Why it made sense at the time: Local rationality questions for healthcare investigations

In my early years as a maternity investigator, when interviewing staff about patient safety incidents, I found that at times the quality and depth of information obtained did not fully answer all the whys around decision making at the time of an incident.

This left me with two options: to repeatedly ask similar questions around the same area, at the risk of staff feeling interrogated and worried they had done something wrong; or to come away with unsatisfactory information for the investigation. Neither option sat right with me, so to address the problem I set out to develop my interviewing style.

This blog lays out my journey to obtain higher-quality information from interviews while protecting staff involved in patient safety incidents.

Whilst the impact of a patient safety incident is often devastating for patients and families, the emotional effects on staff involved are also well documented (Wu and Steckelberg, 2012). So how do we ask questions that explore local rationality and let us really understand why a decision, action or inaction made sense at the time without making staff feel interrogated or blamed?

As a starting point, I carried out a review of safety science literature. I found an almost overwhelming amount of information, which I streamlined and collated into a table of questions (see below) that would help an investigator explore local rationality. For me, the tool needed to be functional, easy to navigate, and suitable for use in daily work when planning interviews.

I structured the questions according to the tell, explain, describe (TED) approach of effective questioning, altering the wording when needed to ensure questions did not appear accusatory. I categorised the questions into areas for focus, relating to a situation, thoughts/decision making, preparedness (knowledge and training), communication, and anticipation/thinking ahead. Supporting information within the table makes it easier to select the type of questions needed to get the right information.

For the past three years, I have embedded this tool into my practice as an investigator and have observed how interviews flow better and feel more like a discussion. The quality of information obtained leads back to system or process issues, or that deviation from usual practice occurred, due to other influencing factors. I feel more comfortable during interviews, as I know that the questions I am asking are not focusing on the person. At the end of interviews staff reported that it was “not a scary interview” but a “pleasant experience”. Some staff have shared how they were initially worried and nervous but instead came away having had a positive experience and greater awareness of our intentions and purpose of improving healthcare services for future families and staff.

I had envisaged the use of these questions becoming automatic the more I used them, and whilst that is the case to a certain degree when I draw from the questions in live interviews, I still use the tool during interview planning to make sure that I am selecting the right type of questions for the information I need. Given that each investigation is different due to ever-changing variables, taking time to consider the questions being asked before an interview, and reflecting on the information shared by staff in response, is always encouraged.

Given the breadth of possible lines of questioning, it is important for the investigator to choose questions that draw out meaningful and relevant responses and provide what we want to know. Asking the right questions enables findings to be more accurate, which is ultimately the basis for making the right recommendations for change.

Whilst the focus of an investigation should be on systems, processes and human factors, we know that, due to the nature of the work, healthcare staff will often individualise blame on themselves when an incident occurs. Our role as the investigator is to ensure that we don’t add to this further by the way that we ask questions. Often the way that we ask a question can stay with staff long after the interview has finished. We have the ability, through the questions we ask, to take it away from the person and show them that it’s about the information that was available at the time, influencing human factors, and the systems, processes, and situation they were working within, that we are really interested in.

Whether you’re new to healthcare investigations, or you have worked in this field for some time, it is hoped that this tool may offer some help to really understand why it made sense at the time, whilst being mindful of the emotional impact on staff.