Author: Jim Conway
Adjunct Faculty, Harvard School of Public Health
Principal, Pascal Metrics
The CMO of a rural community healthcare system was pleased after kicking off a patient safety meeting with more than 100 front-line clinical, administrative and support staff. The organization had shown a dramatic decline in serious adverse events and now the numbers for most months were very small. The chart showing the downward trend was striking. He was therefore stunned with the first comment from staff: “If that’s what you think then it is clear you don’t have any idea of what goes on in my unit every day.”
This story is real. It occurred in an excellent organization, and I was there as it unfolded. The organization’s leaders knew that if you try to do everything, you will accomplish nothing, so they set strategic quality and safety targets and the organization was on an active journey forward. However, they became too focused on these few events, forgetting that their targets were a small piece of the universe of harm and failure, maybe just 5% of it. No mention was made at the meeting of the larger context of failure. No mention was made as to how this data linked to all the incident reports that get filed every day. For the front-line staff, what leadership was saying bore no resemblance to the failure they, patients and family members deal with every day.
This story isn’t unique. Those privileged to be associated with excellent organizations, such as specialty pediatric organizations, have the opportunity to participate in and experience every day exceptional care and caring, hope, and discovery. Yet, with such organizations come enormous risk due to the arrogance of excellence and the normalization of deviance.[i] By spending every moment of every day in what Karl Weick[ii] calls a pre-occupation for excellence, staff can individually and collectively focus on the good and forget to seek out and confront the failure, suffering, harm, waste, tragedy, and death. Often, the design defects that exist are no longer seen. They are lost in the blur that staff must navigate through as they engage in the processes of care delivery. Do you ever question the normalization of deviance in your organization? Just invite someone with fresh eyes in and discover what they see and how quickly they see it.
Karl E. Weick, Kathleen M. Sutcliffe and David Obstfeld[iii] have taught us that a key element of high-reliability organizations—something we all seek for our patients and staff—is developing a pre-occupation with failure or, in other words, becoming an expert at looking for trouble and doing something about it. Effective organizations do this in at least three ways: by treating any and all failures as windows on the health of the system, by a thorough analysis of near failures, and by focusing on the liabilities of success. In my personal patient safety journey as a leader I’ve confronted the tensions associated with this pre-occupation with failure by pushing, probing, digging deeper, and more. When you look hard, your organization’s harm numbers and rates become higher than most and people around you begin to wonder, often aloud, at times of growing transparency, “What about this is good?” In a 2012 meeting discussion with Daved van Stralen, around the pre-occupation with failure,[iv] an attendee noted that in healthcare failure is seen as a weakness and imperfection. They went on to say that part of the view of professionalism in healthcare is that you don’t have failures.
On one occasion during my own career, a physician leader was presenting some strong work from a team on a new clinical information system. At the end of the presentation I congratulated the team and asked “What new categories of error are we implementing with this system?” With a very frustrated and abrupt tone the leader replied, “Aren’t you ever satisfied?” I thought and then said “No, I can’t be.” Years before, I learned from human factors experts at MIT that errors were highest at times of dramatic change—nothing was more dramatic or required more change than a new IT system. From a tragic medical error I had learned what would become a mantra: “Our systems are too complex to expect merely extraordinary people to perform perfectly 100% of the time. We as leaders must put in place systems to support safe practice.”[v] Follow up after the presentation of the work of the above noted clinical information system team, using critical risk assessment methodologies, identified many new categories of possible error with this IS install. While we couldn’t fix every one instantly, we could certainly mitigate their chances of creating error and causing harm. Every time you change a system, what is your approach to critical risk assessment, to failure detection?
I’ve also learned this pre-occupation can become personal. As a young leader I loved being a firefighter, coming in on a great big problem, and leading the team that fixed it. Then a colleague suggested that maybe those problems shouldn’t have risen to that stage if I and we had been doing a better job in the first place. If a strong system had been built, and we were listening to the signals suggesting problems, we could have fixed them earlier. Many clinical colleagues say they’ve seen a similar scenario, often at morbidity and mortality conferences. The focus is on the save and not on the fact that the harm shouldn’t have happened in the first place.
Organizations and their leaders must develop this pre-occupation with failure and then do something with the data. Among the techniques I’m seeing used are:
· The presence of enhanced communication systems. Over and over people say nothing else will matter in patient safety if there isn’t good communication in the organization.
· From my colleague Allan Frankel MD of Pascal Metrics
1. Daily communication where the value is espoused in a briefing (i.e. "We value your being preoccupied with defects")
2. The ability and willingness to identify defects.
3. Evidence that action leads to improvement
4. Leaders who tie 1, 2, 3 to each other - i.e. "you were preoccupied, you identified, this fix occurred" - everyday in every briefing.
· Mechanisms to capture the voice of the patient, family, and front-line staff daily and establish feedback loops. This includes learning to ask the question: “How can we improve?” and then respectfully listening.
