In previous articles we described the HCRO Framework for Reliability:
- Seeing and understanding risk (in order to manage it)
- Improving Systems (to become more effective and resilient)
- Managing Human Behaviors (i.e., choices and errors)
- Organizational Sustainment (both individuals and groups of people)
In the next few articles we’ll examine the criticality of each element of the Framework and explain why this sequence matters to HCRO organizations. Let’s start by examining Part 1.
As seen through the lens of socio-technical science, people and systems combine in probabilistic ways. In other words, organizational risk follows certain mathematical and physical laws of interaction, predictable only in the sense that there are probabilities of outcomes that result from these interactions. This is our central challenge in producing better outcomes in healthcare: We must see and understand how these probabilities occur in order to manage the results.
In mathematical terms, boundary conditions matter. Especially for non-linear dynamic equations and systems. What this means is that slight changes in initial variables and conditions can lead to large, even unstable fluctuations in system behavior over time. Optimizing complex systems requires an understanding of how these initial boundary conditions influence system performance. And this necessitates seeing the variables involved.
Seeing the Risk: A Simple Analogy
Let’s consider an analogy. As any parent will attest, what often worries us most about our children is not being able to manage the risks around them when we’re not there. As our children grow and develop throughout life, our ability to guide and protect them changes with each passing day. Our ability to manage the risks around the loved ones in our care starts with our ability to see the risks. Some risks are easy to see as soon as they are born: whether they are eating, sleeping, moving, and developing at an expected rate. On the other hand, there are numerous hidden risks, not always visible to the parental eye, such as disease and/or genetic conditions that may require additional diagnostics. And because each parent may or may not be able to see all of the hidden risks facing child-rearing there are societal protocols in place to guide us: testing, vaccinations, educational requirements, and certain legal standards of supervision.
Let’s consider a few more examples of the importance of seeing and understanding risk from a personal point of view. For several years, many citizens of developed nations have been buying anti-bacterial soap and cleaning products hoping for improved effectiveness in fighting germs that can cause illness, only to discover that these products may actually increase bacterial resistance leading to even greater risk.
From a medical and healthcare organizational perspective, this is related to the growing focus on antibiotic stewardship. We’re learning that the unrestrained use of antibiotics may actually increase the risk of certain types of infections. The overall challenge of infection prevention in healthcare is heightened by our inability to see and understand the risks associated with bacteria and viruses. The differences in preventing and treating different types of infections are critical: from C-diff to MRSA to influenza to Sepsis to Ebola, our effectiveness in managing these risks start with our ability to see and understand them.
The Iceberg Model of Risk Revisited
Remember the Iceberg Model of risk presented in our HCRO Foundations Learning Modules? While easy to see by analogy, it’s important to note that this is NOT the typical way in which the healthcare industry has managed risk in the past. In fact, most of our attention to risk in healthcare has been focused above the waterline, where adverse events are reported and investigated. The greater challenge lies in managing risk below the surface, absent from reporting systems and RCA’s and outcome measures reported to regulators. The reality we face in healthcare is that of all the outcome measures we typically examine, much of the real risk remains unreported and unmanaged. In addition to infections, Adverse Medical Events, falls, pressure ulcers, diagnostic and surgical errors, readmissions, and other CMS-reported measures, the greatest risks lie below the waterline.
The Sequence of Socio-Technical Reliability
The good news is that the HCRO Framework for Reliability guides us through the sequenced application of the socio-technical science. Within HCRO organizations more time is devoted to gathering data and understanding the mechanisms that produce adverse outcomes, before attempting to manage these risks. This doesn’t mean that RCAs and other event investigations increase in number. HCRO hospitals recognize that yesterday’s adverse event (and resulting investigation) typically represent only one pathway to adversity. In many instances, RCAs and event investigations diminish in number, giving way to a greater focus on hidden risks identified by frontline employees and physicians. The result is that traditional RCAs give way to a more predictive approach to managing risk. This approach allows the organization to begin optimal management of adverse outcomes, by seeing and understanding risks before adversity strikes.
In our next article we’ll continue examining the sequenced HCRO Framework for Reliability by illuminating the differences between effective and resilient systems, and show how both are critical attributes of reliable systems.