By Carol Haraden, Vice President for Patient Safety at the Institute for Healthcare Improvement (Boston, Massachusetts, USA), and Allan Frankel, Director of Patient Safety at Partners HealthCare System (Boston, Massachusetts, USA).
Originally published in Modern Healthcare January 5, 2004.
The report by the Columbia Accident Investigation Board on the causes of the space shuttle tragedy offers lessons that extend far beyond NASA. The healthcare industry, for one, has much to learn from it about patient safety.
The Feb. 1, 2003, Columbia disaster reflected change that had taken place gradually at NASA. In its early decades, the agency was a model of an effective safety — first organizational culture. Even though there were time pressures to meet specific goals, the pace of advancement was based on the safe development of new ideas.
But the mandate of NASA changed as our nation became less enamored with space exploration and more troubled by rising costs. NASA switched to a "value proposition" business model, with expectations of reasonable cost and real productivity. The commitment to safety was thereby diluted.
The same pressures for cost-effectiveness have caused healthcare organizations to deny safety the high priority that it deserves. The Institute of Medicine, our nation's most respected adviser on medical science, predicts that at least 100 patients die every day in U.S. hospitals — not because of their diseases but because of injuries from their care.
Just as at NASA, those deaths are typically not the result of bad people. On the contrary, they generally involve good people doing their best in complex systems. It's the systems that need to be refined, and at least four major lessons for healthcare emerge from the shuttle accident report.
First, when NASA was the model of a safety-first organizational culture, it was characterized by a preoccupation with avoiding failure, a deference to expertise wherever it was found, oversight by someone with safety as a focus, a readiness to adapt and a reluctance to simplify explanations. Those characteristics, which NASA must now regain, should be the hallmarks of healthcare as well.
NASA developed its initial safety culture through the strong leadership of early rocket pioneer Werner von Braun, and healthcare must now promote safety-based leadership, too. An effective tool — developed by the Institute for Healthcare Improvement, piloted at Brigham and Women's Hospital in Boston, and now being tested in many hospitals around the country — is the patient safety leadership "WalkRound." This involves the top executives in each hospital walking around the facilities with senior medical and nursing staff at least once a week to evaluate ways in which the hospital environment could undermine safe care and to determine what to do about them.
Second, the shuttle accident report is replete with descriptions of situations in which managers did not hear the concerns of engineers and other experts. Similarly, the hierarchy in healthcare discourages employees from voicing concerns about potential dangers. Healthcare has far more and diverse stakeholders than NASA, and inadequate communication is the norm. Nurses have endured this problem for ages, and it accounts in part for why we have a national nursing shortage.
A Kaiser Permanente hospital in Orange County, Calif., has improved patient safety in its operating rooms by implementing safety briefings before procedures. These briefings, at which all members of the surgical team share information and concerns regarding possible safety issues, have resulted in marked improvement in staff perceptions of safety and teamwork and also are associated with decreases in case turnover time and improvements in nursing staff retention.
Third, ineffective teamwork at NASA was rampant. The report recommends retraining in teamwork skills — a major need in healthcare as well. A recent study conducted by Johns Hopkins Hospital in Baltimore, using a concept developed by the Institute for Healthcare Improvement, found that patients in intensive care improve faster if doctors and nurses and the entire care team together set specific daily goals for each patient's care. This required that everyone involved in treatment — doctors, nurses, pharmacists and others-go on rounds together, visiting each patient. Improved teamwork thereby led to enhanced patient care and shortened stays in the intensive-care unit.
Fourth, the shuttle accident report concludes that no specific individual was at fault, but many individuals were influenced by the culture of the organization as a whole. The report recommends that one way of shaping a better culture is to have an independent safety officer with "line authority over all levels of safety oversight." The same should be true in healthcare, where safety, rather than being elevated to its appropriate level of authority, is more likely to be combined with other concerns that have the effect of watering it down.
Complex systems — at NASA or in healthcare — are intrinsically risky and inevitably fail in many cases. The challenge in healthcare is to reduce the number of failures as much as possible and to catch the rest before they adversely affect patients. The shuttle accident report has provided a detailed road map to guide us toward greater safety. It should be applied with determination-not only to space exploration but also to the healthcare systems that support us all.
