Karen Cardiff, School of Population and Public Health, University of BC
Samuel B Sheps, School of Population and Public Health, University of BC
Jim Nyce, Department of Anthropology, College of Sciences and Humanities, Ball
State University, Muncie Indiana
Sidney Dekker, Lund School of Aviation, Lund University, Lund, Sweden
June 10, 2010
System Safety Society Canada Chapter—Spring Symposium
Ottawa, Ontario
The findings presented today are based on the thesis work for
completion of an MSc in Human Factors and System Safety
with the Department of Aviation, Lund University
University of British Columbia School of Population and Public Health
Also informed by work that began a decade ago
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Canadian Adverse Events Project (Canadian Institutes of Health Research, 2000-2003)
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Management and Regulation of Safety in Risk Critical Sectors (Health Canada, 2004-2007)
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Creating High Reliability Organizations in the Canadian Health Care System (Canadian Patient
Safety Institute, 2007-2008)
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Current work co-funded by the Canadian Health Services Research Foundation
and the Canadian Patient Safety Institute—a four year multi-partner capacity building
project that is focused on building capacity within acute care hospitals to do critical incident
investigation (Sheps and Cardiff, 2009-2013)
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Interaction with international opinion leaders and experts in system safety on the
emerging ideas of resilience and safety (Sidney Dekker, Eric
Hollnagel, René Amalberti, Richard Cook, etc)
University of British Columbia School of Population and Public Health
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Background
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Why is the topic important
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Theories and models of why things go wrong
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Findings from the thesis work
University of British Columbia School of Population and Public Health
When patients entrust themselves to our care, we make two
implicit, but key professional and organizational promises:
‘we promise to do everything possible to help patients—to
provide good (possibly excellent) care; and, we promise not
to hurt them’ (Reinertsen & Clancy, 2006)
However, there are many instances where people do not get the
care that they need (McGlynn et al 2003) or are inadvertently
harmed through the process of care (Kohn et al, 1999; Vincent et al,
2001; David et al 2002; Norton et al, 2004; Leape et al, 2005).
University of British Columbia School of Population and Public Health
While being concerned with quality for many years, healthcare did not, in general, think
systematically about patient safety until the magnitude of the problem became very clear
and could no longer be ignored.
Now, after more than a decade of activity that has measured, tracked, and in many instances
investigated adverse events in acute care, no one doubts that enhancing patient safety (i.e.
reducing harm) is an important and necessary goal
Although there continues to be widespread buy-in that the healthcare system must take steps
to reduce patient harm, the struggle in how to achieve this, and make it sustainable,
remains.
Even as the number of activities to improve patient safety and quality increases, along with a the
range of tools available to assist with the process the healthcare system has not yet achieved
the status of being a high reliability or resilient industry.
University of British Columbia School of Population and Public Health
While emerging theoretical and applied work acknowledge that quality and safety are distinct
concepts, in healthcare the majority of activities, to date, have focused on activities
designed to improve adherence to accepted standards of care, such as hand-washing,
appropriate use of antibiotics (i.e. telling people what they already know they should be
doing), and are more aligned with the classic quality model than safety – safety by constraint
marked by barriers, regulations, procedures, training and standardization.
The current efforts are largely based on “reductionistic” thinking that attempts to “trouble shoot
and fix things”.
Even though many of these efforts have been met with success, they have largely ignored issues
related to what it means to create safety in complex, dynamic settings, such as preparing
frontline staff to cope with the complexity that they face on a daily basis and supporting
them to become more experienced with anticipating what might go wrong (requisite
imagination) and knowing when and how to adapt their performance under conditions of
uncertainty.
University of British Columbia School of Population and Public Health
‘A model often used in health care is that accidents are thought
to occur when individual components or processes fail to
meet criteria….this model of risk and safety builds on the
assumption that safety, once established, can be maintained
by keeping the performance of a system’s parts (human and
technical) within certain bounds (e.g. people should not
violate rules and procedures) ‘
Sidney Dekker, Past the edge of chaos. 2006
University of British Columbia School of Population and Public Health
The classic quality model was developed to ensure that the system meets prespecified criteria.
