What is Resilience Engineering and What Does it Mean for Patient Safety?
Hospitals and health systems are committed to the mission of patient safety, and the steady improvement in patient safety across the field has been encouraging. But a lingering question remains – can it be sustained? In this conversation, Oren Guttman, M.D., anesthesiologist and vice president of High Reliability & Patient Safety at Thomas Jefferson University, discusses the mindset of resilience engineering, the future of patient safety and the big questions this work reveals.
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00:00:00:14 - 00:00:37:28
Tom Haederle
It's been noted before that 1999's groundbreaking report, "To Err is Human - Building a Safer Health System" was, frankly, a punch in the gut to American health care. The Institute of Medicine's account of preventable deaths due to medical errors ignited today's sharpened focus on patient safety, now considered a core competency that drives everything we do. While patient safety has made great strides over the past 25 years, some caregivers worry it has come to a standstill.
00:00:38:01 - 00:01:03:20
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Every hospital and health system in America is committed to the mission of patient safety, and its measurable improvement has been encouraging. But can it be sustained? In today's podcast hosted by the AHA’s chief physician and executive, Dr. Chris DeRienzo, we explore the past and future journey of patient safety and grapple with the big questions:
00:01:03:25 - 00:01:10:18
Tom Haederle
Are we improving fast enough, and can the current reality of health care be improved? Here's Chris.
00:01:10:20 - 00:01:43:15
Chris DeRienzo, M.D.
Thank you, listeners, and welcome to this episode of our podcast. I'm Dr. Chris DeRienzo, AHA’s chief physician executive, and I am incredibly excited to bring a conversation to you all today that I've been looking forward to a long time. Because our guest is Dr. Oren Guttman, and he is a practicing anesthesiologist, the enterprise leader in safety and high reliability at Jefferson Health, in addition to several other titles that might actually take the full 15 minutes of our podcast together to get through because his leadership in the field is simply unparalleled.
00:01:43:23 - 00:01:58:27
Chris DeRienzo, M.D.
And we get to spend a little bit of time today talking about the journey that we've taken as a field around patient safety over the last 25 years, and where Oren and colleagues like him are leading us to go towards the future. Oren, thank you for joining us.
00:01:59:00 - 00:02:22:28
Oren Guttman, M.D.
Hey, Chris, thank you so much. Thank you for that overly charitable introduction. It's really a privilege and a pleasure to be here with you. And really just to reflect with you on patient safety. I think for most of us, you know, patient safety is really the mission driven piece. It's the core competency of really everything we do in quality and safety and health and equity access.
00:02:23:01 - 00:02:49:10
Oren Guttman, M.D.
I think we just need that moment of reflection on safety. And I'm just so excited that we get to do that today. I think it might be fair to start by saying that, many of us and I'm here giving voice to a growing chorus, kind of feel like the patient safety movement for all the good that it's done, has probably come to a little bit of a standstill.
00:02:49:13 - 00:03:19:22
Oren Guttman, M.D.
And, you know, if we if we were to say that differently, we're not improving fast enough. When we started this, we started in a world where, you know, the public really created an outcry an appropriate outcry over, over safety and the safety of our patients and our hospitals that do no harm focus. And they called our attention. And we used social systems, systems of individual accountability, like just culture systems like, you know, teamwork and team training.
00:03:19:24 - 00:04:01:14
Oren Guttman, M.D.
We looked to other safety industries like the airline industry, and we said, what are they doing to focus on their-quote unquote- mistakes? And they did a lot of resource management. They did a lot of simulation. But what we've kind of learned is that all of that, if we can wrap it up in the bubble of a culture of safety and some of those things being tactics that we use to create a culture of safety, if we're going to be honest and have some courage, we would be forced to the conclusion that they were really expensive, they were not sustainable, and the results they produced when they produced them were not uniformly produced and
00:04:01:14 - 00:04:02:28
Oren Guttman, M.D.
they didn't last.
00:04:03:01 - 00:04:26:13
Chris DeRienzo, M.D.
