Resilient Healthcare Going Forward

Resilient Health Care: going
forward…
8th May 2015
Dr Al Ross (PhD; C.ErgHF; C.Psychol)
Lecturer in Behavioural Science
Glasgow Dental School
FAQ
• What does resilience thinking imply for
Y?
• How does resilience relate to X?
• How can a resilience model inform my
practice with regards to Z?
2
The Safety I model
• Systems are inherently safe and well
designed
– People and technology are unreliable
• Errors and breakdowns cause adverse
events
– Technical rational approaches can be applied
to identify specific failures
– Decomposition allows for understanding
Human error unsatisfying explanation
To Err is Human....?
• Er, well…. in one sense maybe, but…
• But “Human Error” as we use it in context
in healthcare is fundamentally socially
constructed
• It comes with baggage, stigma, blame that
are all learned
Google “cat fail”: 109mil results….
• Cats have no fear of
failure
• They simply explore the
limits of their physical
environment until they
succeed
• They become very
adept very quickly
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•
•
•
•
•
To adapt is human
To test
To get feedback
To try again
To overcome
Error and failure are learned and
constrain us from then on
Michael Hodder
Kerry Hodder in 2007
• ‘[…] I am angry at Network Rail,' she adds. 'They
are guilty of killing 31 people including my
husband. Michael has been vilified as the driver
who drove through a red signal, but he was a
victim as much as anyone else.
• 'The bosses […] had known for years that the
signal outside Paddington Station was dangerous,
yet they did nothing about it. He was led into a
rat-trap and there was no way out.
Obscured signal
Unusual design
Environment
• The red aspect of SN 109 was particularly
badly obscured by the overhead electrification
equipment; it was last of all the gantry 8 signal
aspects to become clearly visible to the driver
of a Class 165 approaching from Paddington
Bridge
Training misaligned
• Trainer: “I was not there to teach ... the routes.
I was totally to teach ... how to drive a Turbo
– The training manager was unaware of this
• No proper route plans; drivers relied on
handwritten sketch plans they passed
amongst themselves
Learning and co-ordination
• Eight trains passed signal SN109 at red in the
preceding six years; nothing had been done
• Railtrack employee with formal responsibility
for action-tracking had been told his
responsibility ended once someone accepted
an action, and did not extend to checking
that they had acted upon it
2
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•
•
•
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Proximal is not enough
Where there's smoke, there's fire.
And fuel.
And oxygen.
And an ignition source.
And a system that put them all in the
same place
In retrospect…
• Misaligned system (design, capacity, learning)
• Brittle system; relied on one thing and one
thing only for it’s safety “SINGLE PATH TO
SUCCESS”
• Front line staff somehow, with reducing
training, and with tight time pressure, had to
pick out the correct action. Every time. And if
they couldn’t adapt, an accident would be
the inevitable consequence.
Ring any bells re. healthcare?
• Design problems, poor learning and
feedback, unhelpful regulation
• Limited training, time pressure
• Reliance on front line staff adapting
• Human error as an after-the-fact
explanation
You are all Michael Hodder…
Supposed to be: Lipitor 10mg PO
1 QD
Read as: Zyrtec 10mg
Filled Rx: Zyrtec 10mg
22
3
Structure is vital
• The chemicals in the human body are easily
obtained
• Mixing them up will not create a person
• Structure is what life emerges from
Root cause analysis
Produces linear structures
Linear trajectories
A way to structure?
Ross et al System resilience CTW 2014;16(1): 91-102.
Consideration of complexity: comorbidity; psychological; social
Organizational
learning takes
place
PATIENT
Patient
information is
gathered and
assessed; initial
decisions are
taken; problems
anticipated
CLINICAL
AIMS
Organizational factors can form
gaps or bridges in resilient
systems
THE WORK SYSTEM
Staffing, procedures, equipment
CARE PLANS
SPECIALIST AND NONSPECIALIST
DECISIONS
Decision
feedback and
support
Clinical aims evaluated
and revised
Care decisions balance
organizational factors and
clinical aims; multi-professional
co-ordination necessary
TREATMENTS
AND
PROCESSES
OUTCOMES
REVIEW AND
MONITORING
Process monitoring; patient outcomes
reviewed
Outcomes emerge from
complex patient and
organizational factors
4 Post hoc investigation is biased
• (Genesis 3:12-13) The man said, ‘The
woman whom you gave to be with me,
she gave me fruit from the tree, and I
ate.’ Then the LORD God said to the
woman, ‘What is this that you have
done?’ The woman said, ‘The serpent
tricked me, and I ate.’
