The first characteristic that defines high-reliability organisations is Sensitivity to Operations, a constant awareness by leaders and staff to risks and a mindfulness of the complexities of systems; essentially an attack on pernicious complacency!
The tremendous advances in healthcare over the past 50 years have been accompanied by substantial increases in the complexities of care. The great successes must be framed within the context of unsustainable growth in healthcare expenditures, overutilization without consistently improved outcomes, and an enormous awareness of the unintended harm that is done everyday. In the USA over 400 patients die daily as a result of healthcare. Success is in the eyes of the beholder.
A root cause is the lack of consistent Sensitivity to Operations. Those of us working in healthcare have become dangerously complacent about our environment and our own behaviour. We don’t see the risks, and even when we do see the risks we don’t recognize them for what they are; and we often don’t act to eliminate them. We must collectively appreciate, that though our intentions may be benevolent, our actions or inactions may result in harm. We do not get up in the morning intending to harm anyone but predictably, with considerable certainty, some of us will.
Professor James Reason’s Swiss cheese metaphor for accident causation is a highly regarded model of how multiple aspects often align in causality and how prevention/avoidance barriers exist in most circumstances. I have learned this lesson well…
A 10-month-old child was admitted on the weekend for evaluation of a renal mass, likely a Wilms’ tumour. The institutional protocol required the oncology registrar to administer Actinomycin-D intravenously as soon as the renal vein had been clamped. I wrote the orders correctly and legibly using our standard double-check process.
Unfortunately, in addition to covering the inpatient oncology service I had weekend obligations for the outpatient clinic and the bone marrow transplant unit, located in two different, though adjacent, hospitals.
If anything can be said about the healthcare industry it might be that it is defined by continuous change. However, continuous change does not necessarily mean continuous improvement. Emerging technologies provide great promise for advancing our diagnostic and therapeutic options though there is a liability that the increasing number and complexity of healthcare options raises the risk of active or latent system failures possibly harming patients.
Every day thousands of patients are harmed and hundreds die in modern well-equipped hospitals staffed by highly trained individuals that have devoted themselves to careers as helpers. Benevolent intentions do not necessarily translate to safety however, and the reasons for this are both known and unknown. No matter how you choose to cut the pie, the healthcare industry is dangerous for patients and also for staff working inside the industry. The challenge that remains is to understand how so many things can go wrong when the intention is to achieve quality outcomes.
Over the past 10-20 years a large proportion of healthcare services have shifted from inpatient to outpatient settings. Many aspects of diagnostic and therapeutic services are now provided outside of hospitals, increasing convenience for patients and reducing costs. This is very good news because hospitals, despite their benevolent focus, are dangerous places. Worldwide, hundreds of thousands of inpatients die every year as a result of errors or system failures and many millions are injured. The term “inpatient healthcare carnage” may not be inappropriate.
As a result of the shift to outpatient healthcare services today’s hospitalized patients are generally sicker than in the past and often suffer from multiple co-morbid conditions. Though new healthcare technologies and medications offer great promise they also contribute to the complexities associated with healthcare, and complexity begets errors. It has been said that never has healthcare had so much to offer while at the same time entailing so much risk and uncertainty. In the USA it has been projected that 400-500 inpatients die needlessly every day!
It seems to be increasingly common that the media, and even government health agencies, publish lists of “best” hospitals or hospitals that are renowned for particularly unique and “best” clinical services, either in broadly focused care or in specific areas, like oncology care. The parameters that serve as the basis for such league tables range widely from discrete high value clinical quality measures, such as disease or procedure related mortality and morbidity rates or healthcare associated infection rates, to less discrete measures, such as media perceptions and opinions amongst providers and patients; some of which are driven by marketing and advertising.
Confounding all of this mess is the fact that where discrete data elements are utilized, the data is often not risk-adjusted for case-mix and acuity. There is generally some disagreement amongst the scientific community as to which risk-adjustment methodologies are most appropriate for particular kinds of data, and many members of the public don’t really understand the practical challenges of risk-adjustment and thus don’t really understand the data. The press is often less than helpful because the reporters who summarize the data for readers are typically themselves not skilled in statistical methodology. The end result is considerable distortion of data and relevancy, and the conclusions drawn, especially by pundits with hidden agendas, are often not supported by the facts or, frankly speaking, suffer from factual perversion.
“What I believe really matters,” my patient said to me, and she was right. It took me a while to get it, but when I did it opened a new frame of reference on quality and safety and achieving desired outcomes. Medicine today can provide more good and yet simultaneously do more harm than ever before. Understanding this modern healthcare conundrum is essential to achieving best outcomes while avoiding harm.
Our patients come to us with ingrained beliefs and experiences that affect their attitudes toward wellness, healthcare and illness; and unless we understand these and incorporate them into our therapeutic planning we may never really achieve desired outcomes. Not only can we harm patients, but they may harm themselves.
I was having a conversation the other day with an old friend who has been in a primary care practice for decades. She is a wonderful person and has been like a sister to me throughout my career, ever since we had to draw blood from each other in medical school; an experience much more harrowing for me, as the blood drawer, than for her as my victim. I nearly fainted… as I recall.
I asked her how she felt about her practice and she shared with me the following sentiment, “I love my profession and I love my patients. Every day I try to do my best and every day I try to do better than the day before. I love my job.” Wow!
Many of us today are working in institutions that are confronting significant financial constraints. Funding for healthcare services and infrastructure is limited while the needs of the patients are increasing and the costs of healthcare technologies are rising. Everyone is clamouring for efficiencies while human resources are being eliminated and/or pushed to limits. Within this complex environment, those of us who have made lifelong commitments to being healthcare professionals must continue to remain focused on our patients and providing care in the safest possible ways. This is a time for systems-thinking and planning; clinically and fiscally.
What I learned watching my sons on the football pitch!
A lot has been written about the importance of teamwork and enhancements in communication skills as important factors in system-wide efforts to improve patient safety. Models that emphasize lessons of crew resource management are held up as examples of success; particularly in the aviation industry. In medicine there are some good examples of this, especially in the realm of specialized surgical teams that train and work together. However, in most healthcare settings, especially where staff turnover is high or day-to-day availability is less predictable, the paradigms of teaming and crew resource management degrade substantially. Staff on a ward or unit may consider themselves as part of the “team” but if they have not trained together, do not know each other well and do not have a common strategy, they are not really a team.
Healthcare is complicated, too complicated for any one person to actually own or control the processes of diagnosis and care. Patients come into our hospitals for care, and for their benefit and safety we all need to look upon ourselves as part of the “system” of care. Risks are all around, but often we fail to see them as our workplace environment becomes more or less background noise. Complacency is our enemy and therefore each patient’s enemy.
In highly reliable organisations, those that really focus on risk identification, prevention and modulation; a culture of systems-thinking has taken hold where each member of staff is regarded as a cog in the system, part of the interactive gear-box that enables the entire machine to work. Pilots become part of their airplanes in a pseudo-transcendental sense, and they are probably the most vulnerable parts of the system because they make mistakes, quite naturally, as we all do. The culture of highly reliable organisations supports members by encouraging them to speak up, to become human early warning systems.