A recent piece in The Journal of Patient Safety, "An NTSB for Healthcare, Learning from Innovation: Debate and Innovate or Capitulate" by experienced, highly-competent Aviators and Medicos prompted me to ask a question about on the subject of Dr Brent James, Chief Quality Officer of Intermountain Healthcare:
The NTSB only recommends, the FAA makes sure those things (and more) are done.Dr James kindly responded to me and I was gently reminded of James Reason's "Blame Cycle" [below] and Dr James own comments on the 2001 ABC's Health Report, "Minimising Harm to Patients in Hospital":
As a regulatory and compliance organisation, the FAA is able to hand out "direct, personal consequences" - and make them stick. [Natural Justice suggests proportionality as well].
Any Aviation Professional who repeats, or allows, a Known Error, Fault or Failure will be discovered and will suffer the consequences. [Hence would a medical version need two bodies?]
Norman Swan: So remove the culture of blame, sort out the legal liability problems, without ignoring the fact that there will be the odd rogue doctor or rogue nurse who needs to be sorted out. What we should be seeing here, we haven't really emphasised it up till now, is that most of the problems that occur when injuries occur, are system problems, the hospital, the management, the organisation of the hospital, rather than an individual going wrong?My central concern with the NTSB-for-Medicine proposal is the necessity for the organisation to not be a "toothless tiger", to have the power to cause change, but simultaneously engender a "Safety Culture" where Openness and Transparency are the norm and individuals do not feel threatened by the system.
Brent James: Exactly. We know that the individuals will have problems. How do we create an environment in which it's easier to do it right, and hard to fail? That's the real issue. It's an institutional responsibility not an individual responsibility. The next thing that we need is an organisational structure. In the United States we're calling them Patient Safety Officers, and in the Institute of Medicine Report we asked that all care delivery groups appoint Patient Safety Officer, usually from existing personnel, usually a good clinician.
Audit reports and Commissions of Inquiry into major failures (QLD) say what's wrong, but have no powers to cause change. They are equivalent to the NTSB, but lack the ability of the FAA to implement, to cause or require necessary change and to check that it is done.This is The Accountability Paradox:
Reason's "Blame Cycle", and my own more extreme "Blame Spiral", require Dr Demings' exhortation to "Drive out Fear" be scrupulously and systemically be applied.
How can these two conflicting objectives be achieved? I've no experience in this.
For real change in the system, any person who repeats, or allows, a Known Error, Fault or Failure, must be held personally liable (including criminally if they caused death or severe injury/disability),
BUT if that is perceived as the Primary Role of the compliance and governance organisation, then it will be ineffective, instead it will engender the "Blame Cycle" as a minimum.
Some references to Prof. Reasons' "Blame Cycle":
"Diagnosing “vulnerable system syndrome”: an essential prerequisite to efffective risk management" (2001, Qual Health Care 2001;10:ii21-ii25 doi:10.1136/qhc.0100021) and
"Managing the Risks of Organizational Accidents" .