Is quality safety Is safety quality Clarity is a priority'

1
Is quality safety? Is safety quality?Clarity is
a priority.

• Sam Sheps
• Karen Cardiff
• Department of Health Care and Epidemiology
• University of British Columbia
• Western Healthcare Improvement Network Conference
• Enhancing Patient Safety Across the Continuum
• Richmond, BC
• June 8, 2006

2
Why are we asking?

• In health care, quality and safety are most often
  talked about together, as if the concepts are the
  same, or at least, highly overlapping.
• System safety experts from other industries have
  thought about the same question, and weve
  discovered that they rarely refer to quality, in
  discussions about safety.
• Our research into the management and regulation
  of high-risk high reliability industries
  aviation, nuclear power and rail led us to
  think about the weakness in using the words
  interchangeably.

3
Brief history of efforts to understand the
concepts quality and safety

• 1930s to 60s
• The fundamentals of good medical care (Lee and
  Jones, 1933)
• Hazards of modern diagnosis and therapy (Barr,
  1955)
• Diseases of medical progress (Moser, 1956)
• The hazards of hospitalization (Schimmel, 1964)
• 2000
• To err is human, building a safer health system
• (Institute of Medicine report. Kohn, Corrigan and
  Donaldson)
• 2001
• Crossing the quality chasm a new system for the
  21st century (Committee on
• Quality of Health Care in America).

4
In health care.

• At present, the words quality and safety are
  often used interchangeably (e.g. media, journals,
  educational initiatives, etc)
• The risk is that people responsible for
  governing, managing and providing health care may
  think these concepts mean the same thing.

5
Why do we think this is a problem?

• Conflating the concepts may implicitly create the
  belief that if you enhance quality, you are
  automatically managing safety.
• We think this assumption is wrong.

6
Familiar examples

• Quality of food versus the safety of food
• Perfectly safe food that is unpalatable and
  unpleasantquality attributes
• Extremely tasty food that is contaminated
• Punctuality as a quality issue in the
  transportation sector
• If you are not on time you will lose a few
  customers, if you are not safe you will lose them
  all (Bob Dodd, Qantas)

7

• Even though people talk about improving safety,
  they may, in their directions and actions,
  actually be trying to do something to improve
  quality.
• Our central tenet is that in order to make
  progress on safety, it is important and necessary
  to separate the concepts, while not losing sight
  of the overlap.

8
Defining quality (Wikipedia)

• Quality refers to the distinctive characteristics
  or properties of a person, object, process or
  other thing. Such characteristics may enhance a
  subject's distinctiveness, or may denote some
  degree of achievement or excellence.
• When used in relation to people, the term may
  also signify a personal character or trait.
• When used in relation to management, the term may
  be easily defined as "reduction of variability"
  or "compliance with specifications".

9

• Quality can be used as a tool of measurement,
  like metric or Fahrenheit, as it is used to judge
  both subjects that are esteemed as credible and
  agreeable as "high quality" and subjects that are
  viewed as confusing, offensive, unhelpful, or
  incredible as "low quality." But quality is also
  used as a positive word, as in the sense of "this
  is a quality chair." Its antonym can be perceived
  as poorness, incredibility, unhelpfulness, and a
  variety of other words that reflect the concept
  of having low quality.
• ISO 9000 defines quality as "degree to which a
  set of inherent characteristics fulfils
  requirements".

10
Defining safety (Wikipedia)

• Safety is the condition of being protected
  against physical, social, spiritual, financial,
  political, emotional, occupational, psychological
  or other types or consequences of failure,
  damage, error, accidents, harm or any other
  event.
• Risk management is the art and science of
  identifying risks, determining how significant
  they are, deciding whether they are worth taking,
  and recommending measures to reduce or eliminate
  particular risks.

