1. High reliability healthcare: how much choice can we afford?
David Mudd
Head of Modernisation
North West London SHA
4 August 2004

2. In this session you can
see comparisons of reliability in healthcare and other industries;
look at how to design for better reliability;
look at the benefits and costs of high reliability organisations;
think about how you can improve the reliability of your service

3. The basics Joined-up services - as seen by users Shared information
Choice – providers, settings, date and time
Redesigned, streamlined services – fewer visits, no avoidable waits
Better working lives for NHS staff

4. Higher expectations over time, the basics get taken for granted
then we expect high reliability
examples – cars, TVs, food industry, civil aviation, nuclear industry

5. High reliability healthcare Don Berwick, Tom Nolan
Reliability = number or % of actions that achieve the intended results
“Getting it right, every time”

6. Healthcare process reliabilities
Reliability
Unreliability
One in.…goes wrong
Process/outcome
90%
10%/10-1 10
Beta-blockers to prevent MI
99%
1%/10-2
100
Polypharmacy in the elderly
Medication harm
Deaths in risky surgery
99.9%
0.1%/10-3
1,000
Neonatal mortality
General Surgery deaths
99.99%
0.01%/10-4
10,000
Deaths in routine anaesthesia
99.999%
0.001%/10-5
100,000
Deaths from major radiotherapy machine failures

7. Reliability in healthcare and other industries (Amalberti; Espinosa & Nolan)
ED reading X-rays (97%)
Blood transfusion
ED reading X-rays - improved (99.7%)
Anaesthesia ASA1
Fatal iatrogenic adverse events
Cardiac surgery (Patient ASA 3-5)
Civil aviation
Medical risk (total)
Railways - France
Himalaya mountaineering
Road safety
Chemical industry (Europe)
Nuclear power industry
10-2
10-3
10-5
10-6
10-4
Very unsafe
Ultra-safe

8. Design for Reliability (Berwick & Nolan)
Level 1: Intent, vigilance and hard work
Level 2: Design informed by reliability science and research in human factors
Level 3: Design of high reliability organisations

9. Level 1: “Intent, vigilance, hard work”
Standardized protocols, feedback, training, checklists
Guidelines easy; getting people to follow them is difficult
But: good evidence exists that this will get you to (99%)

10. Group discussion (5 mins)
Recall an experience – in any setting – in which the request that you ‘try harder’, ‘be careful’, or ‘stay alert’ improved your performance. Why did that work?
Identify a process in your workplace that relies on vigilance. What would you estimate its reliability to be?

11. Factors affecting human vigilance
Fatigue
Environmental conditions
Task design
Psychological conditions
Competing demands

12. Level 2: Design informed by reliability science and research in human factors
Redesign the system; don’t rely on checking
Decision aids and reminders built into the system; automation;evidence as the default; redundancy; scheduling; connection to habits
Can take you from (99%) to (99.9%)

13. Three-level design of safe and reliable systems: Prevent – Identify - Mitigate (Norman)
Design the system to prevent failure
Design the system to make failures visible if they do occur
Design procedures to mitigate the harm caused if failures are not detected and intercepted

14. Physical design, human behaviour (Norman)
Constraints
physical (eg square peg round hole)
cultural (eg Red for Stop)
Memory
eg numbers, passwords, dates
Mapping
eg my cooker

15. Natural mapping – my cooker (Norman)

19. Advantages of automation
Increased capacity and productivity
Reduction of manual workload and fatigue
Relief from routine operations
Relief from small errors
More precise handling of routine operations
Economical utilisation of machines
Damping of small differences

20. Disadvantages of automation
Seen as dehumanising – lower job satisfaction
Low alertness of human operators
Systems are fault intolerant – may lead to larger errors
Silent failures
Lower proficiency of human operators
Over-reliance – complacency, uncritical acceptance of results
False alarms

21. Computers are incredibly fast, accurate and stupid; humans are incredibly slow, inaccurate and brilliant; together they are powerful beyond imagination
Albert Einstein

22. What’s the contribution of IM&T in healthcare?
Shared electronic record – one set of data, available to all
Protocol-driven care as the default – standardising on best practice
Decision aids
Scheduling
Making errors visible and retrievable
Letting every player see the whole system

24. Level 3: Design of high reliability organisations: “ultra-safe” (Weick; Amalberti)
Accepting limits on discretionary actions (eg pilots told when it’s safe to take off/land)
max safety up to 10-2
Abandoning autonomy (eg drive on the left)
max safety up to 10-3
Moving from ‘craftsmanship’ to ‘equivalent actor’ (eg anaesthetics v surgery)
max safety up to 10-4
Sharing the residual risk – how the system deals with failure (eg KAL 007)
max safety up to 10-5
Managing the invisibility of risk (“we’ve never seen one of these before”
max safety up to 10-6

25. Some outcomes of focus for a high reliability healthcare organisation (Berwick)
No needless deaths
No needless pain
No feelings of helplessness
No unnecessary waiting
No waste

26. Constraints Constraints on patient choice
Constraints on professional autonomy
Constraints on the factors which distinguish healthcare organisations (competitive advantage)

27. Challenges Buy-in from clinicians and patients
Protocol-driven care as the default – standardising on best practice
Sharing information – with whom?
Decision aids or decision-taking?
Scheduling – are we ready for it?
Making errors visible and retrievable – aligning the incentives and penalties

28. Summary
Reliability in healthcare is a long way behind other safety-critical industries
We can improve reliability by better design equipment and systems, and by standardisation
Beyond this, improvement comes with reduced choice – standardisation/doing it by the book
Clinicians need to work with standardisation, but be prepared to respond with autonomy
Sophisticated design of human interactions and working relationships

29. Table discussion Think about the clinical service you provide/manage:
What changes must you make to get to 10-4 performance?
What implications does this have for how you select and train your staff?

30. References/further reading
The Design of Everyday Things. Donald A Norman; MIT Press; 1998
Handbook of Human Factors and Ergonomics. G Salvendy (ed); John Wiley, New York; 1997
Managing the Unexpected. Weick and Sutcliffe; Josey Bass; 2001
System changes to improve patient safety. Nolan TW. BrMedJ 2000;320: (18 March)
Reducing errors made by emergency physicians in interpreting radiographs: longitudinal study. Espinosa JA, Nolan TW. BrMedJ 2000; 320: (18 March)
The quality of care delivered to adults in the United States. McGlynn EA, Asch SM, et al. N Engl J Med, 348(26); June 2003
Revisitjng safety and human factors paradigms to meet the safety challenges of ultra complex and safe systems. Amalberti R, In Challenges and pitfalls of safety interventions, Willpert B & Fahlbruch B. Elsevier, North Holland
Wiener EL, Nagel DC, ed. Human Factors in Aviation. New York: Academic Press, 1988.
Various presentations & papers by Rene Amalberti on the Internet (via Google)