Quality is viewed as the characteristics of a service or product that must be
present to meet needs or expectations – such as high professional
standards, effective use of resources and high patient satisfaction
The goal of quality assurance activity is to keep performance variability under
control –organizations develop policies, rules and protocols to keep
performance within a particular bandwidth.
University of British Columbia School of Population and Public Health
In linear production systems (e.g. Toyota, McDonalds) quality may have
safety as an additive result – this is because:
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the systems can be decomposed into meaningful elements
the failure-probability of individual components can be described and
analyzed individually
the order or sequence of events is predetermined and fixed
when combinations of events occur they can be described as non
interacting
the influence of context is limited or quantifiable
(Dekker, 2007)
However, since the process of “producing” healthcare is neither linear nor
fixed, the classic quality model is not adequate.
University of British Columbia School of Population and Public Health
‘in complex systems (such as healthcare), unpredictability and
paradox are ever present, and some things will remain
unknowable….new conceptual frameworks that incorporate a
dynamic, emergent, creative and intuitive view of the world
must replace traditional “reduce and resolve” approaches to
clinical care and service organization’ (Plsek, 2001)
University of British Columbia School of Population and Public Health
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Demand frequently pushes performance goals;
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Rapid introduction of new, complex technology;
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Many discontinuities and transitions in care (e.g. multiple care providers
caring for the same patient and often in multiple settings – emergency
department to operating room to surgical ward—each unit managed
independently);
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Strong autonomous and semi-autonomous professional cultures with
concomitant power struggles;
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Often rapid turnover in staff;
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Continual influx of new patients, each with their own inherent biological
variability and in many instances language and cultural differences.
University of British Columbia School of Population and Public Health
The key challenge of creating safety in complex non linear
systems is that the knowledge base is inherently and
permanently incomplete.
In healthcare work situations are always underspecified (i.e.
the conditions of work rarely match what has been specified
or prescribed), and with this comes an unpredictable
component, and thus adaptation is often necessary (Hollnagel
et al, 2006; Grote, 2006)
Performance variability is both normal and necessary in
complex non linear systems (Dekker, 2007; Hollnagel, 2008)
University of British Columbia School of Population and Public Health
IF keeping things safe equals keeping performance within a
particular bandwidth, why do complex, dynamic
organizations value experience or seniority?
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It is because experience brings a broader bandwidth – people at the sharp end of
care can judge whether that which they used before will work in the current
situation.
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There is always a tension around when and how to adapt rules and protocols to
the set of circumstances one finds themselves in, but the experienced person is
more likely to know when and how to do this.
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Complex systems are generally well protected from vulnerabilities with “barriers”,
but safety is created through practice, i.e. practitioners recognize local pitfalls and
forestall them, and this often involves adaptation.
University of British Columbia School of Population and Public Health
Assumption and consequence:
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Accidents are the natural outcome of a series of events or circumstances
which occur in a specific and recognizable manner (e.g. Domino Model,
Heinrich, 1930)  accidents are prevented by finding and eliminating
possible causes – component failures, such as human technical and
organizational.
Assumption and consequence:
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More recently, accidents have been seen to result from a combination of
active failures (unsafe acts) and latent conditions (hazards)  accidents
are prevented by strengthening barriers and defenses (e.g. Swiss Cheese
Model, Reason, 1990) and safety is ensured by measuring performance
indicators—in particular people rely on understanding past events (e.g.
Root Cause Analysis) to develop solutions for the future.
University of British Columbia School of Population and Public Health
University of British Columbia School of Population and Public Health
Linear models provide the basis for investigators to easily take
the position of retrospective outsider, looking back on a
sequence of events that seems to lead to an inevitable
outcome, and pointing out where people went wrong, or
where individual components of the system failed.
Although this perspective is often adequate in linear systems,
the approach seriously limits what the investigator can learn
about failure in non linear systems ( i.e. the complex and
unexpected combination of system interactions) and may not
help prevent recurrence.