30
Outcome bias
• Did not reach the patient
• Reached the patient; no
harm
• Monitoring required
• Temporary harm and
intervention
• Initial or prolonged
hospitalization
• Permanent harm
• Intervention to sustain
life
• Death
• We investigate red deeper
• We come up with deeper
systems causes
• This is a property of the
attributional bias not the
world
31
• Davies et al 2003: post
event attributions
A way to address post-hoc bias?
5 Incident data are not scientific
• The chances of errors and
violations causing harm are not the
same as the chances of finding
something somebody did wrong
once harm has been identified
P (non-compliance/fail)= big
P (fail/ non-compliance) = small
• The evidence shows that a significant
proportion of errors (probably the majority)
do not result in harm for the patient, either
because they are detected and mitigated […]
A way to quantify effects?
6 Operating procedures are tools
• Don’t mistake the map for the
territory
• SOPs do not align all situations
• Use will diverge as they diffuse
• They bring demands
–They constrain adaptation
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The world
• Analogue
• Fluid
• Dynamic
• Fuzzy
• Qualitative
• Complex
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The protocol
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•
•
•
•
•
Digital
Static
Fixed
Discrete
Quantitative
Linear
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Tools to help us, not faithful
representations
Protocols as tools
• Wallace and Ross in Beyond Human Error
(2006 p219) “Instead [...] of rules with the
hidden implication ‘do this or you will be
fired’, they should perhaps be offered more in
a ‘these are some of the methods we have
developed of doing these particular tasks
here, and we have found them useful”
An unspecified world
• In (the hospital) … hardly anyone knows all
the extant rules, much less exactly which
situations they apply to for whom and with
what sanctions
• […] all categories of personnel are adept at
breaking rules […] when it suits convenience.
… hence the area of action covered directly
by clearly enunciated rules is really very
Strauss A et al. (1963)
small
Page 44
Protocol modification
WHO applied: variations in practice
• Whiteboards in theatre
• Hanging a clipboard from an IV stand that accompanies
the patient from the anaesthetic room into theatre
• Laminated checklists to act as a prompt
• Incorporating the checklist into care pathway
documentation
• Inputting the checklist into IT systems such as Galaxy
• Add ‘check completed’ sticker to patient notes
• Adding a column to the Theatre Register for the
surgeon to sign showing the checklist was used for the
patient
Protocol divergence
•
•
•
•
The rules are just a starting point
Guidelines get interpreted locally
Culture is important and changes over time
Improvisation is inevitable
– Compliance is dehumanising
– Adjustment and modification characterise
humans at work
A way to evaluate tools?
From Kevin MD (online)
I admitted a gallbladder over the
phone at 2am. I gave the nurse
admitting orders which included one
for a broad spectrum antibiotic…
When I saw the patient in the
morning […]
49
From Kevin MD (online)
It had never been given; the floor nurse
held it so that it wasn’t administered until
60 minutes before […] OR time, just like
the algorithm dictates, despite the fact it
had been ordered nearly 8 hours prior to
the case, not for peri-op prophylaxis, but
for treatment of an established pathology
50
From Kevin MD (online)
[…] here you have a situation where health
care providers are so terrified of violating
[…] that they end up withholding
necessary treatment.
It’s just astounding..
Further implications…
• Research
– Model generates questions
• Process mapping
– Higher level processes can be interrelated
• Training
– Aligning demand and capacity
– Studying performance adjustments
A way to design training?
Demand
Alignment
Capacity
Success
Adaptations
Adjustments
Failure
• "Taking a model too seriously is
really just another way of not
taking it seriously at all.“
–Prof Andrew Gelman; Columbia
NY
Delighted to chat more…
janet.anderson@kcl.ac.uk
alastair.ross@gla.ac.uk