And when I reflect on what we may call sort of the first 25 years of the patient safety movement in, in American hospitals and health systems, and that was a fairly seminal report back in 1999 that, as you've indicated, really opened our eyes to, some opportunities that previously we were sort of blind to in, in American health care.
00:04:26:15 - 00:04:49:12
Chris DeRienzo, M.D.
And over the course of that 25 years, no question, we've made incredible strides across numerous axis within patient safety. And I think about in just our practice career, that when we were in medical school, that was the very first literature that was published around...you can actually reduce CLABSI and or eliminate CLABSI or central line infections.
00:04:49:15 - 00:05:18:25
Chris DeRienzo, M.D.
That was not a thing that that the folks who were teaching us in medical school thought about. And now, you know, 25 years hence, we have lots of great bundles of work around that. But what I'm hearing you say is all of that really built a foundation for now where we are today, which because we have built in a number of ways to drive safety improvements, we can now think slightly differently about, what are the next steps that we get to take?
00:05:18:27 - 00:05:49:26
Oren Guttman, M.D.
Yeah. Chris, thanks for really giving voice that way to this. I think that that's absolutely true. And I would invite us to consider, is there an opportunity for us to reflect on the sustainability and whether the current reality of care delivery would still be improved by those foundational tenants? And so I would point our attention to maybe the safety moment of the century, which was the Covid 19 pandemic.
00:05:49:28 - 00:05:56:29
Oren Guttman, M.D.
Health care is a complex, irreducibly complex system. We're not complicated. We're actually complex.
00:05:57:01 - 00:06:04:21
Chris DeRienzo, M.D.
Take us deeper on that, because I remember the first time you described that, I was trying to think in my head what is irreducibly complex actually mean?
00:06:04:24 - 00:06:53:12
Oren Guttman, M.D.
Complicated systems are systems where there are cause and effect relationships, where the realities of the processes are very linear. There's a good sense that things are knowable and you can break things down. It's a macroscopic view of the world. Complexity and particularly irreducibly complex systems, they're very much non-linear. The reality of how you would classify AI or the taxonomy of a irreducibly complex system has to do with the fact that pieces of the system are interacting in ways that are totally unpredictable, that risks in those systems have a probability of risk, and that they're additive in nonlinear ways, that even the barriers can actually introduce risk themselves.
00:06:53:14 - 00:07:07:13
Oren Guttman, M.D.
And, you know, in that regard, sometimes there aren't causes, there are probabilistic contributions. I'm reminded of our my time in pre-med work in quantum mechanics and thinking about Heisenberg's uncertainty principle.
00:07:07:13 - 00:07:10:12
Chris DeRienzo, M.D.
Oh, man, you're bringing me way back.
00:07:10:19 - 00:07:46:16
Oren Guttman, M.D.
You know, I thought I'd never have to remember that again. But the reality is, is that, you know, the same events that interact today and produce success can interact tomorrow and produce failure. I think part of where we've maybe gone a little bit the wrong way is that we've focused a lot on the human contribution to safety. So again, thinking that, you know, we would culture our way to safe, that if we were able to have just better functional teams with higher teamwork scores, then ultimately, you know, we would be able to really become safer as an industry
00:07:46:16 - 00:08:09:03
Oren Guttman, M.D.
and that's probably, I would say, arguably not true. The reason is, is because, remember and when the patient safety movement started, you know, we had about 10% of health systems with an EMR. Today it's ubiquitous. The complexity of technology and how it interfaces with safety. And, you know, the work that we do is socio-technical work.
00:08:09:03 - 00:08:34:26
Oren Guttman, M.D.
You cannot move left or right in health care delivery without being engaged with tools and technology, software and hardware workflows and processes. And we don't have design moments for those things. We generally kind of get those things from industry. We put them into our system. We don't do prospective risk assessments on how we incorporate them, and then we sort of work through that.
00:08:35:03 - 00:08:46:06
Oren Guttman, M.D.
