Healthcare in the United States is not safe. One in four patients admitted to a hospital will suffer some form of unintended harm, one in six will get an infection and about 500 a day will die of a preventable error. Healthcare is considered the most dangerous occupation - more dangerous than coal mining or building skyscrapers.
With so many people getting hurt, many healthcare leaders are trying to import effective safety strategies from other industries. A conference hosted by Johns Hopkins' Armstrong Institute for Patient Safety and Quality explored these ideas. Led by Armstrong's director, MacArthur "Genius Grant" awardee Dr. Peter Pronovost, the conference examined examples of "high reliability" strategies used in manufacturing, transportation and other industries.
One sector Pronovost thinks worthy of particular attention is nuclear power, an industry where -- thank heavens -- safety is king.
In the wake of the 1986 Chernobyl accident, the leaders of every commercial nuclear reactor across the globe created the World Association of Nuclear Operators (WANO), with the goal of achieving industry-wide excellence. WANO sends teams of peer reviewers to observe operations and ensure safety at every commercial nuclear power plant in the world.
"We like to say the entire industry is held hostage to each other," explained Riccardo Chiarelli, WANO senior program manager. "If an accident happens in a nuclear power plant in Japan, the nuclear industry in the U.S. and everywhere else will be impacted. If we want to succeed as an industry, we need to make sure everybody is at the highest level of excellence. We cannot afford low performance anywhere in the world."
Chiarelli was recently asked to speak at a forum of the National Academy of Sciences on future directions for safer patient care, and gave a webinar February 25 at the Imperial College of London, on how lessons learned from the nuclear industry can be applied to patient safety. What follows is a summary of a conversation I had with Chiarelli about the principles of nuclear safety that might be applied to healthcare.
1. Leadership and accountability are inextricably linked.
Nuclear operators put emphasis on leadership at every level, insisting that leadership "treat safety as the highest priority." This is a quality we look for in health systems too. But Chiarelli ups the ante: leadership must take responsibility. When something goes wrong, Chiarelli says, it is necessary to examine the underlying factors that led to the error and be accountable for what happened.
Chiarelli uses "responsibility" to describe what I would consider an alternate form of "just culture"-- one in which the individual mistake-maker is not necessarily pointed to, but the leader is. "At the end of the day, the station director is responsible for everything," says Chiarelli.
2. Focus on outcomes.
WANO's reviewers do not arrive at a plant with an unending list of processes they must check for in every department, as government surveyors and accreditation teams in healthcare often do. Reviewers work from a book called Performance Objectives and Criteria.
"You can organize your plant as you will, according to your culture, your language, your people, as long as it gets results. There is a requirement that you put safety as a priority and train your people to the highest possible level. It is our only requirement. We don't check systems and processes," Chiarelli explains.
Healthcare's heavy focus on checking process boxes leads to burnout, as dedicated clinicians spend enormous amounts of time complying with tasks and less time connecting their work directly to the health of the patient. For the nuclear industry, however, the safest practices focus our eyes on our common prize.
3. When workers speak, leadership listens.
Nuclear operators agree on a set of principles for the culture of safety within a power plant. The peer reviewers in particular check for two aspects. First, "every individual should be free to raise concerns and problems without fear of retaliation." This fear of speaking up was considered one of the root causes of the Chernobyl accident. It is also a well-researched issue for safety in hospitals.
The second key principle is that when employees report problems, those problems are promptly addressed and corrected. At inspections, reviewers check if employees reported problems through the system database, and if they aren't reporting, they ask them why not.
"Everything is logged. If I find a door which is broken I log it. A spurious alarm, I log it," says Chiarelli. "If we find this is a big issue, a repeating issue, we would raise this as a main issue in our report and share it with the station manager."
It is self-evident that even relatively small problems should be reported and fixed. But watch how eyebrows raise when this notion is applied in a healthcare setting. At Chiarelli's session at the National Academy of Sciences meeting, healthcare insiders gave the example of the cacophony of alarms and buzzers that sound off constantly in the average ICU. Many of these are false alarms, and nurses and physicians must learn to interpret which one signals the true emergency.
Chiarelli said that in his industry, each and every time a false alarm went off the worker is expected to report it, and leadership is held accountable for quick correction. Many clinicians find it difficult to imagine reporting each false ICU alert, and would think of it as a time-consuming and fruitless exercise. But Chiarelli points out that the sense of fruitlessness is itself a safety problem. When employees don't feel that leadership will respond, the problems fester and leadership sends an implicit message that safety is not the priority.
4. There are no isolated incidents.
For the nuclear industry, every incident, whether it's a miscommunication among department heads (one of the most common problems) or an error, requires analysis to explain how the system could have prevented it. Leadership is brought in to discuss the system failures and how to fix them.
In healthcare, system failures and miscommunications are so common that only a small portion of them are ever brought to the attention of leadership or made the subject of a root cause analysis. Yet in many respects even minor errors hold the key to serious harms.
5. Aspire to be perfect.
Every country has its own set of regulations governing nuclear operations, and some are stricter than others. Chiarelli says that is appropriate, but WANO seeks to push the industry far beyond compliance with basic standards toward top-performing excellence. "The objective is for everybody to succeed. WANO is a sort of self-regulator, so we get the highest level of safety as an industry."
Hospitals in the U.S. are often focused on compliance with regulations from government and payers. Only a subset of hospitals set aggressive goals for excellence. A handful aim to get to zero infections or accidents.
Chiarelli suggests starting with this question: "What would you expect from the perfect hospital?" Many hospital leaders will scoff that the question itself is outlandish. But instead of cynicism, many healthcare leaders like Pronovost and his colleagues find inspiration in venturing in the land of the outlandish. That means looking far and wide for real solutions, not settling for less than the best and traveling throughout the world and beyond the healthcare industry to seek answers.