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An Introduction to the 4D's from Jeffery Lyth

A few years ago, I had a huge ‘A-ha!’ moment at a Todd Conklin seminar. Since then, I have been telling companies in various industries about something called the 4D’s. Many have experimented with the idea, and some even initiated 4D conversations across the whole scope of their (international) operations! Workers like it, leaders like it, and many proactive improvements are being made to the places where many people work. 
It’s a simple and easy conversation to have, but the act of asking the questions (and then making improvements based on the information received) has led to greater engagement, better worker perceptions of leadership, and numerous opportunities to improve  the operational capacity for achieving more reliably successful work outcomes.
I believe this is because despite their simplicity, whom we are asking, what we are asking about, and how we are using that information to improve the system of work is a practical application of many of the concepts emerging from ‘new view’ safety as well as contemporary leadership thinking. You might say it’s just asking Better Questions or a simple way of having a mini Pre-Accident Investigation, and you’d be right!

The Origins

I first learned about ‘the three D’s’ from Ivan Pupulidy, PhD, one of the amazing speakers at Todd’s seminar in 2019. In that session, Ivan told us about his work with the U.S. Forest Service. Towards the end of his session, he mentioned “the 3-D’s”. He said that in the U.S. Air Force, when pilots graduated from flight school, they were told, “Don't do anything dumb, dangerous, or different!”. In addition, they might be told that if they can't make the decision or resolve the issue, to get their superior involved. These ways of using those words represented a kind of a rule-based approach as in ‘don't do’, then they advanced into a form of stop work authority, as in ‘stop and get your supervisor’. But in industry, we already had an overload of rule-based approaches already, and safety legislation generally gives workers stop-work authority or the right to refuse to work if in danger. What Ivan said next amazed me and really seemed to embody the change that is so desperately needed in safety improvement. 

In his work at the US Forest Service aviation wing, Ivan had applied a humble-inquiry, Edgar Schein-type approach and utilized those questions proactively:
  • Tell us when something seems dumb 
  • Tell us when something seems dangerous
  • Tell us when something seems different 
From my previous work in frontline leadership skills development, the utility of using these words this way struck me as a simple but effective tool that could be easily deployed in organizations without any significant workshopping, policy change, or even permission, for that matter!

I mulled it over and pondered for some time and felt that for this to be most effective in an industrial setting (construction, longshore, manufacturing, forestry, energy, logistics) there needed to be another D-word in the mix: Difficulty. 
  • Tell us when something seems particularly difficult to do or to do well 
I figured that in the U.S. Air Force, on an aircraft carrier, or in the US Forest Service, the difficulty of work was near constant. Maybe that’s why “difficulty” never made the cut for their D words. But in industrial operations, when a task is difficult to perform or to perform well, it could be an important early indicator, so I figured it had an important place in this proactive inquiry. 

DUMB (Sense Making/Frustration)

The word ‘dumb’ is certainly not the best in some circumstances, but it's very effective in the field to initiate a conversation about things that don’t make sense to someone. Contemporary leaders in a very informed, diverse, and multicultural workplace need to start paying attention to how people make sense of their tasks and their surroundings, and any sense-making that might become shared or common on a team needs to be facilitated because doesn't just land in our laps like it used to.

Weick and Sutcliffe said that sensemaking (or sense-making) is the process by which people give meaning to their collective experiences. It has been defined as "the ongoing retrospective development of plausible images that rationalize what people are doing".

Making proactive inquiries into how people make sense of things and having them speak up about anything that doesn't make sense to them is critical information for the leader and the entire crew.

DANGEROUS (Risky/Challenging)  

Oxford Research defines ‘hazard perception’ as the ability of a person to detect potential hazards, and ‘risk perception’ refers to people's subjective judgments about the likelihood of negative occurrences. Both are important to discuss because it will surface which hazards people care about and how they deal with them. It is an important precursor to operational performance, and experts recommend that leaders keep an open dialogue about risk alive.

