Making sense of event investigation by using the Cynefin framework.

Last week was our annual Executive Leadership Course in Global Surgery. We had anaesthetists, surgeons, nurses, and managers in the room. We designed the 5-day course specifically for low-and middle-income settings in Africa, and the aim is to enable leaders in the public, private and voluntary healthcare sectors to become change agents within their context.

During the course, I facilitated a quick 2-hour Cynefin workshop and one of the groups came up with an idea that has been occupying my thoughts since.

I am not going to describe the Cynefin framework in detail, and if you are not familiar with it and would like to read more, see the resources at the bottom of the blog. Briefly, the Cynefin framework is a sense-making and navigation framework that first helps us to locate where we are now (the current state), and to then to determine the most appropriate methods or types of actions for intervention.

Figure: The Cynefin Framework (Source: https://thecynefin.co/cynefin-st-davids-day-2021-1-of-3/)

At the start of the workshop, each table choose an intractable problem that they would like to explore. Just a reminder, that in the conceptual framework, the different aspects of a situation or issue is mapped before lines are drawn to create domains.  One of the groups chose to unpack an adverse event that occurred recently. A teenager went for surgery, during the operation there were complications and the patient died in the surgical ward after.

The group started with a clean slate, mapping the different aspects. Items that were grouped together included using the surgical checklist, moving the patient to ICU post-operatively because of the complications during surgery. In these, the relationship between cause and effect was clear and self-evident, and it can be addressed by changing rules, providing a guideline or procedure. It is predictable if the checklist is not completed there might be problems. And expert consultation might have been helpful to motivate admission to ICU.  

On of the other sides, they grouped items like power imbalances, and who gets to flag a patient issue or concern.  These entrenched systemic issues cannot be resolved with a practice guideline, and it is multi-layered with various factors influencing the interventions e.g. trust, psychological safety, teamwork, even education. It is entangled and a checklist won’t go far to resolving the issues. To effect change requires a multi-prong approach with multiple small interventions to see what will work and what not.

There is also a space for situations in which agreement cannot be reached, or more questions and clarification is required. This is called the aporetic domain and in this group, the aporetic domain was the largest domain. Two items that stood out to me was listening to the patient, and interprofessional rivalry. To me this is the zone of curiosity, and potentially growth. And I found interesting that listening to the patient was mapped here. I would have loved to explore the reasoning!

I liked the way the Cynefin framework was used to explore different contributing factors. In hospitals, adverse events are often investigated using Root Cause Analysis (RCA) to identify one core cause. The unintended consequence of trying to narrow events to one cause, is that often it ends with a ‘guilty’ person being identified. Event investigation is thus often perceived as punitive, restricting organisational learning. RCA focus on structural issues and the linear or chronological sequence of the event and another short coming may be that systemic issues are not explored in depth. For instance, the items grouped together in the complex domain e.g. interprofessional rivalry, or who is afforded the opportunity to raise an anomaly would probably not be mentioned in an RCA.  Yet, as most healthcare professionals attested at the workshop, the unequal distribution of power and lack of trust in interprofessional teams directly impacts the quality of patient care. A deeper dive into systemic and organisational factors contributing to adverse events are required.

It seems intuitive to use the Cynefin Framework to explore these. Within the framework the different aspects of the event can be mapped and managed accordingly. No domain is better than another, it is about utilising what will work in each domain – I love checklists and it works well…but not every issue requires a checklist and neither does it work for every problem. Intractable issues in the system cannot be solved in isolation, but only in the context of related problems. By using Cynefin for adverse event investigation in a multidisciplinary team, more systemic failures are likely to emerge.

One last thought – a definition of the word Cynefin that resonates with this blog is ‘the place of your birth and upbringing, the environment in which you live, and to which you are naturally acclimatised.’  When entering a profession or workplace, the person is acclimatised to think in a specific way, to make certain assumptions and act in a certain way. By using the Cynefin framework in a team with diverse lenses, well-established assumptions can be challenged.

Read more about the Cynefin Framework at https://cynefin.io/wiki/Cynefin