to burnout of professionals. If not the chronic stress variant, then the burning out of one’s capacity, willingness and motivation to take the goal seriously and to pursue the goal any more. Try never/zero thinking as a public health practitioner (they already did). Burnout is inevitable.

What then for safety? Is safety just about never/zero? And if never/zero is unachievable, then is safety worth pursuing at all? There is precious little enthusiasm for traditional safety management (outside of those whose salary depends on it), so is it wise to extinguish the flame altogether with a  never/zero blanket?

10. Never/zero does not equal good safety

What’s the difference between a near miss and a mid-air collision? A little piece of blue sky, and there’s a lot of blue sky out there. So, what if an organisation has lots of near misses but zero collisions? Never/zero focuses on outcomes that can be counted and measured instead of the messy ‘always conditions’ that shape performance, but cannot be measured. Never/zero, then, is a trade-off after all, but a blunt-end trade-off. Because it is easier to set a never/zero goal than to understand how things really work.

If not never/zero, then what?

No-one wants an accident or never event. That’s obvious. It’s not a useful goal though, and it’s not a useful way of thinking either. Never/zero is the stuff of never-never land. You can’t swear off accidents.

There are alternative ways of thinking. There is of course harm reduction, long preferred in public health. There is as low as reasonably achievable (ALARA) or practicable (ALARP) in safety-critical industries where there are major accident hazards.

And then there is Safety-II and resilience (e.g. resilient healthcare). Rather than thinking only about counterfactuals and seeking only to avoid that things go wrong, Safety-II involves thinking about work-as-actually-done, and how to ensure that things go right. This means we have to ask “what is right for us (at this time)?”, i.e. what matters to us and what are our goals? Goals, especially when not imposed externally, promote attraction instead of simply avoidance, and imply trade-offs, since goals are obviously not all compatible. A focus on goals means that we must think about effectiveness, which includes safety (safe operations)  among other things such as demand, capacity, flow, sustainability, and so on. Focus on a goal makes us think of ways toward the goal, not just ways to avoid an anti-goal.

So perhaps instead of a never/zero focus, we should think of goals that we would like to achieve, the conditions and opportunities that that are necessary to achieve those goals, and the assets that we have and may help us to achieve the goals. ‘Always’ is probably as unachievable as ‘never’, but we can always try, knowing that we will not always achieve.

Author: stevenshorrock

This blog is written by Dr Steven Shorrock. I am interdisciplinary humanistic, systems and design practitioner interested in human work from multiple perspectives. My main interest is human and system behaviour, mostly in the context of safety-related organisations. I am a Chartered Ergonomist and Human Factors Specialist with the CIEHF and a Chartered Psychologist with the British Psychological Society. I currently work as a human factors and safety specialist in air traffic control in Europe. I am also Adjunct Associate Professor at University of the Sunshine Coast, Centre for Human Factors & Sociotechnical Systems. I blog in a personal capacity. Views expressed here are mine and not those of any affiliated organisation, unless stated otherwise. You can find me on twitter at @stevenshorrock or email contact[at]humanisticsystems[dot]com.

9 thoughts

  1. An example in our Trust is that WHO Checks must happen and be complete 100% of the time (audit standard). This just means that no one ever admits when they are forgotten or not completed, avoiding learning and teaching staff to play systems.

  2. I stumbled upon this searching Goodhart’s law.

    Beautifully presented, thank you.
    It reminds me of appreciative inquiry.

    Stacking one risk mitigation policy upon another is managerialism at its worst.
    In the end, the policies become counter productive because they cannot be monitored and the culture drifts towards violation of truly safe practice as deviance becomes normalised. (Amalberti)
    The policies seem to exist for the protection of the organisation rather than staff and patients(clients)
    Poorly designed policy, implemented from above, can disrupt teams
    this can result in paradoxically negative effects of introducing checklists in surgery, the 3 hour rule for emergency departments, electronic drug ordering, to name a few

    thanks again

  3. Of all the victims this kind of thinking leaves in its wake, the ultimate responsibility is that of the unrealistic goals of the policy makers and the short sighted corporate elitists who adopt such policies. As Robert Burns mused long before these people tried to reinvent the wheel, “The best laid plans of mice and men gang aft agley.”

  4. You’ve called it Steven. Just last night I came across the Patient Safety Movement who have set a goal for zero never events by 2020. They claim that “With the right people, ideas, and technology, it’s an attainable goal.” I work in patient safety so want to see harm reduced as much as possible but my heart sank when I read it. If the goal had been set back in 1999 post To Err is Human you could understand it but I fear it’s more recent.
    For similar reasons I think we need to be cautious about setting a target for Always Conditions. I’m keen to gain a better understanding of how the application of Safety-II thinking could help us reduce ‘opportunities for harm’. I’m aware of the Learning from Excellence approach – I’d be keen to know of any other practical applications you are aware of.
    Thanks for your great blogs & tweets.

    1. Hi! And thanks. If never/zero targets can be set from above, then can always/100% targets be set from below? If not, why not? It seems only fair and only equally foolish. At least the thought experiment helps to clarify these facts…

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