Typical safety management approaches are not likely to catch this, but an open conversation about people's perception of danger may.

This lowers the perceived threshold of risks worth talking about (i.e., worth a potential stoppage and accompanying fallout, formal and otherwise) and lowers the risk of retaliation for pausing work.


DIFFICULT (Hard/Demanding)

When a work task is difficult or demanding, many will simply just ‘soldier on’ and ‘make do’, possibly assuming that difficulty is just the nature of the task. But task difficulty can be an important sign that the task is being done incorrectly or that something is amiss elsewhere in the system.


Field leaders benefit from creating an open dialogue about the difficulty of work. Sometimes it's just difficult, sometimes it's being done wrong (righty-tighty/lefty-loosey!), and sometimes that difficulty is a red flag, but you don't know if you don't ask, and you really want to lower the threshold on what your crew feels is worth talking about.

DIFFERENT (Change/Surprise)

A weak signal of change can be a quiet early indicator of an emerging issue that may not appear significant at the time but may become significant in the future. Weak signals can be identified as a part of ‘scanning’ the operational environment, can supplement trend analysis and can be used as a foundation for detecting emergent critical risk.

Change is interesting. We can create and achieve incredible things in business, but it's not the magnitude of the work that makes it interesting; it’s the surprises and changes along the way and how we navigate them.


Humble Inquiry
Healthcare 4L's Humble Inquiry
Healthcare 4L's Scenario
Construction 4L's Humble Inquiry
Construction 4L's Scenario
Manufacturing 4L's Humble Inquiry
Manufacturing 4L's Scenario
Humble Inquiry
Copyright (c) 2021 by Edgar H. Schein and Peter A. Schein

Humble Inquiry and the HOP Principles

Humble Inquiry, developed by Edgar H. Schein and Peter A. Schein, is about asking questions in a way that shows genuine interest and curiosity, promoting an environment where individuals feel safe to share their thoughts and experiences. It involves:
  • Asking open-ended questions: Encouraging detailed responses and deeper understanding.
  • Listening actively: Demonstrating genuine interest and respect for the speaker's perspective.
  • Building relationships: Creating trust and openness through respectful and humble questioning.
The five HOP Principles align well with a humble inquiry approach, for example:
  • Error is Normal: Humble Inquiry promotes the acknowledgment of errors as a natural part of human behavior. For example by asking open-ended questions about near-misses and sense making around error, leaders can create an environment where employees feel comfortable discussing errors without fear of judgment or retribution.
  • Blame Fixes Nothing: Humble Inquiry aligns with the principle that blame fixes nothing by focusing on understanding and learning from situations rather than assigning blame. Asking non-judgmental questions helps shift the focus from people to systems.
  • Learning and Improving are Vital: Humble Inquiry fosters a culture of continuous learning and improvement by encouraging individuals to share their experiences and insights. Asking questions that seek to understand and learn from both successes and failures helps identify areas for growth and development.
  • Context Drives Behavior: Humble Inquiry emphasizes understanding the context in which actions and decisions occur. By asking questions that explore the conditions and factors influencing work, leaders can gain a deeper understanding of systemic issues.
  • How You Respond to Failure Matters: Humble Inquiry aligns with the principle that how you respond to failure matters by promoting a response focused on understanding, learning, and improvement rather than punishment. By asking supportive and constructive questions, leaders can turn failures into opportunities for growth.

Using the 4Ls as a Humble Inquiry supports:

  • Focus on Learning and Improvement: This approach emphasizes the importance of learning from experiences and continuously improving processes.
  • Open Communication: Encouraging open communication is a central tenet of this approach, whether through asking humble questions, discussing errors without blame, or reflecting on experiences.
  • Understanding Context: Recognizing the context in which actions and decisions occur ‘local rationale’ is crucial for sense making behavior and improving performance. 
  • Safety and Performance: Each approach aims to enhance safety and performance by addressing underlying issues and fostering a culture of openness and continuous improvement.
Healthcare 4L's Humble Inquiry

Humble Inquiry

During daily rounds, a nurse manager practices humble inquiry by asking team members openended questions about their challenges and concerns. This helps uncover issues that might otherwise go unnoticed and fosters a culture of openness.

