Safety by Design

Safety is implicit in the medical professional’s social contract. To begin with it was seen as social attitude and individual intention. Yet harm remained inevitable due to the uncertainty of the knowledge base However, while greater certainty has been achieved in the knowledge base it was only at the cost of complexity- of both theory and practice and consequent lost opportunities. There link between complexity and harm is itself a new revelation. While safety was presumed by patients and society at large. it was considered rare and  inevitable by  the profession. The recent studies not only brought forward the high incidence but also the varied distribution among vulnerable groups. These epistemological studies brought about the era of patient safety analysis. These variations have implications for the need to bring all healthcare providers to the curriculum whiteboard but also for the direct resolution of the problem. Demographic distribution of risk: studies examining the differences between private and public hospitals that understand the sociology of safety .

Complexity and Incompleteness

Practice when seen as passive trajectory of evidence is itself a threat to safety- errors of omission. It is nature of science that evidence stays ahead of practice and infidelity i.e. lack of implementation of available evidence, becomes a dull face of harm. Individual professionals are reasonably well equipped to manage the knowing- doing gap, but failure attracts blame and defiance.

Poor safety is also a disease of complexity and we realize there cannot be safety without simplicity. The ingredients of the remedy are planning and design. The older sibling discipline of improvement science along with its studious twin –implementation science- has gotten us closer to an action oriented theory of practice and the patient safety movement can easily see further from its shoulders: nevertheless the very same messages are worth repeating : drain the swamps rather than kill the alligators; work on the system or you end up working in it ; the next process is your customer or boss ; prevention is also care; action is worth a thousand pictures ; nothing about me without me ; every patient is the only patient etc

Performance and Design

Safety when viewed as a performance issue can be theoretically achieved by individual professions, but as a design issue can never be achieved without having all the stakeholders on the same page. Similarly while legal and social responsibility for outcomes remain with physicians the process of care is owned by multiple agents .In such situation the benefit to the patient and inversely the harm can best be achieved by common purpose. It is the common aim that best defines the system.

From a design point of view, safety is a system property. Lack of coordination is dissatisfaction at the best of times and harmful otherwise. If we recognize that Complexity is a feature of interdependency.  Our best chance is coordination .Counterproductive hierarchies merely weaken the channels for dialogue and postpone the opportunities for remedy. The idea of working with other professionals is central to performance while working ‘on the system’ is central to design. The composition, status and skill sets of design teams and care teams are different.

In my opinion, the WHO while attempting an inter-professional curriculum must simultaneously deepen the focus in its content from performance to design. Inter-professional relations as well as hierarchies within professions are determined by local practices and are socially and culturally determined. Safety initiatives will do more harm than good, if they are seen as arenas for struggle for power. Design provides a level playing field, as both system design and curriculum interventions are ‘upstream’ activities.

Inter-professionalism must degenerate into multi-professionalism. In working at the design it can only be done in concurrence with other quality parameters. Further contrary to the opinion of experts in the developed world, system development tools are different from safety analysis or quality improvement tools.  System development involves longer period of time and resource commitments. It draws WHO commitment to promote a mixed model of quality which includes quality assurance and improvement. Convergence of solutions would be gradual process as countries choices are and affordability between high tech solutions and low tech solutions. Nevertheless the issues benefit global discussion.

If safety is an essential issue to all health professionals it is only because we all can collectively do something about it, which was not the case two decades ago. The epidemiological studies emphasized that 50% of the errors were preventable. With the new knowledge base of safety science.  While the evidence bases of the various professions are unequal, the knowledge base for safety is common and accessible to all. Though harm, like disease, is experienced by the individual; safety, like care, is provided by the team.

Inter-professionalism and new professions

Inter-professional curriculum play out at two levels: at the level of performance and at the level of design i.e. systems change. Thus epidemiological, performance, design views substantiate multi-professionalism. Inter-professional curriculum are not merely issues of representation of existing professions but require consideration of ‘delivering ‘ or developing new professions like infection control , disease informatics , ventilator therapist , palliative care and not the least professionalization and credentialing  of quality and safety.

Trust First attitude

Safety is the starting point and ending point of trust. Trust and accountability are two sides of the same coin. If we ask the question whom does the patent and society trust then the answer is all health professional .But if we ask who the patient and society expects to protect the trust then the answer is both the patient, society as well as the providers. Trust originates unconditionally in the patient seeking help, but is realized collectively by the experience of care.  System is  the provider’s viewpoint; systemness is the receiver’s viewpoint. Systemness is a design parameter and is a result of a constructivist rather than  engineering approach to work and the results of work.

Safety is a social outcome.

Harm to patients must be categorized in the same category as WHO ‘definition of health: Physical, mental, and social [economic, environmental etc ]. We must redefine improvement in terms of progress and progress in terms of improvement. Not merely the sociology of risk that has spawned large number of efforts at regulation and accreditation rather than empowerment and capability creation. Amartya sen refers to social opportunities loss.

Uncertainty is not a hindrance to systemness.

Quality and clinical outcomes are uncertain. But systems can be assured. Professionalism can be assured. But neither indefinitely. They require maintenance and improvement.

Systems are not merely instrumental but constitutive of care.  An advantage manufacturing and aviation can never dream off is the placebo effect. Standardization is the easiest [ eg checklist] but not the only means to ensuring systemness. Longitudinal uncertainty and horizontal uncertainty. Statistical and Systems thinking.

Design and Performance.

The nature of activities is a feature of design while the nature of action and change is feature of performance. The former is offline and para-clinical and can be enhanced by weekly reviews but action and change is an ongoing process. It is about daily accountability. The tools of the latter are from the real time science of Improvement. yet there is a need and scope for comparative assessments as well as system development . Improvement and system development are local but implementation science is global.

Knowledge from failure

 Any result that does not meet expectation is a failure.  It is the shared understanding of the negative outcome i.e. clinical and personal. It is this shared understanding that provides it with a empirical basis rather than mere reflective practice. Poor quality have causes and one of them is error. Translating them into failures of activities ad action

 Opportunity, Process and Outcomes

Sensitivity, Knowledge, Empowerment and Opportunity are all meta-systemic variables. These are the starting points for systems change. Systems’ thinking and action provides a handle but will not bear the wait of chronic epidemic proportion of system defects. Meta-systems are systems about systems: there are structural, require commitment, leadership, and investment.

System as a model and ideal.

Why micro and macro effectiveness: because the theorem every system is designed to produce the outcome is deterministic and possible at the macro system level but does not hold at the micro system level where individuation is a action not and activity. The above  is a over commitment to hard systems theory or even ‘systemism’. At the macro level the system is a model while at the micro level the system is an ideal. In the former it is foundational, while in the latter it is incremental or a dynamic program.