More on Mental Models in Healthcare

Source: Clipart Panda

Our August 6, 2019 post discussed the appalling incidence of preventable harm in healthcare settings.  We suggested that a better mental model of healthcare delivery could contribute to reducing the incidence of preventable harm.  It will come as no surprise to Safetymatters readers that we are referring to a systems-oriented model.

We’ll use a 2014 article* by Nancy Leveson and Sidney Dekker to describe how a systems approach can lead to better understanding of why accidents and other negative outcomes occur.  The authors begin by noting that 70-90% of industrial accidents are blamed on individual workers.**  As a consequence, proposed fixes focus on disciplining, firing, or retraining individuals or, for groups, specifying their work practices in ever greater detail (the authors call this “rigidifying” work).  This is the Safety I mental model in a nutshell, limiting its view to the “what” and “who” of incidents.   

In contrast, systems thinking posits the behavior of individuals can only be understood by examining the context in which their behavior occurs.  The context includes management decision-making and priorities, regulatory requirements and deficiencies, and of course, organizational culture, especially safety culture.  Fixes that don’t consider the overall process almost guarantee that similar problems will arise in the future.  “. . . human error is a symptom of a system that needs to be redesigned.”  Systems thinking adds the “why” to incident analysis.

Every system has a designer, although they may not be identified as such and may not even be aware they’re “designing” when they specify work steps or flows, or define support processes, e.g., procurement or quality control.  Importantly, designers deal with an ideal system, not with the actual constructed system.  The actual system may differ from the designer's original specification because of inherent process variances, the need to address unforeseen conditions, or evolution over time.  Official procedures may be incomplete, e.g., missing unlikely but possible conditions or assume that certain conditions cannot occur.  However, the people doing the work must deal with the  constructed system, however imperfect, and the conditions that actually occur.

The official procedures present a doubled-edged threat to employees.  If they adapt procedures in the face of unanticipated conditions, and the adaptation turns out to be ineffective or leads to negative outcomes, employees can be blamed for not following the procedures.  On the other hand, if they stick to the procedures when conditions suggest they should be adapted and negative outcomes occur, the employees can be blamed for too rigidly following them.

Personal blame is a major problem in System I.  “Blame is the enemy of safety . . . it creates a culture where people are afraid to report mistakes . . . A safety culture that focuses on blame will never be very effective in preventing accidents.”

Our Perspective

How does the above relate to reducing preventable harm in healthcare?  We believe that structural and cultural factors impede the application of systems thinking in the healthcare field.  It keeps them stuck in a Safety I worldview no matter how much they pretend otherwise. 

The hospital as formal bureaucracy

When we say “healthcare” we are referring to a large organization that provides medical care, a hospital is the smallest unit of analysis.  A hospital is literally a textbook example of what organizational theorists call a formal bureaucracy.  It has specialized departments with an official division of authority among them—silos are deliberately created and maintained.  An administrative hierarchy mediates among the silos and attempts to guide them toward overall goals. The organization is deliberately impersonal to avoid favoritism and behavior is prescribed, proscribed and guided by formal rules and procedures.  It appears hospitals were deliberately designed to promote System I thinking and its inherent bias for blaming the individual for negative outcomes.

Employees have two major strategies for avoiding blame: strong occupational associations and plausible deniability. 

Powerful guilds and unions 

Medical personnel are protected by their silo and tribe.  Department heads defend their employees (and their turf) from outsiders.  The doctors effectively belong to a guild that jealously guards their professional authority; the nurses and other technical fields have their unions.  These unofficial and official organizations exist to protect their members and promote their interests.  They do not exist to protect patients although they certainly tout such interest when they are pushing for increased employee headcounts.  A key cultural value is members do not rat on other members of their tribe so problems may be observed but go unreported.

Hiding behind the procedures

In this environment, the actual primary goal is to conform to the rules, not to serve clients.  The safest course for the individual employee is to follow the rules and procedures, independent of the effect this may have on a patient.  The culture espouses a value of patient safety but what gets a higher value is plausible deniability, the ability to avoid personal responsibility, i.e., blame, by hiding behind the established practices and rules when negative outcomes occur.

An enabling environment 

The environment surrounding healthcare allows them to continue providing a level of service that literally kills patients.  Data opacity means it’s very difficult to get reliable information on patient outcomes.  Hospitals with high failure rates simply claim they are stuck with or choose to serve the sickest patients.  Weak malpractice laws are promoted by the doctors’ guild and maintained by the politicians they support.  Society in general is overly tolerant of bad medical outcomes.  Some families may make a fuss when a relative dies from inadequate care but settlements are paid, non-disclosure agreements are signed, and the enterprise moves on.

Bottom line: It will take powerful forces to get the healthcare industry to adopt true systems-oriented thinking and identify the real reasons why preventive harm occurs and what corrective actions could be effective.  Healthcare claims to promote evidence-based medicine; they need to add evidence-based harm reduction strategies.  Industry-wide adoption of the aviation industry’s confidential reporting system for errors would be a big step forward.    


*  N. Leveson and S. Dekker, “Get To The Root Of Accidents,” ChemicalProcessing.com (Feb 27, 2014).  Retrieved Oct. 7, 2019.  Leveson is an MIT professor and long-standing champion of systems thinking; Dekker has written extensively on Just Culture and Safety II concepts.  Click on their respective labels to pull up our other posts on their work.