4D's Framework

The hospital uses the 4Ds framework to identify problematic areas. For example, they might discover that the process for administering medications is “difficult” due to confusing labelling, leading to redesigning the labels to make them clearer.

4L's Framework

At the end of each week, the team holds a debriefing session using the 4Ls framework to reflect on what they liked about their work, what was lacking, what they longed for in terms of improvements, and what they learned. This structured reflection helps in capturing
valuable insights and driving continuous improvement.
Healthcare 4L's Scenario

Nursing Shift Handover

During daily rounds, a nurse manager practices humble inquiry by asking team members openended questions about their challenges and concerns. This helps uncover issues that might otherwise go unnoticed and fosters a culture of openness.

What they liked during the shift

Outgoing Nurse: "I liked how the new medication administration system reduced the time we spent on each patient's meds today. It seemed more efficient and had fewer errors."

Incoming Nurse: "That's great to hear. I will make sure to continue using the system as you did."

What they lacked during the shift

Outgoing Nurse: "I longed for better communication tools. The pagers often had delays, and it would be beneficial to have instant messaging devices to quickly coordinate with the team."

Incoming Nurse: "That makes sense. I'll bring this up in the next team meeting to discuss potential solutions."Outgoing Nurse: "We lacked enough support staff during the evening rush. This caused delays in patient care, especially with routine checks and assistance with mobility."

Incoming Nurse: "I'll inform the charge nurse to see if we can get additional help during those peak hours to avoid this issue."

What they longed for during the shift

Outgoing Nurse: "I longed for better communication tools. The pagers often had delays, and it would be beneficial to have instant messaging devices to quickly coordinate with the team."

Incoming Nurse: "That makes sense. I'll bring this up in the next team meeting to discuss potential solutions."

What they learnt

Outgoing Nurse: "I learned that starting our rounds slightly earlier in the evening helped manage the patient load better. This allowed us to finish critical tasks before the influx of new admissions."

Incoming Nurse: "Thanks for the tip. I'll try to implement this strategy during my shift to see if it helps maintain the workflow."
Construction 4L's Humble Inquiry

Humble Inquiry

In a construction company, project managers can use Humble Inquiry to understand the challenges faced by construction workers and supervisors. This involves asking open-ended questions about their experiences on the construction site and any difficulties encountered.

4D's Framework

Using the 4Ds framework, the company identifies that certain safety procedures/life saving rules are "dumb" due to their ability to function and "dangerous" because work is being performed close to live energy.

4L's Framework

After a safety incident, the team conducts 4Ls sessions to reflect on what they liked about the life saving rule, what was lacking, what
improvements they longed for, and what they learned.
Construction 4L's Scenario

Near Miss Incident

During a routine housekeeping and cleaning at a construction site, a worker slipped on a wet surface but was able to regain balance without falling. The incident resulted in no injuries, but it highlighted some potential safety concerns.

Liked

Safety Officer: "I liked how the worker was wearing the proper non-slip footwear, which helped him regain balance quickly and prevented a fall."

Lacked

Safety Officer: "We lacked adequate signage to warn workers about the wet surface. There were no 'Caution: Wet Floor' signs in the area."

Longed For

Safety Officer: "I longed for a more proactive approach to identifying and addressing hazards before they become an issue. Specifically, a better system for regularly checking and cleaning walking surfaces to prevent them from becoming slippery."

Learnt

Safety Officer: "We learned that while our workers are equipped with proper safety gear, we need to improve our hazard communication and site maintenance practices to reduce or eliminate the risk moving forward."
Manufacturing 4L's Humble Inquiry

Humble Inquiry

In a manufacturing plant, supervisors can use Humble Inquiry to understand the challenges faced by workers on the shop floor. This involves asking open-ended questions about the daily tasks and any difficulties encountered.

