Wednesday, 15 March 2017

Safer Healthcare

I've just finished reading Safer Healthcare. For me, the main take-home message is the different kinds of safety that pertain to different situations. Vincent and Amalberti describe three different approaches to safety:
  • ultra-safe, avoiding risk, amenable to standardised practices and checklists. This applies to the areas of healthcare where it is possible to define (and follow) standardised procedures.
  • high-reliability, managing risks, which I understand as corresponding to "resilient" or "safety II" – empowering people within the system to learn and adapt. This seems to apply to a lot of healthcare, where the variabilities can't be eliminated, but can be managed.
  • ultra-adaptive, embracing risk. This relies on the skills and resilience of individuals. This applies to innovative techniques (the very first heart transplant, for example) where it really isn't possible to plan fully ahead of time because so much is unknown and it relies on the skills of the individual.
Image may contain: outdoorThe authors draw on the example of rock climbing. The safest forms of climbing (with a top-rope, which really does minimise the chances of hitting the ground from a fall) are in the first category; most climbing falls into the second: we manage risk by carefully following best practice while accepting that there are inherent risks; people more adventurous than me (and more skilled) push the boundaries of what is possible – both for themselves and for the community. But it is also possible to compromise safety, as graphically described by James McHaffie addressing Eve Lancashire whose attitude to safety worries him (see about half way through the post).

Vincent and Amalbeti's categorisation highlights why comparing healthcare with aviation in terms of safety is of limited value: commercial aviation is, in their terms, ultra-safe, with standardised procedures and a lot of barriers to risk; healthcare involves far too much variability to all be amenable to such an approach.

Another point Vincent and Amalberti make is that incidents / harm very often don't happen within one episode of care, but evolve over time. I am reminded of a similar point made in a very different context by Brown and Duguid, who described the way that photocopier engineers learn about their work (and the variability across machines and situations): the describe it as being like the "passage of the sun across the sky" – i.e., it's not really clear when it starts or end, or even exactly how it develops moment to moment. So many activities – and incidents – don't have a clear start and end. Possibly the main thing that distinguishes a reportable incident is that there is a point at which someone realises that something has gone wrong...

Sunday, 12 March 2017

Public health -- personal health

I've just re-read the Academy of Medical Sciences report "Improving the health of the public by 2040". It makes many insightful points, particularly about the need for multidisciplinary training to deliver future professionals who can work across disciplinary silos – whether within healthcare and medical disciplines or with other disciplines such as computing and other branches of engineering. Also, the likely importance of digital tools and "big data" in the future. It does, however, focus entirely on the population, apparently ignoring the fact that the population is made up of individuals, who each control their own health – at least to the extent that they can choose to comply (or adhere) with medical advice and can choose whether or not to share data about themselves. It seems to miss a big opportunity if we don't link the individual to the population because the health outcomes and practices of the population emerge from the individual behaviours of each person. Sure, the behaviours of individuals are shaped by population-level factors, but they aren't determined by them. It's surely time to link the individual and the population better.

This can be compared with the Wachter Review, which focused on the value of electronic health records and other digital technologies for delivering safer and more effective care. That review also highlighted the need for professionals with skills that cross information technologies and clinical expertise, but it also considers issues such as engagement and usability. It notes that "implementing health IT is one of the most complex adaptive changes in the history of healthcare". Without addressing the complexity (which is a consequence of the number of individuals, roles, organisations and cultures involved), it's going to be difficult to achieve population-level improvements – by 2040, or at any time.