High reliability in health care
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c84 (Published 19 January 2010) Cite this as: BMJ 2010;340:c84
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Many industries can lead the health sector into better safety
procedures, but not all translate well across sectors. Car manufacturers
and supermarkets have developed just in time supply chains and have
outsourced almost all their core functions to subcontractors. This leaves
a so called "hollow corporation". This works were skills are basic and
easily hired then fired. It has failed spectacularly in the NHS.
The National Programme for IT / Connecting for Health awarded fat
contracts to slick multinational corporations. They seemed too big to fail.
The little established specialist national companies were sidelined. I met
these firms as they hired "warm bodies" (short term employees lacking
competence but fulfilling the contract by their presence) to do the work
of developing new software. They failed and CfH were surprised. In fact
they were bound to fail due to their business model. The skills to develop
a complex IT package for primary care have come from small firms who
completely understand the business and clinical processes of doctors, the
most sucessful firms having GPs who can instigate programmes directly. Big
corporations have suberb sales teams and legal departments but cannot
deliver sucess as they are hollow.
Similarly the idea that out of hours general practice can be
delivered by any medical practitioner who is parachuted from other parts
of the globe into a night shift is folly.
If one is to have safe care one needs to have locally embedded doctors who
know the BNF doses of diamorphine and local pathways.
Medical and Computer expertise in complex healthcare is not the same
as a supermarket supply chain where tins of beans can be translocated
round the globe just in time. We need the wisdom to adopt the safety
culture of the airline whilst rejecting the simplicity of the bean
counters.
Competing interests:
NHS GP
Competing interests: No competing interests
The recent editorial by Vincent and colleagues struck a chord. Experience both as an anaesthetist and an airline pilot has led me to the not particularly startling conclusion that the safety culture so desired by healthcare organizations is a product of having a safety system and that the two are interdependent.
All high reliability organizations - including most airlines - have a Safety Management System, featuring basically the same requirements as clinical governance, with one very important addition which, as far as I can tell, no healthcare provider has implemented - an operations manual. This is the backbone and the glue which keeps the system together and makes it work: concise but authoritative written information and instructions as to who does what, when and how. When backed up by good communications, information flow and training to impart and maintain appropriate knowledge, skills and attitudes, the result is a flexible and resilient organization which can be both proactive and reactive.
As the authors say, this ideal of reliability and resilience may be approached in some teams and in some parts of healthcare organizations. Many of the elements are often there already, but the point about safety systems is that they are systems and they are organization-wide. Perhaps the absence of an operations manual is indicative of the failure to understand this or maybe it’s just too difficult a step to take.
The recent implementation of the WHO Surgical Safety Checklist is a good example. The concept of a checklist, used at a critical point to confirm that (literally) vital actions are complete, is familiar to all pilots who will, however, also assume that such actions would normally have already occurred as part of clearly defined procedures. Unfortunately, this is often not the case and the reason why these items were included in the checklist. The junior doctor may know (or soon finds out) that the consultant (who he / she may not have met) ‘likes’ antibiotic prophylaxis written up; there may be a protocol if he / she is aware of it; the anaesthetist will ‘probably’ check the drug chart and, if not distracted by something else, may ‘remember’ to give them. Now, if all else fails, it will be caught by the checklist, but I wouldn’t like to be a passenger on an aircraft operated like this.
I agree that the methods and concepts used in aviation and other industries must be applied intelligently and appropriately to healthcare and that the resilient healthcare system may turn out to be unique in some respects. However, I do not buy the argument that healthcare is an activity so much more complex that this cannot be done. Unravelling the effects of multiple reforms on management structures, clinical staffing and training will be quite challenging, but a systematic approach is possible – there may even be gain without pain, but not without change.
1 Vincent C, Benn J, Hanna GB. High Reliability in Healthcare. BMJ 2010;340:c84.
Competing interests:
None declared
Competing interests: No competing interests
Wikisurgery scripts, test beds for high reliability systems in health care.
Professor Vincent and his colleagues stress the need for strong basic
procedures for high reliability operations in the health service 1. Dr
Toff, in a rapid response to the editorial, points out a fundamental lack
of operation manuals from healthcare providers.
At Wikisurgery, the free online surgical encyclopedia, we have developed
scripts that fulfil both requirements 2,3. The scripts aim to provide all
the information that one or more surgeons use when performing even very
complex operations. They contain not only the World Health Organisation’s
pre- and post operative safety checks, but a multitude of previously
undocumented intraoperative safety checks.
As well as being useful for training today’s experience -starved trainees,
the scripts have already been shown to have roles both as research
resources and research tools 4. They are ideal for testing and
implementing ideas aimed at promoting high reliability in health care.
1 Vincent C, Benn J, Hanna GB. High Reliability in Healthcare. BMJ
2010;340:c84.
2 Knox RA, Edwards MH. Aortic aneurysm graft.
<http://www.wikisurgery.com/index.php?title=Aorticaneurysm-graft-
Operationscript <2 February 2010>
3 Macdonald A, Edwards MH. Rectum anterior resection and total
mesorectal excision.
<http://www.wikisurgery.com/index.php?title=Template:Rectum-anterior-
resection-and-total-mesorectal-excision Operationscript < 2 February,
2010>.
4 Edwards MH, Coughlan J, Morar SS Eliciting and storing operative
information from expert surgeons using surgical scripts. Int J Surg. 2007;
5 (4): 267-272.
Competing interests:
Michael Edwards FRCS and Riaz Agha MB BS (Hons) BSc (Hons)are editors of Wikisurgery
Competing interests: No competing interests