4D's Framework

During safety audits, the plant uses the 4Ds framework to identify areas that are "dangerous" or "difficult." For example, they might discover that a machine setup is "dangerous" due to inadequate guarding.

4L's Framework

Following major production runs, the team conducts 4Ls sessions to reflect on what they liked about the process, what was lacking, what improvements they longed for, and what they learned.
Manufacturing 4L's Scenario

Machine Breakdown

A machine in the production line experienced a malfunction, causing a 30-minute halt in production. No injuries occurred, and the machine was quickly repaired by the maintenance team.

Liked

Review Team Member: "I liked how quickly the maintenance team responded to the incident. Their prompt action minimized the downtime and allowed production to resume swiftly."

Lacked

Review Team Member: "We lacked a clear communication protocol for informing the production supervisor immediately when a machine malfunction occurs. There was a delay in communication that could have been avoided."

Longed For

Review Team Member: "I longed for better preventive maintenance schedules. Regular checks and maintenance could prevent such malfunctions from occurring in the first place."

Learnt

Review Team Member: "We learned that having a spare parts inventory for commonly failing components can significantly reduce repair time. We should ensure that our inventory is well-stocked with essential spare parts."

Why use the 4L's

Safe Open Communication

The 4Ls foster a psychologically safe environment where workers can share their thoughts without fear of blame or retribution. This is crucial in safety situations because it encourages open communication about safety concerns,
work conditions that surprised them, and near-miss incidents.

Promoting and encouraging psychological safety with the 4Ls helps support a workplace environment where workers feel comfortable reporting hazards, suggesting safety improvements, and discussing lessons learned from events.

Holistic Reflection on Operational Practices

The 4Ls approach provides a holistic view of operational practices (safety, quality etc) by examining what went well, what was lacking, what team members wished for in the future, and what was learned. 

This reflective learning practice allows workers to identify strengths and weaknesses in work systems and environments. It helps to reduce the gap between Work As Imagined and Work As Done.

Focus on Small Continuous Improvement

One of the 4Ls' core benefits is its emphasis on continuous improvement. This focus is vital for supporting a positive and inclusive safety culture in safety situations. By regularly conducting 4Ls retrospectives, teams can create action items to address identified safety risks and track progress over time. 

This ongoing improvement process helps to ensure that safety practices evolve to meet changing needs and that the “weak signals” from normal everyday work safety are managed before they become amplified with incidents or more serious events.

Simplified Structure and Flexibility

The simplicity of the 4Ls structure makes it easy to implement in various safety settings. Whether in a physical workplace or a virtual environment, the technique's straightforward approach allows for flexibility in conducting retrospectives. Teams can adapt the process to suit their specific safety needs, ensuring it remains relevant and effective. This flexibility is particularly useful when working with diverse teams or remote work environments.

Promoting a Psychologically Safe Culture

The 4Ls retrospective technique promotes an organization's positive, engaging, and psychologically safe culture. By encouraging open communication, recognizing work and safety successes, learning from events, addressing gaps, and learning and improving, the 4Ls helps to foster an environment where safety is done with people, by people, compared to the traditional approaches of doing safety to people or for people.

Practical Application of the HOP Principles

The 4Ls technique applies the HOP Principles in recognizing that;
  • Error is a consequence of an event and a symptom of a degraded or brittle system.
  • System, work design, and conditions in work need to support normal everyday work.
  • Blame degrades psychological safety, silences the voice of workers to share about work, and prevents learning from happening.
  • Leaders can listen and learn from the outcomes of the 4Ls, and lead the organization in sustainable improvement.
  • Learning supports change at the worker, workgroup, and organizational levels, which drives the improvement of better work and better operational outcomes.
Download the 4Ds Introduction Guide Here