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…
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.
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.
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.
“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.
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.
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!
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.
