A much-belated follow-up to Dr. Woods' post

Fri Dec 21 14:17:50 UTC 2018

Dr. Woods’ post (included below) illuminates leverage points to advance the science and practice of systems safety in healthcare. I am grateful for this—a number of key domain differences are concisely and helpfully articulated.


Marketing/advertising that utilizes hospital ‘safety scores’ is another noteworthy difference:


*	Advertising hospital “safety scores” to attract patients constitutes an unwitting deception of the public and may reflect an undue sense of accomplishment among organizations that score well.  In my experience these scores are not useful in gauging a hospital’s ability to detect, assess, and manage emergent system behavior. Specifically--  


*	Hospital safety surveillance is commonly focused on reportable process and outcome measures. Our narrow [often phenotypic] measures of patient safety are not, by themselves, trustworthy indicators of an organization’s ability to detect, analyze, and address deeper dynamics which may produce novel (unanticipated and unmonitored) conditions for failure and harm. 
*	I have served on teams assessing clinical units in numerous hospitals advertising “A” safety scores.  All had resident (“normalized”) unsafe conditions, that were either undetected or inadequately assessed and addressed once identified. For example, a medication dispensing unit on a pediatric cardiac ICU had an unreliable biometric lock. After technicians thrice tested the lock without failure the unit was not replaced, but left in place. There was no plan to take further action although nurses continued to assert that the unit failed unpredictably.  During observations of the unit I witnessed a nurse bolting to a satellite pharmacy for critical meds when the child being cared for developed an emergent problem.  Although the medication needed was in the dispensing unit in the child’s room, the nurse ran (literally) to retrieve the medication from the pharmacy rather than risk delay if the lock did not function.  This was the new normal for nursing staff assigned to that ICU room. Faulty equipment was allowed to remain in service and the risk of failure was normalized, jeopardizing the survival of a critically ill child.  This is analogous to the Lion Air example mentioned by Dr. Woods.  It is disturbingly common to uncover normalized risk when conducting cognitive work analyses in clinical settings. 
*	We cannot assert that good performance on the existing crop of safety measures is reason for confidence in the safety and quality of care in a facility. Good performance may simply mean that reportable process and outcome measures are carefully managed.
*	Ultimately, safety may be achieved or lost in a heartbeat, and to promote a hospital on the basis of frail and stale safety measures is wrong. When—in recent decades--have we seen an airline advertise on the basis of its safety record?  


Best regards, Jeff



Jeff Brown
Safer Healthcare, LLC
Belfast, Maine




From: Woods, David <woods.2 at OSU.EDU> 
Sent: Saturday, December 1, 2018 8:58 AM
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 Woods

Releasing the Adaptive Power of Human Systems


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



Department of Integrated Systems Engineering 

The Ohio State University



Resilience Engineering Association



Human Factos and Ergonomic Society



8th Biennial International Symposium on Resilience Engineering

Kalmar Sweden, June 24-27, 2019


woods.2 at osu dot edu




keynotes on resilience and complexity see

 <https://www.youtube.com/watch?v=7STcaWjJoww&index=7&list=PL055Epbe6d5YDU6sikjqcd_YM9XT4OehD> https://www.youtube.com/watch?v=7STcaWjJoww&index=7&list=PL055Epbe6d5YDU6sikjqcd_YM9XT4OehD


 <https://www.youtube.com/watch?v=zHJdDMQJXiw&index=8&list=PL7_JAXDeVTvIZ_Y-ddqCiGF-ZKxtM5MLe> 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> 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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