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Making soft intelligence hard: a multi-site qualitative study of challenges relating to voice about safety concerns
  1. Graham P Martin1,
  2. Emma-Louise Aveling2,
  3. Anne Campbell3,
  4. Carolyn Tarrant1,
  5. Peter J Pronovost4,
  6. Imogen Mitchell5,
  7. Christian Dankers6,
  8. David Bates7,8,
  9. Mary Dixon-Woods9
  1. 1 Department of Health Sciences, University of Leicester, Leicester, UK
  2. 2 TH Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
  3. 3 School of Pharmacy, Queen’s University Belfast, Belfast, UK
  4. 4 UnitedHealthcare, Minnetonka, Minnesota, USA
  5. 5 Australian National University Medical School, Canberra, Australia
  6. 6 Department of Quality and Safety, Brigham and Women’s Hospital, Boston, Massachusetts, USA
  7. 7 Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
  8. 8 Harvard Medical School, Boston, Massachusetts, USA
  9. 9 THIS Institute, University of Cambridge, Cambridge, UK
  1. Correspondence to Prof. Mary Dixon-Woods; md753{at}


Background Healthcare organisations 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 organisational 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 organisational 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.

  • risk management
  • qualitative research
  • patient safety

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  • Funding This study was funded by the Wellcome Trust (grant number: WT097899) and by one of the participating hospitals; Graham Martin’s contribution was supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care East Midlands. The views expressed in this article are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care.

  • Competing interests Some individuals from the participating hospitals are also investigators on the study.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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