High reliability healthcare:
how much choice can we
afford?
David Mudd
Head of Modernisation
North West London SHA
4 August 2004
[email protected]
In this session you can
• see comparisons of reliability in
healthcare and other industries;
• look at how to design for better
reliability;
• look at the benefits and costs of high
reliability organisations;
• think about how you can improve the
reliability of your service
The basics
• Joined-up services - as seen by users
• Shared information
• Choice – providers, settings, date and
time
• Redesigned, streamlined services –
fewer visits, no avoidable waits
• Better working lives for NHS staff
Higher expectations
• over time, the basics get taken for
granted
• then we expect high reliability
• examples – cars, TVs, food industry,
civil aviation, nuclear industry
High reliability healthcare
Don Berwick, Tom Nolan
• Reliability = number or % of actions
that achieve the intended results
• “Getting it right, every time”
Healthcare process
reliabilities
Reliability
Unreliability
One
in.…goes
wrong
Process/outcome
90%
10%/10-1
10
99%
1%/10-2
100
99.9%
0.1%/10-3
1,000
99.99%
0.01%/10-4
10,000
Deaths in routine anaesthesia
99.999%
0.001%/10-5
100,000
Deaths from major
radiotherapy machine failures
Beta-blockers to prevent MI
Polypharmacy in the elderly
Medication harm
Deaths in risky surgery
Neonatal mortality
General Surgery deaths
Reliability in healthcare and
other industries
(Amalberti; Espinosa & Nolan)
ED reading
X-rays (97%)
Blood transfusion
ED reading X-rays improved (99.7%)
Anaesthesia ASA1
Fatal iatrogenic
adverse events
Cardiac surgery
(Patient ASA 3-5)
Himalaya
mountaineering
Civil aviation
Medical risk (total)
Railways - France
Road safety
Chemical industry
(Europe)
10-2
Very unsafe
10-3
10-4
Nuclear power
industry
10-5
10-6
Ultrasafe
Design for Reliability
(Berwick & Nolan)
• Level 1: Intent, vigilance and hard
work
• Level 2: Design informed by reliability
science and research in human
factors
• Level 3: Design of high reliability
organisations
Level 1: “Intent, vigilance, hard
work”
• Standardized protocols, feedback,
training, checklists
• Guidelines easy; getting people to
follow them is difficult
• But: good evidence exists that this
will get you to 10-2 (99%)
Group discussion (5 mins)
• Recall an experience – in any setting – in
which the request that you ‘try harder’, ‘be
careful’, or ‘stay alert’ improved your
performance. Why did that work?
• Identify a process in your workplace that
relies on vigilance. What would you
estimate its reliability to be?
Factors affecting human
vigilance
•
•
•
•
•
Fatigue
Environmental conditions
Task design
Psychological conditions
Competing demands
Level 2: Design informed by
reliability science and research in
human factors
• Redesign the system; don’t rely on
checking
• Decision aids and reminders built into
the system; automation;evidence as
the default; redundancy; scheduling;
connection to habits
• Can take you from 10-2 (99%) to 10-3
(99.9%)
Three-level design of safe and reliable
systems: Prevent – Identify - Mitigate
(Norman)
• Design the system to prevent failure
• Design the system to make failures
visible if they do occur
• Design procedures to mitigate the
harm caused if failures are not
detected and intercepted
Physical design, human behaviour
(Norman)
• Constraints
– physical (eg square peg round hole)
– cultural (eg Red for Stop)
• Memory
– eg numbers, passwords, dates
• Mapping
– eg my cooker
Natural mapping – my cooker
(Norman)
Advantages of automation
•
•
•
•
•
Increased capacity and productivity
Reduction of manual workload and fatigue
Relief from routine operations
Relief from small errors
More precise handling of routine
operations
• Economical utilisation of machines
• Damping of small differences
Disadvantages of automation
• Seen as dehumanising – lower job
satisfaction
• Low alertness of human operators
• Systems are fault intolerant – may lead to
larger errors
• Silent failures
• Lower proficiency of human operators
• Over-reliance – complacency, uncritical
acceptance of results
• False alarms
Computers are incredibly fast,
accurate and stupid;
humans are incredibly slow,
inaccurate and brilliant;
together they are powerful beyond
imagination
Albert Einstein
What’s the contribution of IM&T
in healthcare?
• Shared electronic record – one set of data,
available to all
• Protocol-driven care as the default –
standardising on best practice
• Decision aids
• Scheduling
• Making errors visible and retrievable
• Letting every player see the whole system
Level 3: Design of high reliability
organisations: “ultra-safe”
(Weick; Amalberti)
• Accepting limits on discretionary actions
told when it’s safe to take off/land)
– max safety up to 10-2
• Abandoning autonomy
(eg pilots
(eg drive on the left)
– max safety up to 10-3
• Moving from ‘craftsmanship’ to ‘equivalent actor’
(eg anaesthetics v surgery)
– max safety up to 10-4
• Sharing the residual risk – how the system deals
with failure (eg KAL 007)
– max safety up to 10-5
• Managing the invisibility of risk
of these before”
– max safety up to 10-6
(“we’ve never seen one
Some outcomes of focus for a high
reliability healthcare organisation
(Berwick)
•
•
•
•
•
No needless deaths
No needless pain
No feelings of helplessness
No unnecessary waiting
No waste
Constraints
• Constraints on patient choice
• Constraints on professional autonomy
• Constraints on the factors which
distinguish healthcare organisations
(competitive advantage)
Challenges
• Buy-in from clinicians and patients
• Protocol-driven care as the default –
standardising on best practice
• Sharing information – with whom?
• Decision aids or decision-taking?
• Scheduling – are we ready for it?
• Making errors visible and retrievable
– aligning the incentives and penalties
Summary
• Reliability in healthcare is a long way
behind other safety-critical industries
• We can improve reliability by better design
equipment and systems, and by
standardisation
• Beyond this, improvement comes with
reduced choice – standardisation/doing it
by the book
• Clinicians need to work with
standardisation, but be prepared to
respond with autonomy
• Sophisticated design of human interactions
and working relationships
Table discussion
Think about the clinical service you
provide/manage:
•What changes must you make to get to
10-4 performance?
•What implications does this have for
how you select and train your staff?
References/further reading
•The Design of Everyday Things. Donald A Norman; MIT Press; 1998
•Handbook of Human Factors and Ergonomics. G Salvendy (ed); John Wiley, New York; 1997
•Managing the Unexpected. Weick and Sutcliffe; Josey Bass; 2001
•System changes to improve patient safety. Nolan TW. BrMedJ 2000;320: 771-773 (18
March)
•Reducing errors made by emergency physicians in interpreting radiographs: longitudinal
study. Espinosa JA, Nolan TW. BrMedJ 2000; 320: 737-740 (18 March)
•The quality of care delivered to adults in the United States. McGlynn EA, Asch SM, et al.
N Engl J Med, 348(26); 2635-2645 26 June 2003
•Revisitjng safety and human factors paradigms to meet the safety challenges of ultra
complex and safe systems. Amalberti R, 2001. In Challenges and pitfalls of safety
interventions, Willpert B & Fahlbruch B. Elsevier, North Holland
•Wiener EL, Nagel DC, ed. Human Factors in Aviation. New York: Academic Press, 1988.
•Various presentations & papers by Rene Amalberti on the Internet (via Google)