Why do capable and committed people sometimes make decisions that might appear unsafe? Why do some organisations learn from failure while others repeat the same patterns? How do we view our successes and failures within organisations?
The five principles of Human and Organisational Performance (HOP), described by Dr Todd Conklin in his 2019 book, The 5 Principles of Human and Organizational Performance, provides a framework for exploring these questions. The principles help organisations understand how people really work, how the surrounding system influences their decisions and why the response to success and failure matters.
For healthcare organisations, HOP provides a valuable perspective on patient safety, human factors and healthcare governance. It encourages leaders to move beyond asking who made a mistake and instead explore how work was organised, why actions made sense at the time and what can be learned to make future care safer.
The Five Principles of Human and Performance in Healthcare.
What Is Human and Organisational Performance in Healthcare?
Human and Organisational Performance (HOP) helps healthcare organisations understand why people and systems usually succeed, as well as why they sometimes fail. Rather than treating individual error as a sufficient explanation when something goes wrong, HOP examines how factors such as workload, staffing, equipment, technology, the working environment, organisational priorities and established processes shape the decisions and actions of healthcare professionals.
Healthcare is not a predictable production line. Charles Vincent described it as being like 20 industries under one roof: it is a complex and continually changing system in which the needs of patients, the availability of resources and the pressures facing staff can change from one moment to the next. Healthcare professionals must constantly interpret information, balance competing priorities and adapt their work to meet the conditions they encounter.
Understanding how work is actually carried out, and why an action made sense to those involved at the time, provides a stronger foundation for patient safety improvement. It helps organisations identify the interactions and conditions that influence performance, strengthen the system around staff and make the safest course of action the easiest course of action.
This is closely aligned with Erik Hollnagel’s Safety-II perspective, which encourages organisations to study how everyday work succeeds under varying conditions, rather than learning only from incidents and adverse outcomes. By examining both success and failure, healthcare organisations can better understand the adaptations that support safe care and design systems that are more robust and resilient when circumstances change.
How Human and Organisational Performance Improves Patient Safety
Leadership That Seeks to Understand
Human and Organisational Performance changes how leaders respond to the realities of everyday work. It encourages them to move away from focusing primarily on individual actions or relying on blame and punishment to drive improvement. Instead, leaders seek to understand the perspective of the people delivering care, the conditions in which they were working and why their decisions made sense at the time.
This does not remove accountability. It creates a more constructive form of accountability, based on curiosity, learning and shared responsibility for improvement. By working collaboratively with staff to understand and resolve problems, leaders can address the system conditions that influence performance rather than responding only to the actions of individuals.
A Culture in Which People Can Speak Up
HOP supports a culture in which staff feel able to speak openly about where work is more difficult, uncertain or dangerous than it should be. This includes situations where staff must adapt a mandated process to meet the needs of patients, where procedures conflict with one another, or where the purpose of a required way of working is unclear.
These adaptations are often essential to keeping care moving safely, but they can remain invisible to leaders and governance systems. Listening to staff helps organisations understand the difference between how work is expected to happen and how it is actually carried out.
When staff experience and expertise are taken seriously, the workforce gains greater ownership of how work is designed and improved. Staff are no longer viewed simply as people who implement decisions. They are recognised as a vital source of knowledge about risk, resilience and patient safety.
Governance Based on Insight Not Compliance Alone.
HOP strengthens healthcare governance by reinforcing that good governance is fundamentally about informed decision-making, not compliance alone. Governance processes should help leaders understand how care is actually delivered, where risks are developing and whether organisational decisions are producing meaningful and sustainable improvement.
Creating better ways for staff, patients, service users and families to be heard gives leaders a fuller and more accurate account of everyday work. This narrows the gap between work as done and work as reported, enabling boards and senior leaders to make decisions using information that better reflects the realities of care.
This insight supports more effective decisions about service design, new ways of working and the management of operational challenges. It also provides leaders with stronger assurance about whether agreed actions have changed practice and improved patient safety, rather than producing activity that demonstrates completion without delivering meaningful change.
Principle One: Human Error Is Normal
Human error is an inevitable part of everyday work. Even the most experienced, capable and committed healthcare professionals can forget, misunderstand, misinterpret or take an action that does not produce the intended outcome. Particularly when working within complex and changing conditions.
Recognising that human error is normal does not mean accepting avoidable harm or removing accountability. It means acknowledging that telling people to be more careful, retraining them or adding another procedure will not always prevent a similar event from happening again. If a healthcare system depends on every person performing perfectly every time, it is unlikely to be a safe or resilient system.
