Start with the System – Culture will Follow

It seems every time I read about culture in healthcare the literature often has it backwards. So much attention and emphasis is placed on repairing, enriching, creating, implementing, and assessing culture in healthcare. Yet the same literature places precious little emphasis on the clinical systems and processes that supports the very culture that is discussed.

Personally, I’ve always referred to culture as “the way we do things around here especially when no one is watching.” To explain, “the way we do things around here” is the system or environment. In other words, “the way we do things around here” in my hospital, my unit, my ED, my lab, my pharmacy, and so on. “Especially when no one is watching” means when management personnel aren’t around (nights, weekends, etc.). And let me assure you, no two hospitals operate the same way in exactly the same manner just like no two airlines, who happen to fly the same type of aircraft, operate the same way. How can that be you ask? Because of culture.

Unfortunately, no one seems to recognize, or at least write much about the fact that “the way we do things around here” is predicated on the systems and processes provided by the environment in which we work. You know, the hospital, airline, where ever… Where do the systems and processes that exist in our places of work come from? You guessed it, management. Management is solely responsible and accountable for the systems and processes that are provided in our places of work. It’s specifically from those very systems and processes that culture is manifested.

Looked at another way, poorly designed, fragmented, broken systems and processes that lead to “work-arounds” are a classic enabler through which culture is developed. Front line personnel quickly figure out how the “system” works and what “work-arounds” are acceptable. They also clearly recognize, even witness management’s tolerance of these deviances, and come to expect that “this is the way we do things around here!”

I’ve often said that healthcare is decades behind other high-risk, high-reliability industries like commercial aviation, petroleum, nuclear power, and others. I believe this is so because of education and training on human factors, safety, risk, and quality management, accident (adverse event) analysis and investigation, and, of course, culture.

The solution lies in the system. Fix the clinical care systems and processes and culture will follow. By “fixing” I mean, design system safety into all clinical care systems and processes so that specific, definable, data-driven, safety and quality attributes become identifiable, measurable elements of the system. Designing safety into systems and processes rather than trying to inspect safety into them makes each system more risk averse, of higher quality, and part of an integrated whole which is far easier to manage, hence the beginnings of a Safety Management System (SMS). Don’t believe me? Call up any airline and ask for a tour of their safety department. Ask to see their SMS, their system and process documents, their internal evaluation programs? Then ask to see how safety is integrated into training programs, line operations, and technical publications. Ask to see how “lessons learned” are de-identified and communicated back to the entire operation without the threat of punishment. And finally ask front line personnel what their roles and expectations in safety are and have them show you the tools that are available for them to use in communicating, reporting, and protecting themselves from a standpoint of safety.

After taking the tour, ask yourselves how safely designed systems combined with a management system to oversee them impact culture. If this exercise isn’t convincing that the system drives the culture I’m not sure what will.

Airline-Style Certification for Healthcare IT

Wouldn’t that be interesting, airline certification, perhaps even regulation for healthcare IT! Today, Tony Collins posted in his blog “Does hospital IT need airline-style certification?” Mr. Collins makes the argument that perhaps patient safety can be improved with airline-style certification or regulation. Very interesting concept to say the least!

When aircraft are designed, flight critical systems and components, including IT, must be failsafe to 10⁹. That’s one in one billion chance of failure!! If flight critical systems and components cannot achieve 10⁹ independently then redundancy must be designed into those systems and components to compensate. Failsafe design is an integral part of a risk management protocol known as system safety and from my experience, system safety is a completely foreign concept in healthcare, certainly healthcare IT.

To this point, Mr. Collins’ blog states that, “routinely hospital boards order the installation of information systems without proven backup arrangements and certification. Absent in health IT are the mandatory standards that underpin air safety.” And, “those who fly sometimes owe their lives to the proven and certified backup arrangements on civil aircraft. Compare this safety culture to the improvised and sometimes improvident way some health IT systems are tested and deployed.” I for one cannot agree more!

Frankly, I was a bit surprised to read about some of the deficiencies cited in an independent study of the Summary Care Records and its database. Some of the deficiencies cited include:

• Omitted some medications
• Listed “current” medication the patient was not taking
• Included indicated allergies or adverse reactions which the patient probably did not have

The independent study also claimed, “electronic health records can also record wrong dosages of drugs, or the wrong drugs, or fail to provide an alert when clinical staff have come to wrongly rely on such an alert.” Not exactly the kind of things a patient wants to hear.