11
The key distinctions

• Quality is a characteristic of the
  system/organization
• something the system has
• Safety is something that the system/organization
  does
• its proactive
• Quality is an attribute that we try to enhance
• Creating safety is something we do to mitigate or
  prevent harm

12
Quality improvement

• Embraces a philosophy of meeting or exceeding
  customer expectations through the continuous
  improvement of the processes or producing a good
  or service
• Posits that the quality of goods and services
  depends foremost on the processes by which they
  are designed and delivered
• Focuses on understanding, controlling, and
  improving work processes rather than correcting
  problems after they occur.
• Assumes that uncontrolled variance in work
  processes is the primary case of quality problems.

13
If you enhance quality you are managing
safety

• Why do we think this premise is wrong?
• Its based on what we have learned from other
  risk- critical high-reliability industries about
  making progress on safety.

14
Unlikely events.surprise

• In large, complex, dynamic, event driven
  organizations one should expect that the
  unexpected will occur, that unimaginable
  interactions will develop, that accidents will
  happen
• Scott Sagan, The limits of safety, 1993

15

• We live in a world of hazardous technologies and
  some risk of catastrophic accidents is therefore
  ever present. We try to keep these risks as low
  as possible, yet in recent years, the names of
  many social and environmental tragedies have been
  etched into our memory
• Scott Sagan, The limits of safety, 1993

16
Accidents in technologically complex environments

• Chernobyl, the Exxon Valdez, the space shuttle
  Challenger, Bhopal, the Titanic and the Queen of
  the North
• Are accidents like these avoidable?
• Or, are these the predictable result of the
  widespread use of hazardous technologies and
  would they be addressed by quality improvement
  activity?

17
What creates safety and causes accidents in
complex organizations?

• Two major schools of thought
• High reliability theory
• Normal accident theory

18

• The ideas are rooted in the organizational theory
  literature
• Different understandings of how organizations
  work
• Different views on how best to analyze complex
  organizations
• Competing explanations
• Proponents of each school of thought focus
  attention on a specific set of factors that they
  believe contributes to or decreases safety

19
High reliability theory

• Optimistic view
• Extremely safe operations are possible, even
  with extremely hazardous technologies, if
  appropriate organizational design and management
  techniques are followed.
• Scott Sagan, The limits of safety, 1993

20
Normal accidents theory

• Pessimistic view
• Serious accidents with complex high technology
  systems are inevitable.
• Scott Sagan, The limits of safety, 1993

21
Contrasting views

• High reliability theory
• Accidents can be prevented through good
  organizational design and management
• Safety is the priority organizational objective
• Redundancy enhances safety duplication and
  overlap can make a reliable system out of
  unreliable parts
• Decentralized decision-making is needed to permit
  prompt and flexible field-level responses to
  surprises

• Normal accidents theory
• Accidents are inevitable in complex and tightly
  coupled systems.
• Safety is one of a number of competing
  objectives.
• Redundancy often causes accidents it increases
  interactive complexity and opaqueness and
  encourages risk-taking.
• Organizational contradiction decentralization is
  needed for complexity, but centralization is
  needed for tightly coupled systems.

22
Contrasting views

• Normal accidents theory
• A military model of intense discipline,
  socialization, and isolation is incompatible
  with democratic values.
• Organizations cannot train for unimagined, highly
  dangerous, or politically unpalatable operations.
  
• Denial of responsibility, faulty reporting, and
  reconstruction of history cripples learning
  efforts.

• High reliability theory
• A culture of reliability will enhance safety by
  encouraging uniform and appropriate responses by
  field-level operators.
• Continuous operations, training, and simulations
  can create and maintain high reliability
  operations.
• Trial and error learning from accidents can be
  effective, and can be supplemented by
  anticipation and simulations.