HOP encourages organisations to look beyond the identification of error and ask what conditions made the error possible and why the system was unable to detect, absorb or recover from it. This shifts the focus towards designing equipment, technology, processes and working environments that support people to provide safe care. The aim is to make the safest action easier, make potential errors more visible and prevent a normal human mistake from resulting in harm.
Principle Two: Blame Fixes Nothing
Blame can provide a simple and emotionally satisfying explanation when something goes wrong, but it rarely helps anyone to understand why it happened or how to prevent it from happening again. Focusing primarily on the individual can divert attention from the working conditions, organisational decisions and system weaknesses that influenced their actions.
This does not mean that people are never accountable for their behaviour. HOP distinguishes between fair and proportionate accountability and a reflexive search for someone to punish. A constructive response considers a person’s actions alongside what they knew at the time, the pressures they faced, the clarity of the rules and the way the wider system was designed.
In healthcare, blame can also discourage staff from reporting incidents, raising concerns or speaking openly about the realities of their work. When people fear punishment, important information about risk, unsafe conditions and necessary adaptations can remain hidden.
Moving beyond blame allows healthcare organisations to ask better questions, learn more effectively and take action that addresses the conditions that contributed to an event. The aim is not to excuse what happened, but to create a fair response that supports accountability, organisational learning and safer care.
Principle Three: Learning Is Vital
Learning is essential to improving patient safety, but organisations cannot learn effectively if they look only at incidents, harm and failure. Most healthcare is delivered safely because staff continually adapt to changing patient needs, operational pressures and the resources available to them. Understanding how these everyday adaptations support successful care can be just as valuable as investigating what happened when an outcome was not intended.
HOP encourages organisations to learn from the people who do the work. Staff hold valuable knowledge about where systems support safe care, where work is more difficult than it should be and where processes require adaptation to meet the realities of clinical practice. Patients, service users and families also provide essential perspectives on how care is experienced and where opportunities for improvement may exist.
Learning requires more than completing an investigation, publishing a report or delivering additional training. It means listening with curiosity, testing assumptions and using what has been discovered to create meaningful and sustainable change. Organisations must also evaluate whether their actions have improved everyday work and reduced risk, rather than assuming that completing an action means the underlying problem has been resolved.
When healthcare organisations learn from both success and failure, they develop a more complete understanding of how care is delivered. This enables them to strengthen the conditions that support good performance, respond more effectively to emerging risks and build safer, more resilient systems of care
Principle Four: Context Drives Behaviour
People make decisions and take actions within the conditions surrounding them. In healthcare, behaviour can be influenced by workload, staffing, fatigue, equipment, technology, the physical environment, access to information, team relationships, competing priorities and organisational culture. These factors shape what people notice, the options available to them and what appears to be the most reasonable course of action at the time.
When reviewing a patient safety incident, it can be tempting to judge an action using information that became available only after the event. HOP encourages organisations to understand the situation from the perspective of those involved: what they knew, what they were trying to achieve, the pressures they faced and how the system supported or constrained their decisions.
Understanding context does not mean that behaviour is predetermined or that every action is acceptable. It means recognising that sustainable improvement requires more than instructing an individual to behave differently. If the conditions that influenced an action remain unchanged, another person may make a similar decision when faced with the same situation.
By examining and improving the context in which care is delivered, healthcare organisations can make safe actions easier, reduce unnecessary complexity and support better decisions. This moves patient safety improvement beyond correcting individuals and towards designing systems that help people provide safe, effective and reliable care.
Principle Five: How Leaders Respond to Failure Matters
The way leaders respond when something goes wrong sends a powerful message about the organisation’s values and priorities. A response centred on judgement, blame or punishment can discourage people from reporting incidents, raising concerns and speaking openly about uncertainty. It may also focus attention on defending individual or organisational reputations rather than understanding what happened and improving the system.
HOP encourages leaders to respond to failure with curiosity, fairness and a commitment to learning. This means seeking to understand the perspectives of those involved, the conditions in which care was delivered and the organisational factors that shaped the outcome. It also means listening compassionately to patients, service users and families, whose experiences may reveal risks and system weaknesses that are not visible through formal reporting processes.
A learning response does not mean avoiding difficult decisions or removing accountability. Leaders remain responsible for addressing unsafe behaviour, setting clear expectations and taking proportionate action where necessary. However, those decisions should be informed by evidence and context rather than hindsight, assumptions or the desire to identify someone to blame.
Leaders also shape whether learning results in meaningful improvement. Their responsibility extends beyond commissioning an investigation or approving an action plan. They must ensure that agreed actions address the conditions that contributed to the event and establish whether those changes have made everyday care safer.
When leaders respond to failure with openness, compassion and constructive accountability, they create the conditions for people to speak up, learn and improve. Their response can determine whether an event becomes a source of fear and silence or an opportunity to strengthen patient safety.
