Part 6 is about systems thinking and patient safety. We have to ask ourselves, what do we mean when we talk about a system or a complex system? A system is where there are more than two interacting parts. A complex system is where there are so many parts that it's impossible to predict what's going to happen. And healthcare is a complex system at this point. We have to have interest in simplification, and the Institute of Medicine has observed that in healthcare there are too few interests and policies that lead to simplification. We have to recognize that most healthcare will be delivered in systems-based care in the future. And we have to continue to think about how we can use systems to improve the safety of our patients. Now, there are many different systems. Those of us who work in office practices, ambulatory care centers, and other settings all are working within a system, whether it's specifically identified as one or not. We involved in quality improvement have to think about what in our system can be improved. As you can think, as you can see, there are many other systems that are involved in a hospital setting, not just the physicians. In a hospital or in any system, the services are interacting with each other. But how do they interact? It's important for those of us involved in patient care to think about how to make the systems work better with each other in ways that are predictable, simplified, and lead to better patient care. Thinking about, as we mentioned before, the Swiss cheese model is helpful in this setting to think about the various slices of Swiss cheese that may represent systems, barriers, or defenses to protect patients from harm. There are some cases where errors may occur and be stopped and not go any further. Those are called near misses. Near misses, from the perspective of continuous quality improvement, are as important as errors that lead to patient harm. The fact that an error got to that point, regardless of whether it touched the patient, is important information that the system can use and should use as freebies, so to speak, to help the system improve itself. It's important not to lapse into a blame and shame culture in one's hospital. That's antithetical to the system's view as well as the human factor's view. Now laziness or sloppiness might be blameworthy. Violations are certainly blameworthy, but we don't necessarily see that as much as we see the risk for errors from poor processes and inadequate simplification. It's rare that there's just one cause to an adverse event, and that's the attitude that we have to take as we look at improving our systems of care. Healthcare systems should strive to become high-reliability organizations. These would be enterprises where their functioning does not get affected by new or novel or unanticipated situations that might affect it. There should be an interest in failure-free performance. As we discussed before, aviation and nuclear power and the military are certainly enterprises where there is no tolerance for failure. A good healthcare system that is interested in systems-based care has a focus on functioning in a failure-free manner, with a preoccupation to potential failures, a commitment to resilience, a sensitivity to operations, meaning the things that happen at every scintilla level, and a culture of safety. A workaround is a situation where when an error has occurred or when a process is not working right, a quick fix is made. That quick fix might not always be the best solution, and in fact if a workaround is accepted, that's a sign that the system is not working, that somehow the system is not working enough to pay attention to what could be the best way to fix the problem. Improved education and policies would be the best way, rather than a quick workaround. We also have to think about the many systems in which healthcare is delivered. There is the experience of the patient, there is experience in what is called the microsystem and the macrosystem, as well as finally the physical environment and the policies and regulations in which the setting works. Systems in healthcare that can be addressed include many different things. The administration of medications, the appearance of medications, the conveyance of information from the laboratory, diagnostic errors, correct site when we're talking about procedures, or healthcare-associated infections. All of these are systems that can be addressed. We can also think about examples where policies and rules can be harmful. For example, one example might include the prohibition of co-teams or the barriers of co-teams to get on to an inpatient psychiatric unit that's locked. Another example of failure through policies would be where sharps were not collected from previously suicidal patients. Error reduction spans a continuum within the system. It can include forcing function into tools or procedures, it can include the standardization of work, or it can include the changing of clinician behavior or attitudes. All these are different ways in which error reduction can occur through the system, thinking about different levels of the system. Another important point is that the system as a whole needs to be able to gather information about what is happening. Leadership needs to be sensitive to operations, meaning they are aware of what's happening at all levels of the organization. Systems also need to rely on reporting, not just by the clinicians, but to have systems of reporting, whether it's through incident reporting or reporting of sentinel events to external organizations, such as the Joint Commission. When a sentinel event has occurred, or when other events have occurred, a root cause analysis should be performed, and that should be able to lead to concerns, as they exist throughout the system, and the ways in which those problems may have led to the adverse event. And so, thinking about the different manners in which reviews occur of physicians, of the hospital plant, of the hospital functioning, are all important in maintaining patient safety and quality improvement. For those individuals involved in systems, one needs to know how to report risks or hazards, know how to keep good documentation, and where to get help when there are problems. One other component that's part of the systems-based care is the new introduction of the concept of patient-centered care. Healthcare has always been slightly evolving, and recently there's been movement away from the disease-centered model towards the patient-centered model. The patient-centered model really puts the patient in the center of consideration of choices and information flow. And as we've discussed already here, inclusion of the patient as part of the team is a good part of patient safety, and a good part of this new systems-based care that's evolving.

systems thinking

patient safety

healthcare systems

Swiss cheese model

high-reliability organizations