Raising the safety bar

Dr Dan Cohen, International Medical Director, Datix, explains what healthcare can learn from high reliability organizations.

High reliability organizations (HROs) are dangerous industries that have established cultures and processes designed to reduce the likelihood of system failures and human errors that often result in harm. HROs recognize that in the interactions between humans and technologies, it is the humans that represent the most substantial sources of risk. Structurally, and culturally, continuous safety monitoring and quality improvement is quintessentially embedded in these organizations.

It has been argued that if the healthcare industry would simply adopt the characteristics of HROs, we would move the bar for safety higher and would continuously improve outcomes. If this is true, then why, in an industry with professionals so deeply committed to improving health, is there such inertia in our system, inertia that plagues our improvement strategies?

The healthcare industry is dangerous for patients and staff

Every day thousands of patients are harmed and hundreds die in modern hospitals staffed by benevolent professionals. Benevolent intentions do not necessarily translate to safety, however, and the reasons for this are numerous. The healthcare industry is dangerous for patients and staff.

But numbers and statistics don’t tell the real story regarding human impact. The patients who are injured or die are not merely numbers on a bar graph. They are mothers and fathers, children and grandparents who will now miss graduations, weddings, births and celebrations, all the joys of life.

The challenge is to understand how so many things can go wrong when the intention is to achieve quality outcomes. How can we tolerate so much risk when we know that the outcomes of such tolerance are injuries, deaths and associated malpractice claims and litigation? Why is high reliability not part of our culture when it is obviously so relevant, crucial, and urgent?

The healthcare industry has unique characteristics

My perspective is that the healthcare industry possesses a variety of unique characteristics that interfere with adoption or adaptation of many HRO processes. Even though the principles that work in HROs can be transferred or translated in specific circumstances, there are other factors that encumber our processes and that may not apply to other industries.

The guiding principles of HROs have been summarized by Weick and Sutcliffe as follows.

1. Sensitivity to operations: a constant awareness by leaders and staff of risks and prevention, a mindfulness of the complexities of systems in which they work and on which they rely.

Those of us working in healthcare have become dangerously complacent about our environment and our own behavior. We often don’t see or acknowledge the risks.

The primary focus at all levels must be on patient safety. Governing boards must recognise their unique obligations to create and sustain a robust patient safety culture in which questions are asked proactively and clinicians are supported pragmatically in their efforts to care for patients. Sensitivity to operations in healthcare begins with trusting one another and listening and valuing the contributions of all stakeholders.

2. Reluctance to simplify: avoidance of simplistic explanations for risks or failures and a commitment to delve deeply to understand sources of risk and vulnerabilities within systems.

In healthcare, all too often we have succumbed to the pressure of finding a quick fix or someone to blame instead of investigating and probing to understand the complexities of our processes and the confounding influences of human factors.

When individuals make mistakes, and we all make mistakes, there are often multiple contributing factors. Each one warrants thorough understanding in order to design improvements, as do the interconnections among factors. A premium must be placed on transparency and encouraging in-depth analysis. Sadly, in many settings we have not yet achieved this mindset.

3. Preoccupation with failure: a focus on predicting and eliminating harm rather than reacting to harm; a ‘collective mindfulness’ that things will go wrong and that near-misses and complaints are opportunities to learn and improve.

In healthcare, we tend to view ourselves as benevolent and that viewpoint feeds complacency. We don’t see ourselves as sources of harm, but we certainly are. The simple error of failing to wash one’s hands or placing a dirty stethoscope on a patient’s chest can cause considerable harm, yet getting clinicians to wash properly, in some settings, is a seemingly insurmountable challenge.

Inadequacies in communication, whether between clinical staff or between clinicians and patients/family members, represent enormous sources of errors, especially when we expect our patients to successfully implement care plans. We really do not partner very well, and most of this is driven by a pernicious complacency; we simply don’t appreciate the risks.

