Ian Leistikow: The three stages of safety improvement

At an international Roundtable Meeting that BMJ hosted in Riyadh in 2018, speakers from nations with very different cultural backgrounds, came to the similar conclusion that healthcare needs a culture of openness and inclusiveness if it is to continue improving quality and safety. The importance of culture has been recognized for some time now, and is increasingly addressed at healthcare safety meetings. But why focus on culture, and why do it now?

If you look at how safety improves, you can recognize three very similar stages of development in diverse sectors. In the first stage, knowledge and technology improves safety up until a certain point. In stage two, management systems are put in place to handle this knowledge and technology and improve safety further. This is the stage of guidelines, rules, and regulation. When this stage reaches its point of diminishing returns, it is time for the third stage in which further safety improvement is reliant on culture and behaviour. An example is traffic safety. First we learned to understand the technology and built cars that didn’t fall apart, then these machines became so complex that we needed driving exams and traffic rules to further increase safety. Now, many countries are in the stage in which behavior and culture are the weakest link in road safety. In 2016, 50% of road deaths in the Netherlands were due to speeding or alcohol. The concept of these three stages was developed during the “Hearts and Minds” safety programme that the oil company Shell started in the 1990’s. Many readers will remember one of the other concepts that was used in the same programme: James Reason’s Swiss cheese model.

The three stages of safety development are also applicable to healthcare. The previous century brought us incredible advances due to knowledge and technology. We learned how to diagnose and treat diseases which we previously didn’t even know existed. Quality and safety improved dramatically, increasing life expectancy around the globe. Then came the second stage of safety improvement. Guidelines, rules, and regulations helped healthcare providers reach the same outcome for patients in varying circumstances. But in the last decade we’ve see increasing unease regarding rules, guidelines, and regulations. These have sometimes become a system of their own, with questionable added value for, or even detrimental effect on, quality and safety of healthcare. Examples are nurses filling out falls assessment scores, but not using the outcomes to reduce the risk of falling, or physicians who lack the time for proper engagement with their patients because of time consuming mandatory fields in the electronic patient record. It seems the second stage has reached its peak. To improve quality and safety further, we need to work on the third stage: addressing our values, culture and behavior.

Recognizing the three stages of safety development helps understand why healthcare is facing some of its current safety challenges, how we came to be in this place and what we need to do to move on. “Changing the culture” is not a random new idea, it’s the next logical step in the path we’ve been on since the dawn of healthcare.

Ian Leistikow inspector at the Dutch Health and Youth Care Inspectorate and professor at the Erasmus School of Health, Policy and Management in Rotterdam, the Netherlands. He is author of the book “Prevention is better than cure. Learning from adverse events in healthcare.”

Competing interests: none declared.

Twitter: @IanLeistikow


1. Holsvoogt R, Graaf G van der, Zijlker R, Hudson P. Hearts and Minds programmes the road map to improved HSE culture. Symposium series 151. Shell 2006.

2. Reason, James (1990): Human Error, Cambridge University Press.