A couple of questions

Bob Latino blatino at RELIABILITY.COM
Tue Dec 4 14:35:26 UTC 2018


Thank you for your well laid out and thoughtful response.  Much of this is well-known to those of us outside of healthcare.  We wonder ‘Why HC is lagging and not leading in the Safety space’?  After all, HC’s product is ‘quality of life’.

No other industry can make that claim.  In manufacturing we just make widgets/units.  Service industries provide quality services.  Aviation provides transportation.

Given the picture framed below about the current state, what defined plans and efforts are in place in HC to move towards a desired state (and catch up with the other industries noted) where Patient Safety is concerned?

Robert (Bob) J. Latino
CEO
Reliability Center, Inc.
804-458-0645 (Work)
804-452-2119 (Fax)
blatino at reliability.com<mailto:blatino at reliability.com>
www.reliability.com<http://www.reliability.com>
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Connect on LinkedIn<http://www.linkedin.com/in/robert-bob-latino-3411097>

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From: Woods, David [mailto:woods.2 at OSU.EDU]
Sent: Saturday, December 01, 2018 8:58 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] A couple of questions

On question 1:

Many such meetings have occurred.  This began first with anesthesia patient safety where international experts from multiple industries got together with APSF in 1990.

The original Annenberg meetings in 1995/1996 that mark the beginning of patient safety as a movement had representatives from multiple industries.  The former Chairman and CEO of Alcoa, Paul H. O’Neil, became heavily involved around 1997, especially focusing on C suite leadership.  Results from many directions defined C suite role in safety (e.g., the CEO leads safety; in cannot be delegated to others;  it must be on the agenda, and first, for board meetings; there should be a subcommittee of the board on safety, ... — and steps like these are minimum floor).

Remember health care is dealing with faulty physiology; aviation does not fly planes with hints of faults (or is not supposed to, e.g., the Lion Air accident is a violation of that and highlights why that is so important in aviation).  This is a major difference among many. Every pilot practices multiple crises every year in recertification training; despite the prevalence of simulation facilities in hospitals, ask how many clinicians have done 1 crisis sim?  then ask how many have done 2? Does any one practice regularly with feedback, reflection, and generalization?  In all of the discussions of improving diagnosis how much does ongoing practice of a systematic set of hard cases figure in? By the way, aviation monitors its crisis training and has become worried that its crisis training programs aren’t effective enough — remember, the goal of practicing realistic difficult situations isn’t simply to be better should that case arise in the real world; they practice hard cases to be better on real cases that are different than ones they have practiced.

Today, aviation has an explicit proactive management approach to safety. While aviation struggles mightily to be proactive, it does not wait for events with harm before taking steps.  It is supposed to monitor early signals through various ongoing efforts and take actions without waiting for bent metal or passenger injuries. Aviation has multiple joint forums between various groups in the industry that worry about and debate early signals and interventions.  Pointedly, aviation does not think of safety as a state, organizational checklist, or result; but rather, there are omnipresent and changing threats to safety and ongoing effort is required to sustain safety. Aviation also backslides: (a)  I was part of the team that reviewed Air France’s safety program after the 447 accident and we had to revise and invigorate the C suite’s role in safety management based on the principles mentioned above; (b) aviation instituted the CRM team training approach that hospitals have tried emulate (in limited ways); a comprehensive aviation industry wide assessment in 2013 found many signs that team work was deteriorating and that team training needed to be reinvigorated and recharged.

Health care does not do much if any of what aviation is focused on in safety today.  Adverse events are wide spread and same ones reoccur and deeper patterns recur; adverse events that are identified usually generate little to no meaningful change.  The institution having adverse events investigates itself; aerospace is built on independent looks at major mishaps. Note the contrast between the independent and public investigation of the Columbia space shuttle accident that focused on it as an organizational failure with widespread changes that are still visible today (I played a minor advisory role and have some connections to more recent near miss events) versus the contemporaneous Jesica Santillan botched double transplant at Duke University Hospital where press reports and lawyer vetted press releases were the only public information.

Yes health care has tried to have dialogues with other industries and sometimes to look more deeply at fundamental patterns in systems safety.  Other industries struggle to sustain safety efforts and to build proactive learning mechanisms.  And yes health care lags well behind the vector of learning and change in systems safety and complex systems safety.  No one industry has the answers.  And threats to safety change dramatically (e.g., ransomware).

I have been told many many times in the last 30 years don’t bring up current difficulties, ongoing struggles, and new directions in systems safety because health care is just trying to catch up to and adopt some basics from where aviation was 10 or 20 years ago (or fill in the blank with whatever industry and whatever time frame).  Meanwhile change continues, complexity grows, systems scale and how to create safety doesn’t stand still.

David




David Woods
Releasing the Adaptive Power of Human Systems

follow @ddwoods2<https://twitter.com/ddwoods2>

Professor
Department of Integrated Systems Engineering
The Ohio State University

Past-President
Resilience Engineering Association

Past-President
Human Factos and Ergonomic Society

SAVE the DATE
8th Biennial International Symposium on Resilience Engineering
Kalmar Sweden, June 24-27, 2019

woods.2 at osu dot edu
614-946-0123


keynotes on resilience and complexity see
https://www.youtube.com/watch?v=7STcaWjJoww&index=7&list=PL055Epbe6d5YDU6sikjqcd_YM9XT4OehD
or
https://www.youtube.com/watch?v=zHJdDMQJXiw&index=8&list=PL7_JAXDeVTvIZ_Y-ddqCiGF-ZKxtM5MLe

on the Strategic Agility Gap
https://drive.google.com/open?id=1ISBZPkxxEvEt4mCAiJaarxQ1umwDYUld








On Nov 30, 2018, at 6:01 PM, ROBERT M BELL <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG<mailto:0000000296e45ec4-dmarc-request at list.improvediagnosis.org>> wrote:

A couple of questions.

  *   Other industries appear to have better safety records than healthcare - airline, nuclear come to mind. Have meetings between the airline and healthcare industries ever been held to share problems/issues? What were the results? I would have thought that such meetings, even if only preliminary, would have taken place at some time. Have they?
  *   Also, I have always felt that the stethoscope maybe responsible for many errors in diagnosis. One would guess that there would be error differences, assuming good hearing, in say a medical student, intern, resident, fellow, practicing internist and a cardiologist with 30 years of experience. And with hearing loss things may be worse. Does anyone know of any studies that have been undertaken that confirm this hypothesis?
Robert Bell, M.D.



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