4. Deference to expertise: leaders and supervisors listening to and seeking advice from front-line staff that know how processes work and where risks arise.

Standard organizational charts are used to portray the relationships of authority and responsibility in hospitals. Typically missing from these diagrams are the people who sit in the ‘white spaces’ inside or outside the boxes. These are the front-line staff who are continually crossing the organizational lines and communicating, those who provide the most pragmatic aspects of work in the hospital and who touch the patients and hold the hands of family members. These are the nurses and doctors who know how the processes really work and where risks arise, and whose perspectives are enormously important.

The healthcare industry is different from many dangerous industries because, unlike the aviation industry, which often is viewed as the quintessential HRO, patients are not simply passengers passively receiving services provided by airline pilots, cabin staff and their highly engineered airplanes. Achieving safe outcomes is enormously complex, especially when treating the desperately ill and individuals with multiple co-morbid conditions. Patients are thus on the front lines of healthcare; they are the experts in ‘patienthood’ and we need to seek and value their input also.

5. Resilience: leaders and staff trained and prepared to respond when systems fail and to work effectively as teams to overcome urgent challenges. For HROs, resilience means dealing with emergencies, preventing translation of these mishaps into harm and instituting corrective actions.

The Institute for Healthcare Improvement (IHI) has prepared a white paper advising hospitals on how to plan for patient safety crises. The key elements of this white paper focus on honestly and compassionately disclosing information to patients and their family members and also supporting front-line staff when things go wrong. A quintessential component of this strategy includes a ‘Just Culture’ paradigm, in which individuals are treated appropriately and fairly when errors occur.

Only by planning and training can further injury be avoided and malpractice claims avoided or reduced by processes of disclosure, transparency and, most important, accountability and apology.

If the healthcare industry is a forest of complexities, then two giant coastal redwood trees set it apart from other HROs. These giants are (1) the frequency of human-to-human interactions that result in increasing complexity inherent in the challenges associated with communication; and (2) a highly appropriate world view that envisions patients not just as passive recipients of healthcare services, but rather as essential components in a system appropriately focused on achieving optimal and safe healthcare outcomes.

Communication and partnering with patients for active engagement and improved outcomes: two giant trees standing high above the forest floor. 

Also available from Dr Dan Cohen: Achieving High Reliability in Healthcare: Late Night Thoughts can be downloaded at: http://www.datix.co.uk/news-and-events/publications/achieving-high-reliability-in-healthcare/

Datix has been a pioneer in the field of patient safety since 1986 and is today a leading supplier of software for patient safety, risk management, incident and adverse event reporting. Datix aims to help healthcare organizations build a culture and practice that drives excellence in patient safety.  It recruits and retains people committed to the healthcare sector and continually invests in its software and services to ensure that it integrates best practice and learning.

Datix customers include many of the world’s leading healthcare providers. In the UK, more than 75 percent of the NHS uses Datix. In addition Datix has a proven track record in very large, system-wide implementations in the US, Canada and Australia, as well as major hospitals in the Middle East and Europe.

About Dan Cohen

Dr Dan Cohen was formerly chief medical officer and executive medical director for the US Department of Defense health plan that provides or purchases healthcare services for more than nine million beneficiaries worldwide. As director, office of the chief medical officer, Dr Cohen was responsible for important aspects of oversight for clinical quality, patient safety, population health and medical management initiatives across this comprehensive system.

He trained in pediatrics and hematology/oncology at the Boston Medical Center, Boston University, and the Boston Children’s Hospital, Dana Farber Cancer Institute, Harvard Medical School. He is a Senior Fellow of the Royal College of Paediatrics and Child Health and a Fellow of the American Academy of Pediatrics. He retains a faculty appointment in the Department of Pediatrics at the Uniformed Services University of the Health Sciences, F. Edward Hébert School of Medicine, Bethesda, Maryland, US, where he once served as dean for student development. Datix can be contacted at: info@datixusa.com