University of British Columbia School of Population and Public Health
Assumption and consequence:
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Accidents result from unexpected combination (resonance) of normal
performance variability – hazards emerge from expected (and necessary)
variability within the system and accidents are prevented by monitoring and
damping the variability.
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The variability of normal performance is rarely sufficient to result in an accident,
but the variability from multiple functions may combine in unexpected ways to
produce a non linear effect, thus safety is an emergent property of the system
and cannot be explained by simply examining individual components of the
system and/or trying to identify a root cause.
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Complex socio-technical systems (such as healthcare) are dynamic—the systems
change and develop in response to competing demands, production pressures
and changes in technology and knowledge. Resilience exists when operators in
the system are able to recognize, absorb and adapt to disruptions/changes that
fall outside of their design base.
University of British Columbia School of Population and Public Health
An emerging model that attempts to understand the
dynamics of “normal” organizational activity
University of British Columbia School of Population and Public Health
Non linear accident models provide investigators with the basis
to find out why people’s actions and assessments made sense
to them at the time; rather than identifying what rule,
protocol or process the person violated (people often adapt
their actions given the context at hand and this is part of the
“normal performance variability” that takes place as part of
“normal work” in dynamic, complex systems).
‘Human error is not an explanation, but demands an
explanation’
Sidney Dekker, 2006
University of British Columbia School of Population and Public Health
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In contrast to this, linear models provide the basis for investigators to
easily take the position of retrospective outsider, looking back on a
sequence of events that seems to lead to an inevitable outcome, and
pointing out where people went wrong, or where individual components
of the system failed.
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Although this perspective is often adequate in linear systems, the
approach seriously limits what the investigator can learn about failure in
non linear systems (i.e. the complex and unexpected combination of
system interactions) and may not help prevent recurrence.
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Hindsight Bias!
University of British Columbia School of Population and Public Health
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“Hindsight bias” is always present when the outcome is known – a
retrospective outsider can easily confuse post hoc reality with the actual
reality surrounding people during the event.
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Hindsight bias is a powerful reason for “old view” explanations for human
error and accidents – tending to look for: individual components of the
system that need fixing; people deficient in skills; or egregious mistakes.
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Hindsight bias makes it difficult to objectively judge behavior leading up
to the outcome. In particular, past complexity is transformed into a linear
string of “bad” decisions, missed opportunities, flawed assessments, and
faulty perceptions.
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Thus, recommendations too often focus on protecting the system from
“unreliable humans” through procedures, automation, training and
discipline.
University of British Columbia School of Population and Public Health
The aim of the thesis work was to begin to explore the extent,
and in what ways, safety and quality are conflated in
healthcare, at both the sharp and blunt ends of care in an
acute care institutional setting within a large health
authority in Canada.
The key questions this research sought to answer are:
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How are the notions of patient safety operationalized through local
context?
How is safety thought about and constructed?
How is it discussed?
Is it neglected?
University of British Columbia School of Population and Public Health
Survey work: interviewed key informants (registered nurses
working in acute care; nurse managers responsible for acute
care units; and senior decision makers).
Semi-structured face-to-face interviews were conducted
(interview guide was developed to support the discussion
and contained a series of open ended questions) to find out
how the key informants thought about safety and how they
feel they contribute to safety on a day-to-day basis.
University of British Columbia School of Population and Public Health
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How long have you worked as a registered nurse?
How do you define the term safety?
What factors and activities help contribute to patient safety
at your institution, in general, and in particular, on your unit?
What do you think would improve patient safety in acute care
hospitals, in general, and in particular, on your unit?
University of British Columbia School of Population and Public Health
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What is your role in the organization?
How long have you worked in healthcare?
How do you define the term safety?
What factors and activities help contribute to patient safety
at your institution?
What do you think would improve patient safety in acute care
hospitals?
Does the work you do contribute to safety? If yes, in what
ways?