· Cultures are established where caregivers are able to speak up if they perceive a failure. The Keystone Initiative has found this the strongest predictor of clinical excellence.[vi] Extensive reviews have been forthcoming on interventions to improve safety culture[vii] [viii] [ix]and a variety of tools exist to check up on culture.[x]
· Organizational courage to begin to utilize the IHI Global Trigger tool[xi] [xii]to understand the full extent of harm, all cause harm, and mitigate it moving forward. Note is made of the exceptional leadership from members of the pediatric community in this area.[xiii] [xiv] [xv]
· The presence of daily huddles, patient safety huddle boards and other vehicles to communicate today’s failures today with a goal of eliminating them for tomorrow.
· Systematic study of handoffs and transitions. Every time a team does this they are wowed at all the steps that don’t add value and all the failures that occur.
· Patient Safety/Executive Walk Rounds[xvi] should be more than a pass-thru and include specific discussions of what’s not working, what are the failure points. In the community hospital where I serve as a trustee, the trustees are an integral and respected part of these rounds.
· The utilization of crisis management and other systematic processes to assure respectful management of serious clinical adverse events.[xvii] With every probe, every “but why,” leaders will be stunned by all that is news to them that is familiar to those at the point of care.
· Routine application of approaches and tools such as lean, six sigma, process mapping, critical risk assessments and failure mode & effects analysis to probe for failure points.
· Fresh eyes welcomed to look at the work. They can come from new staff recruited from other organizations, patients and family members, staff from another part of the organization, or staff from another organization.
· Continuing education in high reliability through programs such as High Reliability Organizing
· Application of tools developed by Karl Weick and colleagues to audit your current practice.[xviii]
Dr. Seuss has taught us “the more that your learn, the more places you will go.” John Kelsch of Xerox noted “To do things differently, we must see things differently. When we see things we haven’t noticed before, we can ask questions we didn’t know to ask before.” Each of us has seen and been part of exceptional care and caring. A pre-occupation with failure will help us move closer to that being the experience of EVERY patient, family member, and staff member, EVERY time.
[i] Banja, John. The normalization of deviance in healthcare delivery. Business Horizons 53.2 (2010): 139-148.
[ii] Weick KE, Sutcliffe KM, Obstfeld D. Special issue: frontiers of organization science part 1 of 2: Organizing and the process of sensemaking. Organization Science, July/August 2005. 16: 409-421.
[iv] Personal Communication with Daved van Stralen, February 22, 2013
[v] Conway J., Nathan DG, Benz E, et al. Key learning from the Dana-Farber Cancer Institute’s ten-year patient safety journey. In Am Soc Clin Oncol 2006 Ed Book. 42nd Annual Meeting, Atlanta, GA, 2006:615-619.
[vi] Hudson, Daniel W., et al. Contemporary Critical Care. (2009).
[vii] Singer SJ, Vogus TJ. Reducing hospital errors: interventions that build safety culture." Annual Review of Public Health (2013).
[viii] Morello RT, et al. Strategies for improving patient safety culture in hospitals: a systematic review. BMJ Quality & Safety (2012).
[ix] Leonard M, Frankel, A. Thought Paper. How can leaders influence a safety culture? Health Foundation. May 2012.
[x] Tutorial, Tool. "A check-up for safety culture in “my patient care area”." The Joint Commission Journal on Quality and Patient Safety 33.11 (2007).
[xi] Classen DC, Resar R, Griffin F, et al. Global Trigger Tool shows that adverse events in hospitals may be ten times greater than previously measured. Health Affairs. 2011 Apr;30(4):581-589.
[xii] Sharek, PJ. Perspective. The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety. AHRQ Web M&M. May, 2012.
[xiii] Kirkendall E, et al. Measuring adverse events and levels of harm in pediatric inpatients with the global trigger tool. Pediatrics 130.5 (2012): e1206-e1214.
[xiv] Sharek PJ, Classen D. The incidence of adverse events and medical error in pediatrics. Pediatric Clinics of North America 53.6 (2006): 1067-1078.
[xv] Matlow AG, et al. Description of the development and validation of the Canadian Paediatric Trigger Tool. BMJ Quality & Safety 20.5 (2011): 416-423.
[xvi] Schwendimann R, et al. A Closer Look at Associations Between Hospital Leadership Walkrounds and Patient Safety Climate and Risk Reduction A Cross-Sectional Study. American Journal of Medical Quality (2013).
[xvii] IHI. Leadership Response to a Sentinel Event: Respectful, Effective, Crisis Management
[xviii] Weick KE, Sutcliffe KM. Managing the Unexpected: Assuring High Performance in an Age of Complexity. This audit tool and other assessment tools for High Reliability Organizing can be found at: http://www.wildfirelessons.net/OrgLearning.aspx