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An Introduction to the 4L's from Brent Sutton

A few years ago, Jeffery Lyth introduced the community of HOP (Human and Organizational Performance) to the 4D’s. Many organizations have deployed 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.

The 4D’s is 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. One of the great outcomes was learning. Learning happened at the worker and workgroup level, where people face the risk in normal everyday work. And at the organization and governance level, where the organizations continues to strive to improve operational excellence.

I sort to compliment the 4D’s with a retrospective learning tool adapted from the work of Mary Gorman and Ellen Gottesdiener in Agile (© EBG Consulting, 2015-2019) that embedded the sole of the 4D’s into a humble inquiry (© 2021 by Edgar H. Schein and Peter A. Schein) and retrospective learning approach for operational learning.

Like

What do you like about the task, activity, or situation?


Long for

What do you think would make the situation better?

Lack

What makes the situation dumb, dangerous, difficult or different?

Learnt

What insights have we gained and how should we share them?

LIKE (Identification of Successes)

The "Like" category in the 4Ls technique allows one to celebrate why and how work goes right whilst understanding that error is still present in normal everyday work. This positive reinforcement boosts morale and encourages workers to engage meaningfully in a safe work system.
By recognizing what worked well, including what controls were effective in an event, teams can learn and then share the successful safety practices across the organization, contributing to a safer workplace.
Also, we don't want people bending over backwards to make sense of things at work.
Ideally, we're lowering the threshold of what we want to hear about and what we want to talk about, and we are demonstrating that we appreciate that the workforce’s interpretation of the work environment is the most important interpretation, the only one that really matters.

LACK (Identification of Conditions in Work) 

The "Lack" category from the 4D’s (Dumb, Dangerous, Difficult, and Different) is crucial for identifying gaps in systems, processes, resources, and controls. By discussing what was lacking, teams can pinpoint areas where changes in work or improvement of system and
controls are needed. This feature of the 4Ls technique ensures that safety risks are not overlooked and that the necessary steps are taken to address them. It also helps prioritize safety improvements.

DUMB: Situation, task, process, or control that doesn’t make sense or frustrates you.
DANGEROUS: Risky or challenging task, process, situation or hazard.
DIFFICULT: Unusual, difficult, or demanding situation, task, process, or control.
DIFFERENT: Changed or surprising situation, activity, task, or control.

LONG FOR (Forward-Looking Aspirations)

The "Longed For" category encourages teams to think about safety aspirations and improvements for safety and operations “BetterWork” they wish to see in the future. 

This forward-looking approach helps teams set goals for safety enhancements and fosters a sense of ownership over safety outcomes.

By incorporating these aspirations into safety plans, organizations can work toward creating a safer and more secure environment for all workers by doing safety with people and by people. 

LEARNT (Learning from Change and Events)

The "Learnt" category allows teams to reflect on the lessons learned from; change in normal everyday work safety incidents or near misses.

This reflection helps identify the conditions in work, the design of work, and the systemic drivers of error, which then determines what learnings and improvements can be implemented to reduce similar incidents in the future. Sharing these lessons across the organization contributes to a collective understanding of safety risks and encourages a productive approach to safety. 

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 4Ls Introduction Guide Here