23
High reliability theory The organization is a
rational actor

• Organizations, properly designed and managed, can
  compensate for well-known human frailties
• High reliability hazardous organizations are
  rational ? highly formalized structures and
  are oriented toward the achievement of clear and
  consistent goals (i.e. reliable and safe
  operations)
• Richard Scott, Organizations Rational, natural
  and open systems, 1987

24
High reliability theory Organizational
characteristics and safety

• Leadership safety objectives
• The need for redundancy
• Decentralization, culture and continuity
• Organizational learning

25
Normal accident theoryThe organization is not a
rational actor

• Fits within the natural open systems tradition
  organizations actively pursue goals of narrow
  self-interest, e.g. security, survival, not just
  the official goals, such as profit, production or
  reliability.
• Organizations are seen as open i.e. constantly
  interacting with the outside environment, both
  influencing and being influenced by the broader
  social and political forces.
• Richard Scott, Organizations Rational, natural
  and open systems, 1987
• The garbage can model
• Cohen, March and Olsen, A garbage can model of
  organizational choice, 1986

26
Normal accidents theory Organizational
characteristics and safety

• Structure, politics and accidents
• Complex and linear interactions
• Tight and loose coupling

27
What are the implications for health care?

• Unlikely eventsadverse events can happen in
  what is thought of as an environment that is
  providing high quality care.
• e.g. transition care the quality of the
  discharge planning process may
• be fine, but the nature of transition itself
  creates the potential for
• unexpected events (that may threaten safety).
• Care may be considered high quality, but harm can
  still occur.
• Harm is an emergent characteristic of the system
  
• The dangerous accidents lie in the system, not
  in the components
• Charles Perrow, Normal accidents Living with
  high-risk technologies, 1984

28

• Creating quality involves ensuring an acceptable
  standard of care (hopefully, a predictable
  characteristicyou can guarantee quality).
  Quality is an attribute of a normally functioning
  system.
• Creating safety involves asking what if it
  anticipates what could go wrong (the
  unpredictable nature of safetyyou cannot
  guarantee safety). Safety is linked to the
  capacity of a system to handle surprise or
  instability.
• Creating safety lies within the realm of dealing
  with things which havent happened yet, whereas
  creating quality involves doing something to
  enhance an ongoing process.

29

• Quality focuses on the centre of distribution of
  care. Normal curve ? move the whole curve to the
  right.
• Safety focuses on the tail of the
  distributionyou are trying to truncate the tail.

30
The normal curve
31

• Different methods are used to investigate quality
  versus safety problems.
• This is another important reason to keep the
  concepts of quality and safety distinct.

32
Methods.guidelines, standards, patient
satisfaction, outcomes

• Quality compare characteristics/activities to
  evidence-based, and agreed upon, guidelines,
  standards measure patient satisfaction and
  monitor and evaluate outcomes

33
Methodsincidents, adverse events, hindsight
bias, and sensemaking

• Incidents/accidents incidents and accidents in
  complex organizations are usually signs of
  trouble deeper within the system however, a
  large portion of incidents and adverse events in
  health care are still attributed to human
  errorit is critical to understand why people did
  what they did, rather than judging them for doing
  what we now know (in retrospect) they should have
  done.
• Its challenging to reconstruct the human
  contribution to incidents the problem of
  hindsight bias.
• There are specific methods to mitigate the
  effects of hindsight bias.

34
Conclusions

• Quality and safety are distinct concepts.
• Quality is a characteristic of the systemyou
  enhance quality.
• Safety is a set of activities that actively
  identifies risks and harms with the goal of
  preventing incidents and accidents.
• Good quality is necessary, but not sufficient, to
  ensure safety.
• Safety can be best developed on a foundation of
  quality, but can exist as a system property on
  its own.
• You dont have a quality system without safety.

35

• Safety management systems actively seek hazards
  as a core function surveillance oriented,
  actively managing culture, monitoring it, and
  developing policies to encourage safety culture.
• The quality model can distort efforts at trying
  to achieve safety you lose focus on safety if
  you conflate it with quality
• Personal communication with Bob Dodd, Qantas