University of British Columbia School of Population and Public Health
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Designing robust organizations (prescriptive practice)
Designing robust organizations (compliance)
Designing robust organizations (rules and procedures are important but
insufficient to create safety)
Expertise and experience
Adaptation of work, depending on the context and competing priorities
Efficiency-thoroughness-tradeoff
Unpredictable notion of safety
Learning from near misses and critical incidents
Storytelling as a form of learning
Communication and teamwork
Leadership
Competing system challenges
Vigilance and troubleshooting
University of British Columbia School of Population and Public Health
There were notable differences regarding the
emphasis that each group placed on the respective
themes.
University of British Columbia School of Population and Public Health
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Safety is important, but people are still looking for standard fixes and are
influenced by conventional opinion leaders (e.g. Safer Health Care Now campaign,
and Saving 100,000 Lives Campaign).
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Confusion regarding the difference between safety and quality exists and the
confusion is greater at more senior levels in the organization (i.e. people continue
to think that if you improve quality through standardization, guidelines,
procedures, etc that safety will automatically follow).
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People at senior levels focus on the need to develop robust systems that are
marked by guidelines, protocols, rules and also focus on training, technology, rules
and enforcing compliance as solutions.
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People at the front lines (the practitioners) understand the need to adapt their
behaviour and practice in unusual situations, but are tentative in how they discuss
this with both their peers and managers, aware of potential negative
consequences or sanctions, if things don’t work out well.
University of British Columbia School of Population and Public Health
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Set of ingrained attitudes about how work is performed, i.e. there is no gap
between work as imagined and work as done, i.e. work can be performed in a
high quality manner, despite the context – this is an easy perspective for senior
management to adopt since it feeds off the sense, amongst most professional
groups in healthcare, that they are, or should be, perfect and can provide high
quality care under a range of conditions.
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Lack of deep understanding of the source of failure in complex organizations.
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Superficial understanding of hindsight bias and its impact on what you look for
when you are doing critical incident investigations.
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Accountability remains a thorny issue, particularly at the senior management and
governance level, with little consideration of the accountability/authority
dynamic.
University of British Columbia School of Population and Public Health
In practical terms conflating the concepts of quality and safety in a complex,
dynamic setting such as healthcare can result in investing efforts to solve
the wrong problem and thus potentially misappropriates limited human
and financial resources.
Besides the potential misappropriation of resources, if quality and safety are
conflated, it is far too easy to assume that if one improves quality that
safety will automatically follow, and thus the system, unfortunately,
continues doing “more of the same”; neither fully understanding or
adequately tackling the problem.
University of British Columbia School of Population and Public Health
Safety and quality are often conflated in health care and this may limit
progress on both creating safety AND enhancing quality.
Safety is the attribute of being able to respond to surprise or instability of
the system--creating safety involves anticipating what could go wrong.
Non linear accident models, based on an understanding of both high
reliability and resilience theories, and empirical evidence from high risk,
dynamic settings, can help us appreciate why safety and quality need
separate strategies.
There were noticeable differences in how the key informants (from the
thesis work) talked about safety and the perspectives of the people at the
sharp end of the system (point of care) are fairly consistent with what the
thought leaders in system safety are telling us about creating safety in
complex dynamic environments.
University of British Columbia School of Population and Public Health
Making progress in safety may be supported by a better understanding by
system leaders about how work at the frontline actually gets done
(normal work) as well as a better understanding about the necessity and
value of performance variation in complex, dynamic systems. There needs
to be discussion around the tension between developing robust systems
(marked by rules, procedures etc), while at the same time, supporting
performance variation.
A dedicated interdisciplinary Safety Management System, with a broad
mandate, is one structural tool that may help healthcare organizations
make progress on safety
 Develops an analytical framework for critically monitoring safety using a
non linear perspective;
 Keeps the discussion of risk alive within the organization;
 Enables people at the sharp end to actively look for the things that could
go wrong and understand how to keep these at bay;
 Surveillance activity
University of British Columbia School of Population and Public Health
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