And when things don't go well, we don't redesign value streams with the right lenses. And this is where I would point to maybe a further opportunity for us.
00:08:46:08 - 00:09:09:18
Chris DeRienzo, M.D.
You're making me think back to in the old days of aviation, there was both a cultural problem. So they had to build a different culture within those cockpits. But there was also a cockpit problem that the system in which the people operated was not optimized. And I think in health care, we have spent a lot of time and energy
00:09:09:18 - 00:09:38:29
Chris DeRienzo, M.D.
and you've written extensively on this, on trying to improve the relational culture. And I think what we're what we've come to appreciate is that is necessary and insufficient for driving the kinds of transformational patient safety outcomes that we know every hospital is striving to achieve here in the 21st century. And perhaps this is a good time to talk our listeners through, you know, we hit on the Heisenberg uncertainty principle there for a moment.
00:09:38:29 - 00:10:08:12
Chris DeRienzo, M.D.
And so for those of you who weren't forced to take physics in premed, you know that that is a you can't actually measure certain particles in physics without affecting the measurement that you're taking. Even more fascinating concept to me in this construct is, the way that I've heard you talk through the difference between reliability or, again, we have spent a lot of energy building highly reliable organizations and adaptive resiliency.
00:10:08:14 - 00:10:20:29
Chris DeRienzo, M.D.
But let's go there for a moment, because I think our listeners would really benefit from hearing how you've taken that concept, from frankly other fields and are now applying it in health care.
00:10:21:01 - 00:10:57:16
Oren Guttman, M.D.
I would call our listeners attention to this idea, which has been really transformational for Jefferson Health. I think that for a long time we have focused on high reliability organizing as a health care, as a framework to get to safe, right? We want to have highly reliable, we want six Sigma failure rates. And what's really interesting, actually, is when you look at the other industries from which these studies are originated from and how we are able to try and adapt those concepts in high reliability organizing into health care,
00:10:57:18 - 00:11:26:21
Oren Guttman, M.D.
there's some really interesting observations, right, about trying to make processes more reliable. The challenge is that in a lot of those other organizations - and industries, I should say - there's a lot more knowable about the inputs. There's a lot of more control over some of the foundational elements that are then being focused on, with a preoccupation for failure and a reluctance to simplify and a deference to expertise, etc..
00:11:26:23 - 00:11:56:29
Oren Guttman, M.D.
Health care is orders of magnitude more complex than a lot of those other industries. And so in that space, you know, we recognize the resilience engineering world offers us something, I think, a lot more pragmatic. And it's basically, in a nutshell, this idea that not every error is failure and that we have to almost have a predictable unpredictability, that things are actually going to have errors all the time.
00:11:57:01 - 00:12:22:09
Oren Guttman, M.D.
And rather than try and error proof a process - work as imagined would be that we would actually error proof a process perfectly - it's a more honest view of what happens at the sharp end of care. At the sharp end of care is that errors happen all the time, but better organizations are able to detect those errors, and they're able to rescue those errors from turning into failure.
00:12:22:12 - 00:12:48:29
Oren Guttman, M.D.
Dr. Amrika Ferrie published a really nice article in New England Journal about 15 years ago or so. Don't quote me on the exact time, but it was basically, a review of the surgical administrative claims data where they had, you know, the same complication rates between hospitals, but they actually had different outcomes. And, you know, he attributed it through some abstraction work that they did to actually the ability to actually detect errors early on and rescue them from turning into failure.
00:12:49:01 - 00:13:09:10
Oren Guttman, M.D.
That concept is a resiliency engineering idea. We have to have better mechanisms in place to detect errors and actually be able to rescue them from turning into failure when failures already happened, at least contain them. We need a different model in health care. We have to have the ability at the unit level to detect errors that have not yet become failures.
00:13:09:10 - 00:13:26:15
Oren Guttman, M.D.
