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Safety requires a state of mindfulness (Part II)

From the March 23, 2006 issue

Many healthcare organizations are trying to adopt the cultural characteristics of high-reliability organizations (HROs). These organizations have sustained impressive safety records despite operating in unforgiving and complex environments. One defining characteristic, termed mindfulness involves a vital set of cognitive processes used to continuously discover and correct errors, especially under adverse conditions. Workers in HROs pay attention to their work in a different, mindful way than workers in less reliable organizations. Two of the cognitive processes that contribute to this - preoccupation with failure and reluctance to simplify interpretations - were presented in part I in our March 9, 2006 newsletter (www.ismp.org/Newsletters/acutecare/archives.asp). Here in part II, we describe the remaining cognitive processes that lead to mindfulness. 

Sensitivity to operations. In HROs, the big picture of the organization is maintained and monitored more widely, and by more people, than in less reliable organizations. Workers are familiar with operations beyond their own jobs. They also provide and receive real-time information about current operations, explanations about symptoms that may be related to known or unexpected problems, and ongoing monitoring information that may lead to revised assessments of the operation as a whole (1-3). So "sensitivity to operations" means having not only a big picture of operations at any given moment, or even what it should look like in the future; it also means that workers participate in a dynamic, ongoing assessment process that permits the early identification of problems. Thus, small problems get undivided attention, and unexpected events are attended to more quickly, seldom growing into large-scale issues.

Commitment to resilience. HROs spend an enormous amount of time anticipating potential system failures and taking the necessary steps to prevent them. However, they wisely devote equal resources to the cultivation of workers' abilities to improvise and cope with unexpected hazards (1,3). Reliable organizations do not expect zero deficits (2). They accept that they cannot foresee everything or fully eliminate human error, technical failures, or system weaknesses that can creep into the organization. But they have created resilient systems that are more resistant to the adverse effects of these unforeseen failures (2).

HROs know that, in the real world, problems will arise for which the usual rules for solving them will not apply. Workers will be required to think creatively about these problems in order to solve them (4). Thus, reliable organizations continuously build workers' competence to quickly recognize and assess approaching hazards, detect and respond to failures, contain them, and when necessary, to recover from them (1-3). Consequently, workers have a deep knowledge of the basics and can skillfully improvise to contain new, unforeseen failures. 

Unlike anticipation, which encourages workers to think before acting to avoid problems, resilience requires workers to act while thinking about a problem that has already occurred. When lives are at stake, this occurs quickly, most often through a rapid pooling of knowledge from informal networks of people who self organize to respond to the crisis (1) Once the danger is past, the failure is further analyzed and steps are taken to prevent reoccurrences.     

Deference to expertise. To manage the unexpected, HROs allow decisions to migrate to those with the expertise to make them, not necessarily to the person with the most seniority or authority (1, 4). In most organizations, important decisions are made by important decision makers. In less reliable organizations, important decisions are often made by those at the top of the hierarchy. HROs have hierarchies too, but position does not necessarily dictate who is an important decision maker (3).

When problems arise, workers in HROs follow a more flexible decision-making structure which does not include a fixed important decision maker. Instead, they rely on a combination of important decision makers from all levels of the organization, which changes based on worker or team specialization and expertise (3). Decisions have to be made quickly, so those closest to the problem and/or its resolution are empowered to make important decisions (1-3). However, if workers get into situations they don't understand or can no longer manage, they're not afraid to admit that they need help. In fact, it's considered a sign of strength and confidence to know when you've reached your limit and enlist help from others, including senior leaders (3).

Reliability, not repeatability. While reliability is broadly defined as the capacity to produce quality outcomes repeatedly, it is misleading to consider repeatability a key defining characteristic of HROs (1). When work conditions fluctuate in unexpected ways, reliable organizations must be resilient and manage these fluctuations without compromising outcomes. The problem is, standard procedures alone cannot handle unanticipated problems (1). Managing the unexpected requires HROs to be resourceful and flexible when necessary. While this leads to some variation in activities when unanticipated problems arise, stable cognitive processes that focus on failures, operations, resilience, and expertise direct these activities and aid in uncovering and correcting unintended consequences, and preventing them from happening again.

Conclusions. Comparisons between the healthcare industry and HROs in other industries have been criticized by some in healthcare, citing that the work environment, complexity, unpredictability, error-proneness, and consequences of failure are not really similar. But consider Weick and Sutcliff's depiction of life on an aircraft carrier, as described by a Navy veteran:

Imagine that it's a busy day, and you shrink the San Francisco airport to only one short runway and one ramp and one gate. Make the planes take off and land at the same time, at half the present time interval, rock the runway from side to side, and require that everyone who leaves in the morning returns the same day. Make sure the equipment is so close to the envelope that it's fragile. Then turn off the radar to avoid detection, impose strict controls on the radios, fuel the aircraft in place with their engines running, put an enemy in the air, and scatter live bombs and rockets around. Now wet the whole thing down with sea water and oil, and man it with twenty-year-olds, half of whom have never seen an airplane up close. Oh, and by the way, try not to kill anyone (3, page 26).

Is the environment in healthcare any more complex or unpredictable than on an aircraft carrier? Are the work conditions so different? Are the consequences of failure on a carrier any less dire than the consequences of failure while providing healthcare? Carriers may seem quite different but their workers, like those in all HROs, confront and solve the same types of problems that healthcare providers face (3). The differences are only in the details, not in the character, scope, or urgency of the problems. HROs are a worthy resource from which to learn as we begin to maximize the skills, processes, and systems necessary for handling the unexpected and achieving reliable healthcare all the time, despite adversity.

References
1) Weick KE, Sutcliffe KM, Obstfeld D. Organizing for high reliability: processes of collective mindfulness. Research in Organizational Behavior 1999; 21:81-123.
2) Reason J. Managing the risks of organizational accidents. Burlington, VT: Ashgate Publishing Company; 2000.
3) Weick KE, Sutcliffe KM. Managing the unex- pected: assuring high performance in an age of    complexity. San Francisco: Jossey-Bass; 2001.

4) Leonard M, Frankel A, Simmonds T, Vega K. Achieving safe and reliable healthcare: strategies and solutions. Chicago: Health Administration Press; 2004.
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