In my experience, patient safety in healthcare is a good 30 years behind commercial aviation and other high-risk, high-reliability industries. My fear, therefore, is that on a large scale patient safety won’t improve all that much unless some significant external catalyst drives change. Maybe airline-style certification and regulation is that catalyst…

Business as usual…with one very risky exception!

This past summer the county in which I reside warmly welcomed a brand new $350 million state-of-the-art hospital. Nestled in a scenic yet growing part of the state the hospital opened its doors and welcomed its first patients with much fanfare. Dignitaries abound, speeches made, and after several years in the making, the new 621,000 square foot hospital was finally open for business!

The hospital, touted as the first to be built in the state in more than 20 years, was proudly introduced as being able to deliver first-class, state-of-the-art quality patient care. Politicians and senior hospital officials eagerly declared that residents of the county and surrounding areas will no longer have to go to the big city. They can stay right here close to home, close to family, close to friends, and care for their health in the comfort of their own community. And of course with the new facility came frequent energized reference for the strong desire to deliver high-quality, safe patient care.

Now, a little more than three months later, the shining new hospital stands proudly in a clearing once filled with overgrown woods adjacent to an intersection of east-west, north-south interstates. Grass has begun to slowly cover areas of exposed dirt left over from construction and the building is architecturally pleasing to look at making it a positive addition to the community. The hospital really does look great!

But I was curious, transitioning to a new hospital, especially one of this size is no simple task. I was wondering how things were going?

About a week ago my wife and I went out to dinner with friends. The dinner has become a post Thanksgiving reunion of sorts. With our busy lives and some of us separated by distance, most of us don’t get to see one another throughout the year as much as we’d like, if at all. So our annual reunion has become a highly anticipated evening of pleasant conversation and good food. Professional backgrounds of our friends vary widely from pilot and consultant (me), firefighter, nurse, Wall Street financier, electricians, money manager, physical therapist, office manager, and former professional ballet dancer now very busy stay-at-home mom to three kids (my wife).

As you can imagine conversations covered just about everything – kids, holidays, work, politics – you name it. What I did find interesting was one particular conversation we had about work with our friend who happens to be a nurse at the newly christened hospital. Our friend was quite adamant about the complete lack of training on new equipment, inadequate staffing, and how supplies were hard to come by and very difficult to locate at the new facility.

In and of itself I didn’t find our friends claims terribly unusual. Frankly, I’d be surprised not to hear about equipment, communication, supplies, and work-flow issues at a new facility. However, the problem I was having is this was not the first time I’d heard these very same claims about this very same hospital. In fact, I can directly attest to our friend’s claims as I happened to be a patient at the new hospital for a minor procedure just a few weeks ago. I witnessed, first hand, nurses openly complaining about not knowing how to use certain equipment properly because they were not trained. Nurses also complained about the lack of both equipment and supplies and many still had difficulty finding their way around the new facility. Believe me when I say there were yellow post-it notes loosely hanging in many locations serving as gentle reminders about a variety of subjects including directions to other hospital locations.

One would think the issues regarding training, equipment, staffing, and supplies are bad enough but what really concerned me was the entrenched attitude of “business as usual.” Nurses and other staff were clearly frustrated but otherwise rather unfazed at their working conditions. I have long argued that the “business as usual” attitude exhibited by “unfazed” nurses, physicians, and staff combined with senior management’s incessant public claims of patient safety and quality being high-priorities is where the real hospital culture resides. Front line personnel have little choice but to press-on with their work doing whatever it takes to get the job done, thus establishing and continually reinforcing the “work-around.” Worse yet, senior management is aware of the deviances in clinical work practices yet tolerates the deviances until something bad happens, of course.

All right, enough about culture, what about risk? Has anyone at the new hospital done a risk assessment (prior to as well as after the move) not only in the few areas discussed above but in all areas that should be contained in a systems-based Safety Management System or similar type of Patient Safety Program? Because from my chair the risk in light of the deficiencies we’ve been talking about is off the charts HIGH!