I'll give you just a demonstrated example. Think about CLABSIs for a minute, right? Classically, how have we thought about CLABSIs? We thought about a bundle. We thought about not putting into many lines. We've thought about ensuring that, you know, we don't put in femoral lines, for instance. And when we do it, when we put them in, we have to put them in sterile.
00:13:26:18 - 00:13:48:24
Oren Guttman, M.D.
And there are various other things that we put in bundles. A resiliency engineering approach to this looks a little different. And it looks like, you know, we don't want to put in femoral lines. But the reality is, is that people are going to come into the emergency room all the time. They're going to be emergencies. They're not going to have time to drop in sterile necklines, and they're going to put in femoral lines.
00:13:48:27 - 00:14:10:05
Oren Guttman, M.D.
And what we need to do is be able to detect those things at a unit level and get them exchanged out really, really quickly. Another good example. You know, we expect our CHG bathing to keep our lines clean to happen every day. We want reliable processes to make sure that we do that reliably. We want to have reliable ways of changing dressings.
00:14:10:07 - 00:14:30:16
Oren Guttman, M.D.
The challenges is that care at the unit level is not always perfectly reliable. And that's the work as it's actually done. On any given day, you know, there could be a call on the unit, there could be students observing that are creating distraction, you know, necessary learners. But you know, it can be a cognitive overload situation. We could have new orientees coming on, too.
00:14:30:17 - 00:14:58:27
Oren Guttman, M.D.
It could be a shift change. There could be team changes. And all of those things together create stresses in the system that may in fact create the error of the 12-hour shift went by, and we did not, for good reasons, potentially have an event called CHC math. But if we create a process at shift change where we have a detectability of that error and we can get it reassigned, we can rescue that in a reliable way.
00:14:58:29 - 00:15:11:23
Oren Guttman, M.D.
We will then prevent failure. Resiliency engineering is constantly looking to try to find errors and actually prevent them from progressing into failure.
00:15:11:25 - 00:15:32:04
Chris DeRienzo, M.D.
If I am listening in from, a hospital, say not part of a larger system, hearing you describe this concept of resilience and saying, great. You know, I, I want to both be able to continue the work that we're doing. But I also want to focus some energy now on taking the first steps towards becoming a more resilient.
00:15:32:04 - 00:15:41:04
Chris DeRienzo, M.D.
And, as you described it, a more adaptively resilient organization. What is your guidance to that quality and safety leader? What is step one?
00:15:41:06 - 00:16:05:06
Oren Guttman, M.D.
I'm going to give you a top three. I'm going to break down adaptive resiliency into human resiliency, process resiliency, and training resiliency I think very pragmatically, our humans are sources of resiliency in our system. One of the most misunderstood ideas that I think we've sort of lived with in the patient safety movement is this idea of a human error.
00:16:05:09 - 00:16:29:22
Oren Guttman, M.D.
The truth of the matter is, is that we have operator errors, because we have a constant focus on thinking that human capability capacity failed. And so it was a human error. But we failed to ask the question about how the system facilitated and contributed to those errors. So here's a very pragmatic approach to increase your human resiliency: turnaround your Great Catch program.
00:16:29:24 - 00:16:52:18
Oren Guttman, M.D.
We actually took the vantage point of saying, we're going to ask the people in our system who hold themselves to really high professional standards, to tell us anytime they see a broken process, broken technology, broken tools, or those tools are not supporting the people who use them in the way they need to be supported, and actually report that when you do, we'll give you a Great Catch award.
00:16:52:20 - 00:17:14:29
Oren Guttman, M.D.
We're not going to give you a great catch award anymore for just getting in the way of harm. We actually segmented that off for extraordinary human vigilance and call that a Great Save Award. That's important. We want to honor people for that contribution. But what that doesn't do is ask the harder question of why did it take more human vigilance to actually get in the way of harm?
00:17:15:01 - 00:17:40:26
Oren Guttman, M.D.
What happened all the way upstream of these events? What processes and systems in the sociotechnical system did not facilitate the best care experience for the patient and their family? What can we do there? And so we actually completely changed around Great Catch reporting and started honoring when people gave us system failures that we then put through a process of fixing and shared back, you know, really the highlights of those of those fixes.
