High reliability organizations (HROs) are successful at containing errors before they become unmanageable disasters. Healthcare organizations need to copy their successful methods to protect patients. That is a big lesson that I learned from Karl Weick and Kathleen Sutcliffe from their excellent book, Managing The Unexpected, 2007.
One of RCM’s clients had been misdiagnosed and spent several months in hospital being treated for the wrong disease. The correct diagnosis was eventually made. He got better. He wanted to tell his story to the doctors at rounds at the hospital. Everyone would then be able to learn from his example.
When I asked the head of medical staff at the hospital about this opportunity, he said that he had never heard of anything like this before. He was abrupt and passed this issue down the ladder. In essence, he said that mistakes like this don’t happen here, even though they obviously do.
HROs such as aircraft carriers, fire fighting operations and nuclear power plants follow the same 5 principles:
1. pre-occupation with failure (not success) and continuous articulation of near misses and mistakes (large or small) in order to learn and to prevent complacency
2. reluctance to over-simplify in order to see more knowing that the world is uncertain, unpredictable, unstable and unknowable
3. focus and sensitivity to operations in order to develop high levels of situational awareness. This allows for continuous adjustments that prevent errors from accumulating and enlarging.
4. commitment to resilience in order to keep the organization in a dynamically stable state. HROs are not error free but errors do not disable them.
5. deference to expertise not authority. Rigid hierarchies are vulnerable to errors. To contain errors the decision must go either up or down the organization to find the greatest expertise to deal with the errors.
Weick and Sutcliffe emphasize the need for institutional mindfulness which they define as “a rich awareness of discriminatory detail”. Mindfulness is focused on clear and detailed comprehension of emerging threats and on factors that limit that understanding. They describe the hazards of labels. Our misdiagnosed patient was the victim of hazardous labelling.
Every organization will have errors and adverse events. Planning does not prevent errors in complex systems. The focus should be on methods of containing the error before it grows to an unmanageable threat.
For healthcare organizations to minimize errors, there must be mindfulness and pre-occupation with errors and near misses. These must be collected, shared and discussed. There has to be an obsession with detail and with any hint of trending to failure. That’s the start of creating a safer healthcare organization.