Another friend at our annual dinner, the Wall Street financier, told me a story about Robert Crandall, former CEO of American Airlines. As the story goes, American Airlines was revitalizing one of their South American stations and Mr. Crandall wanted to cut costs. Sounded reasonable enough. Anyway, the story centered on the station manager and his security budget (pre-9/11). The station’s budget called for two full-time security guards as it was a relatively small station. Mr. Crandall asked the station manager how much crime took place or other security issues that posed enough risk to require two full-time security guards. The station manager replied that crime was very low and there were no apparent security issues to speak of. Mr. Crandall instructed the station manager to fire one of the security guards and let him know if crime or security problems increased.

A few months went by and Mr. Crandall called the station manager to inquire about how things were going with one less security guard. The station manager replied “no change.” Mr. Crandall then instructed the station manager to fire the remaining security guard and get a guard dog to replace him and call him right away if anything changes. The station manager complied.

Another few months go by and Mr. Crandall again calls the station manager to see how things are going. The station manager again reports “no change.” As such, Mr. Crandall then instructs the station manager to fire the guard dog and install security cameras with the same request to immediately call if anything changes.

The moral of the story are the systematic actions Mr. Crandall took to cut costs without increasing subsequent risk as a result of the changes made to the stations security. After each cost cutting change, orders from the former CEO were clear, “call me if anything changes.” Mr. Crandall was undoubtedly ready to immediately respond to negative changes in security as he actively searched for a tolerable cost (risk) point in the system.

While Mr. Crandall may not have been a safety, quality, or risk management expert he was keenly aware how the system worked and how risk exists and needs to be respected as well as managed in daily business decisions, at least in this case. All of this makes me wonder, is it possible the senior management team at the new hospital calculated and deployed risk countermeasures to the hospital’s grand opening in a way similar to Mr. Crandall’s example? Or was it simply business as usual with the additional risk exposure of moving into a new, unfamiliar hospital hoping things work out?

Georgia Hospital Lands Airline Pilot to Lead Patient Safety

Combining commercial aviation safety experience and patient safety has certainly gotten Administrators attention at the Northeast Georgia Health System, Inc. (NGHS). The article titled, “Georgia Hospital Lands Airline Pilot to Lead Patient Safety” describes Dr. Michael Appel’s, NGHS new Chief Patient Safety Officer, combined experience in commercial aviation and more than 20 years in healthcare. Dr. Appel’s expertise should serve NGHS well as they strive to be “real pioneers in patient safety.”

I particularly agree with and fully support one of Dr. Appel’s final comments, “There are no short cuts. No lecture is going to do anything for patient safety.”

Hopefully hospital and health system administrators will take notice and take real, systems-based patient safety improvements!

Enjoy the article!

Big Brother Watching…

I came across an interesting article in the New York Times Opinionator section titled “An Electric Eye on Hospital Hand-Washing.” When I first saw the article’s title I thought “Big Brother” is slowly finding its way into the healthcare arena. In short, the article elaborates on the video tracking of hand-hygiene rates at the North Shore University Hospital’s I.C.U. in Manhasset, NY.

Upon reading the article I was pleased to learn that North Shore’s approach to its video technology tracking application is one that appears to be completely de-identified and non-jeopardy! The video technology tracks and presents aggregate data only and that is very important for lasting success, not too mention cultural acceptance!

The video tracking technology also presents data to front-line personnel in real-time and adds the unique twist of providing fun messages such as “Great Shift!!!” based on the hand-hygiene rate. This strategy provides immediate feedback to front-line personnel and serves as a friendly, professional challenge of sorts, in a health kind of way (no pun intended). Similar tracking technologies are being used in commercial aviation and have done a wonderful job at providing useful information and most importantly improving safety!

The latter part of the article discusses some of the difficulties associated with hand-hygiene tracking and raises an interesting, or maybe better said, troubling point…medicine only pays attention when there are studies in a peer-reviewed journal. The good news is North Shore Study is now published in the journal of Clinical Infectious Diseases. The bad news is why does it take a peer-reviewed clinical study in order for safety, risk, quality, and cultural improvement solutions to be recognized, let alone implemented? If commercial aviation and other high-risk, high-reliability industries adopted this strategy we’d be in big trouble!

Don’t get me wrong, peer-reviewed clinical trials provide excellent value and ideally serve to allow adequate review and implementation of clinical care practices and equipment in an effort to improve patient care. However, especially given the current state of safety and quality in healthcare today there is neither the time, resources, or other valid reason to apply the same strategy to safety, risk, quality, and cultural improvements. Just imagine if commercial aviation took this approach…