00:17:40:26 - 00:18:12:00
Oren Guttman, M.D.
And I'll tell you what happens. When you do that, people report more harm because you're fixing stuff that's really been difficult for them. See, the truth is, is that they've been making all these little micro adjustments all the way around. An old frame of safety called safety one, we used to call that normalization of deviance. The reality is, the safety sciences tell us is that actually those folks are making micro adaptations on a daily basis to actually not let the system catastrophically fail.
00:18:12:02 - 00:18:34:03
Oren Guttman, M.D.
And if they're elevating that to us and we can actually focus on system improvement, then we'll actually make our humans much more resilient. And they're really great sources of resiliency there. So that's an example of human resiliency. I would say for process resiliency I think your shift changes, you know, creating a focus on ensuring, you know, just old school paper and pencil, right?
00:18:34:10 - 00:19:01:06
Oren Guttman, M.D.
Making sure that a part of the handoff is any omission errors that have occurred over the shift and getting them reassigned as it relates to safety critical processes. We happen to have a dashboard that does this, but frankly, it's just as easy to just make sure that you're centralizing that information on a shift report that would be overseen, for instance, by a charge nurse, so a lot of success with that.
00:19:01:06 - 00:19:45:10
Oren Guttman, M.D.
And, you know, finally, I would just invite us to thinking about training resiliency. You know, we train task oriented things like bag mask ventilation. And we trace, you know, we train adaptive things like handoffs. What's really important in training classically is we've taught it from an error avoidance perspective. Here's how you do this correctly. What's super important is in all of our training modules, a resiliency approach would invite us to include at every step how that step could fail and include that in the actual training, because by priming people and helping them understand the errors that could lead to failure, and then also teaching them how you rescue the error from the coming failure,
00:19:45:12 - 00:20:09:16
Oren Guttman, M.D.
you make that process more resilient. And so that's called an EMT training model, error management theory training model. And you know, it's really not complicated to do. We've done this with iPhones. Just straight simple videos. We put it even in our S-bars and show examples of, you know, this is how you don't want to send test tubes down, you know, various you know, forms of misapplied labels, for instance.
00:20:09:16 - 00:20:14:17
Oren Guttman, M.D.
Right? These are that we sensitize people to errors so they can rescue them before they send them down incorrectly.
00:20:14:20 - 00:20:40:07
Chris DeRienzo, M.D.
Such practical advice, and I was rounding with a team in a hospital earlier this morning. And this is exactly the conversation we're having there. Step one is trying to optimize their hand off because they knew they were some opportunities to ensure we had some structured communication and got that part right. And then step two is how do you make the handoff process itself resilient to what inevitably happens in health care, which is all of a sudden there's a code in room 12.
00:20:40:07 - 00:21:02:27
Chris DeRienzo, M.D.
And so the handoff is going to get interrupted. How do we make sure that the end outcome at the transference of all the right information to the next person gets there, recognizing that it's not going to be perfect 100% of the time, or if you are leading the field in this space. This is one of the longer podcasts I've gotten to do, and I could go another three hours on this topic.
00:21:03:00 - 00:21:31:24
Chris DeRienzo, M.D.
We are so grateful that you spent the time with us. And to listeners, thank you all for joining us on the podcast today. If your organization is not yet signed up with AHA's Patient Safety Initiative, I highly encourage you to join us. And by becoming a member, you not only gain access to a wealth of resources and a collaborative opportunities, but you also get access to a community of folks just like Dr. Guttman, who are lifting up their innovations.
00:21:31:24 - 00:21:48:25
Chris DeRienzo, M.D.
And this kind of innovation is one that I am confident over the next 25 years, patient safety leadership, we are only going to see become exponentially more important. We thank you all for listening and hope you continue to stay engaged. Stay tuned for more episodes and be well.
00:21:48:27 - 00:21:57:09
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.