**  The article is tailored for the process industry but the same thinking can be applied to service industries.

Safety II Lessons for Healthcare

Rod of Asclepius  Source: Wikipedia

We recently saw a journal article* about the incidence of preventable patient harm in medical care settings.  The rate of occurrence of harm is shocking, at least to someone new to the topic.  We wondered if healthcare providers and researchers being constrained by Safety I thinking could be part of the problem.  Below we provide a summary of the article, followed by our perspective on how Safety II thinking and practices might add value.

Incidence of preventable patient harm

The meta-analysis reviewed 70 studies and over 300,000 patients.  The overall incidence of patient harm (e.g., injury, suffering, disability or death) was 12% and half of that was deemed preventable.**  In other words, “Around one in 20 patients are exposed to preventable harm in medical care.”  12% of the preventable patient harm was severe or led to death.  25% of the preventable incidents were related to drugs and 24% to other treatments.  The authors did not observe any change in the preventable harm rate over the 19 years of data they reviewed.

Possible interventions

In fairness, the article’s focus was on calculating the incidence of preventable harm, not on identifying or fixing specific problems.  However, the authors do make several observations about possible ways to reduce the incidence rate.  The article had 11 authors so we assume these observations are not just one person’s to-do list but rather represent the collective thoughts of the author group.

The authors note “Key sources of preventable patient harm could include the actions of healthcare professionals (errors of omission or commission), healthcare system failures, or involve a combination of errors made by individuals, system failures, and patient characteristics.”  They believe occurrences could be avoided “by reasonable adaptation to a process, or adherence to guidelines, . . .” 

The authors suggest “A combination of individual-level measures (eg, educational interventions for practitioners), system-level*** measures (eg, human-centred design of healthcare tasks and work environments), and organisational-level measures (eg, introducing quality monitoring and improvement processes) are likely to be a promising strategy for mitigating preventable patient harm, . . .”

Our Perspective

Let’s get one thing out of the way: no other industry on the planet would be allowed to operate if it unnecessarily harmed people at the rate presented in this article.  As a global society, we accept, or at least tolerate, a surprising incidence of preventable harm to the people the healthcare system is supposed to be trying to serve.

We see a direct connection between this article and our Oct. 29, 2018 post where we reviewed Sydney Dekker’s analysis of patient harm in a health care facility.  Dekker’s report also highlighted the differences between the traditional Safety I approach to safety management and the more current Safety II approach.

As we stated in that post, in Safety I the root cause of imperfect results is the individual and constant efforts are necessary (e.g., training, monitoring, leadership, discipline) to create and maintain the individual’s compliance with work as designed.  In addition, the design of the work is subject to constant refinement (or “continuous improvement”).  In the preventable harm article, the authors’ observations look a lot like Safety I to us, with their emphasis on getting the individual to conform with work as designed, e.g, educational interventions (i.e., training), adherence to guidelines and quality monitoring, and improved design (i.e., specification) of healthcare tasks.

In contrast, in Safety II normal system functioning leads to mostly good and occasionally bad results.  The focus of Safety II interventions should be on activities that increase individual capacity to affect system performance and/or increase system robustness, i.e., error tolerance and an increased chance of recovery when errors inevitably occur.  When Dekker’s team reviewed cases with harm vs. cases with good outcomes, they observed that the good outcome cases “had more positive characteristics, including diversity of professional opinion and the possibility to voice dissent, keeping the discussion on risk alive and not taking past success as a guarantee for safety, deference to proven expertise, widely held authority to say “stop,” and pride of workmanship.”  We don’t see any evidence of this approach in the subject article.

Could Safety II thinking reduce the incidence of preventable harm in healthcare?  Possibly.  But what’s clear is that doing more of the same thing (more training, task specification and monitoring) has not improved the preventable harm rate over 19 years.  Maybe it’s time to think about the problems using a different mental model.

Afterword

In a subsequent interview,**** the lead author of the study said “providers and health-care systems need to “train and empower patients to be active partners” in their own care.”  This is a significant change in the model of the health care system, from the patient being the client of the system to an active component.  Such empowerment is especially important where the patient’s individual characteristics may make him/her more susceptible to harm.  The author’s advice to patients is tantamount to admitting that current approaches to diagnosing and treating patients are producing sub-standard results. 


*  M. Panagioti, K. Khan, R.N. Keers,  A. Abuzour, D. Phipps, E. Kontopantelis et al. “Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis,” BMJ 2019; 366:l4185.  Retrieved July 30, 2019.

**  The goal for patient harm is not zero.  The authors accept that “some harms cannot be avoided in clinical practice.”

***  When the authors say “system” they are not referring to the term as we use it in Safetymatters, i.e., a complex collection of components, feedback loops and environmental interactions.  The authors appear to limit the “system” to the immediate context in which healthcare is provided.  They do offer a hint of a larger system when they comment about the “need to gain better insight about the systemic and cultural circumstances under which preventable patient harm occurs”.

****  M. Jagannathan, “In a review of 337,000 patient cases, this was the No. 1 most common preventable medical error,” MarketWatch (July 28, 2019).  Retrieved July 30, 2019.  This article included a list of specific steps patients can take to be more active, informed, and effective partners in obtaining health care.