Let’s All Feel Superior: Individual Failures Require Leadership, Systems, and Culture to Bind

I read this op-ed piece from David Brooks in the New York Times with great interest. While talking about the Penn State scandal, Brooks identifies several fascinating psychological constructs that we use as individuals to avoid taking the "right action":

• Normalcy Bias - "shut down and pretend everything is normal" 
• Motivated Blindness - "don't see what is not in their interest to see" 
• Bystander Effect - "the more people are around to witness the crime, the less likely they are to intervene" 
• Self Deception - "we attend to the facts we like, and suppress the ones we don't" 
• Blind Spots - "when it comes time to make a decision, our thoughts are dominated by thoughts about how we want to behave; thoughts of how we should behave disappear" 

His key point is that we're in denial of "the underside of our own nature", which I would have to believe is likely true. However, as Brooks also points out "in centuries past people built moral systems that acknowledged this weakness .. they helped people make moral judgments and hold people responsible amidst our frailties." I would argue that this is the real weakness. Human nature has not changed, but society has evolved into such a complex organism such that the systems to keep "human nature in check" are not functional.

But this is ultimately what is means to be a leader - whether spiritual, political, or organizational - and to create an organizational culture: help to guide human nature - despite its many failings, blind spots, self deception, and biases - to achieve a purpose and pursue actions that no individual would undertake on his/ her own.

Many of us see these individual failings consistently in our healthcare organizations, which have largely been build around the notion that failure of behavior is an individual failing. Sometimes these individual failings are just as egregious as the examples used by Brooks when staff, managers, and executives "stand by" and allow for actions to be taken that lead to patient harm in the guise of "its just the way things work around here".

However, as many industry leaders have been pointing out - particularly the stalwarts for patient safety - individual behavior may contribute to a failing, but it is not the cause. The system (i.e., culture or society) that allows that behavior to be manifest is the cause. If we want better behavior, decisions, actions or ultimately the outcomes which result from these behaviors, then we have to work with greater diligence to build the leadership, systems, and culture that will allow individual failings to be overcome or at least held in check. The likelihood of harm is just as great, and not at all excused because the victims are sometimes unknown, or because it happens within a building and not on the street.

Improving Surgical Safety: Time-Outs, Use of Checklists, Systems Improvement

This article in Hospitals and Health Networks provides some interesting insights into successful interventions undertaken by many hospitals to reduce the likelihood of "wrong-sided surgeries" - an event so infrequent, that it is hard to muster an institution's scant resources to address. However, a number of institutions referenced in this article did exactly that.

One of the most helpful lessons from this article are the reasons that The Joint Commission found as the leading "root causes" for this "never event":

Operating Room

• Lack of intraoperative site verification when multiple procedures are performed by the same provider 
• Ineffective handoff communication or briefing process 
• Primary documentation not used to verify patient, procedure, site and side 
• Site mark(s) removed during prep or covered by surgical draping 
• Time-out process occurs before all staff are ready or before prep and drape occur 
• Time-out performed without full participation 
• Time-outs do not occur when there are multiple procedures performed by multiple providers in a single operative care 

Organizational Culture

• Senior leadership is not actively engaged 
• Inconsistent organizational focus on patient safety 
• Staff are passive or not empowered to speak up 
• Policy changes made with inadequate or inconsistent staff education 
• Marketplace competition and pressure to increase surgical volume leads to shortcuts and variation in practice 

The article also identifies the following interventions that seem to have been effective in different settings:

• Implementation of the WHO "Surgical Safety Checklist" to ensure critical aspects of the impending surgery are reviewed (Safe Surgery 2015) 
• Implementation of "Time-Out" to ensure surgical team synchronization (Minnesota) 
• Improving communication regarding the scheduling of surgeries (AnMed Health Women's and Children's Hospital, SC) 
• Support from Hospital Association and local hospital leadership (South Carolina Hospital Association) 
• Insistence upon use of evidence-based standards (Pennsylvania Patient Safety Authority) 
• "Labor-intensive practices" - including staff support, physician support, meetings, observations, a role for everyone (Lifespan, RI) 

These are great examples of "good-old-fashioned" performance improvement - get leadership involved, create a multi-disciplinary team, measure the critical steps in the process, share the data with staff and medical staff, implement the evidence-base, ensure that not implementing the evidence-base is not an option.
There are many other interventions that can also be implemented to help improve surgical safety. Some of these may not directly impact the likelihood of "wrong-sided surgery", but they can have a major impact in the greater endeavor to make surgery safer.

• Pre-Operative Checklist: Helps to standardize a number of items that need to be in place before a patient is "cleared for surgery", including: 
• Cardiology Evaluation (required in high-risk cases to ensure patient's cardiac condition is appropriately treated prior to surgery) 
• Pulmonary Evaluation (required in high-risk cases to ensure patient's respiratory function is appropriately maximized prior to surgery) 
• Anesthesia Evaluation (identifies risk for complications of intubation, anesthesia, and surgery) 
• Administration of Beta-Blockers (specific medications that can reduce risk of cardiac complications) 
• Pre-Operative Testing, including Labs, EKG (to ensure that there are no latent underlying conditions that need to be treated prior to surgery) 
• Prophylactic Antibiotics (medications to prevent infection) 
• VTE Prophylaxis (medications to prevent blood clots) 
• Plan for Peri-Operative Pain Management (a proactive plan can improve pain control, and post-operative recovery) 
• Post-Operative Checklist: Helps to standardize a number of items that need to be implemented and monitored post surgery, including: 
• Monitoring of Blood Loss and Fluid Status (can be signals of underlying complications) 
• Monitoring of Pain (can be a signal of an underlying complication) 
• Monitoring of Cardiac Rhythm (can alert to underlying cardiac complications) 
• Monitoring of Bowel and PO Status (are signals of overall recovery from surgery) 
• Sepsis Screening Protocol (monitor signs to alert for impending infection) 
• Prophylactic Antibiotics (medications to prevent infection) 
• VTE Prophylaxis (medications to prevent blood clots) 
• Removal of Foley Catheter within 24 to 48 hours (can reduce the likelihood of a urinary infection) 
• Intra-Operative Pause: 
• The "Time-Out" is a process by which all team members stop what they are doing prior to surgery so that they can all get "into synch". 
• The Intra-Operative Pause similarly provides a break during prolonged procedures so that team members have a chance to "re-synch". 
• Severity of Surgery Assessment: 
• A formal means to improve communication prior to surgery about the potential for complications. 

I'll provide more details about some of these interventions in subsequent blogs.

Respectful Management of Serious Adverse Events + Daily Safety Check-in

Combine the thinking of: 

• the paradigm proposed by Jim Conway, Frank Federico, Kevin Stewart, and Mark Campbell of the Institute for Healthcare Improvement about a framework for respectful management of serious adverse events in this article from HealthLeaders Media 

with: 

• the concepts proposed in this article from Patient Safety and Quality Healthcare by Carole Stockmeier and Craig Clapper about instituting a "daily safety check-in" 

and you start to get the makings of a powerful real-time and retrospective risk mitigation and patient safety system, which incorporates the following elements:

• Proactive, immediate, and retrospective responsiveness
• Heightened awareness of risk
• Early resolution of problems
• Accountability
• Leadership presence at the frontline
• Involvement of the frontline staff in safety
• Furthering the culture of safety
• Team-based approach to improving safety
• Development of a structured plan for dealing with safety issues
• Structured risk assessment and mitigation

Thanks to the vision and insights shared by the authors above and for their leading the charge to develop a patient safety system we can all be more proud of.