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Making soft intelligence hard: a multi-site qualitative study of challenges relating to voice about safety concerns

journal contribution
posted on 2018-01-26, 17:19 authored by Graham P. Martin, Emma-Louise Aveling, Anne Campbell, Carolyn Tarrant, Peter Pronovost, Imogen Mitchell, Christian Dankers, David W. Bates, Mary Dixon-Woods
Background: Healthcare organizations often fail to harvest and make use of the “soft intelligence” about safety and quality concerns held by their own personnel. We aimed to examine the role of formal channels in encouraging or inhibiting employee voice about concerns. Methods: Qualitative study involving personnel from three academic hospitals in two countries. Interviews were conducted with 165 participants from a wide range of occupational and professional backgrounds, including senior leaders and those from the sharp-end of care. Data analysis was based on the constant comparative method. Results: Leaders reported that they valued employee voice; they identified formal organizational channels as a key route for the expression of concerns by employees. Formal channels and processes were designed to ensure fairness, account for all available evidence, and achieve appropriate resolution. When processed through these formal systems, concerns were destined to become evidenced, formal, and tractable to organizational intervention. But the way these systems operated meant that some concerns were never voiced. Participants were anxious about having to process their suspicions and concerns into hard evidentiary facts, and they feared being drawn into official procedures designed to allocate consequence. Anxiety about evidence and process was particularly relevant when the intelligence was especially “soft”—feelings or intuitions that were difficult to resolve into a coherent, compelling reconstruction of an incident or concern. Efforts to make soft intelligence hard thus risked creating “forbidden knowledge”: dangerous to know or share. Conclusions: The legal and bureaucratic considerations that govern formal channels for the voicing of concerns may, perversely, inhibit staff from speaking up. Leaders responsible for quality and safety should consider complementing formal mechanisms with alternative, informal opportunities for listening to concerns


This study was funded by Mary Dixon-Woods’ Wellcome Trust Investigator award (WT097899) and by one of the participating hospitals. Graham Martin acknowledges the support of the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care East Midlands (CLAHRC EM). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.



BMJ Quality and Safety, 2018

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