42 lines
8.9 KiB
Markdown
42 lines
8.9 KiB
Markdown
# The Problem With Nonpunitive Safety Culture
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- **期号**: SRE Weekly Issue #380（2023-07-09）
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- **作者**: Robert Poston MD
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- **链接**: https://robpostonblog.wordpress.com/2023/07/04/the-problem-with-nonpunitive-safety-culture/
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## 简介
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In a blameless culture without consequences, what’s the incentive for learning to make the system more reliable? This is an incredibly thought-provoking article and I’m still not sure how I feel about it.
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## 正文
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It is widely accepted nowadays that punishment for making errors is the greatest impediment to safety in health care. This was not always the prevailing view. The first effort to improve the safety of surgery can be traced back 3,800 years to the Babylonian Code of Hammurabi: “If a surgeon performs a major operation and caused the death of this man, they shall cut off his hands.”(1) This code emphasized, in the strongest way possible, what is at stake. S[urgeons without hands] and teams that support them are never again able to perform operations. This punishment, excessive by today’s standards, was a potent method of quality assurance. Teams agreed to work under these conditions only when fully committed to the survival of their patient. No bond of trust was ever stronger than between a patient and the Babylonian surgical team. They literally had “[skin in the game]”.
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Perhaps it is a coincidence that punishments are now milder and modern teams and their hospitals have lost their fervor over patient safety. In order to avoid sanctions from regulatory agencies, insurance companies, or the public, hospitals faithfully focus on metrics of safety performance defined as “core measures”. (2) Striving to improve scores on these metrics often comes at the expense of things that would actually improve safety (3). Every day, patients hospitalized at facilities with outstanding safety metrics continue to be harmed by preventable errors such as administering the wrong medication, by decisions based on incomplete information, or by forgetting to do important tasks. Making mistakes that elude measurement by any metric is inevitable[—]that is not the tragedy. The problem is there is usually no mechanism in place to learn from such mistakes, so they keep happening. According to expert analyses, the risk of preventable harm is as high in US hospitals now as when this issue was first brought to attention in 1999 (4).
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The lack of progress in patient safety is not the fault of hospital administrators. Managers cannot impose a passion to learn from mistakes “top-down” or dictate it by decree. A truly safe environment for patients occurs when front line staff feel as if their hands will be cut off if it doesn’t happen. That type of emotional connection comes from the bottom-up. Safety in hazardous fields is intrinsically motivating for those who understand the stakes, particularly those in jobs hazardous to their own survival such as aviation, nuclear power and military special forces. They have cultures that are so zealous about safety, they are characterized as “high-reliability organizations (HRO).”
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It is a pragmatic fact for any skilled worker, even one employed at an HRO, that political and economic considerations must be tactfully navigated in order to be effective. A classic example is the need to overcome management’s perception of safety and profits as a zero sum game (5). An HRO gets around this by only hiring those with an intrinsic, religious zeal for safety, even at a manager position. These organizations recognize that safety throughout the ranks is often the only thing that stops a plane crash, plant melt down or failed mission that might have otherwise succeeded–fates far more punishing than losing a hand[.] Harsh, ever-present personal risks have a way of keeping politics in perspective. Politics and finance mean nothing if you and/or a team member die on the job. If you work at an HRO and your best friend or beloved boss does something unsafe, you cast aside other considerations and call out the transgression. Both of you welcome this assertive act, regardless of each other’s rank or position, because you trust the problem to be addressed and corrected immediately, potentially averting a future catastrophe. In stark contrast, hospitals do not face the same harsh accountability to its safety results. Perhaps it is not a coincidence that speaking up is now far less common. In its place, economic pressures sneak in that force us to do too many things at once. Political pressures silence our voices, lest we become labeled as disruptive to hospital operations. When you dare speak up, safety problems often remain uncorrected. Workers and managers at hospitals are not motivated by the same harsh risk of dying on the job as for other HRO’s. After all, healthcare is hazardous, but only patients face the risks. Managers, doctors and staff don’t die on the job, leaving them with no “[skin in the game]”, willfully blind to how they might work together to keep patients safe.
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Surgeons didn’t die on the job 3,800 years ago but faced an equally harsh punishment because that drove iron-clad commitment to results. Surgeons today recommit to these same excellent results by being proactive and deliberate in their efforts to build high-performance teams. Such teams staffed by members skilled in excellent and assertive communication don’t happen by accident. They are forged by regular debrief meetings outside of the OR designed to reflect on things that went well, hold each other accountable for things that didn’t and make necessary improvements. I’ve served as the moderator of these debriefings with my surgical teams for two decades. As the lead surgeon, I got critical feedback from my team that has at times been hard for me to hear, but I always appreciate it; hospital culture makes it just as hard to give tough feedback as it is to receive it. Everyone participating in an open discussion must chop off a bit of their ego, if not their hands, to improve our self-awareness and hold ourselves accountable.
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It is an immense challenge to lead an effective debrief. On one hand, the moderator is a fallible human being and has a moral duty to forgive mistakes. On the other hand, that duty must not be confused with meek toleration of wrongs. As Wachter and Pronovost have said, “unidimensional focus on a blame-free culture carries its own safety risks” (7). Blame is an appropriate tool for those wrongdoers that refuse to accept responsibility. Without it, other teammates can become cynical about safety, which harms overall performance and ultimately patients. Failing to blame is also disrespectful. It sends the implicit message that the underperformer is too incompetent to improve and steals away their chance to apologize, be forgiven and mature as a teammate.
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Debriefs are a small investment with big rewards but remain a remarkably uncommon aspect of surgical practice (6). One big reason is that they are uncomfortable. Despite best efforts to strike the right balance between no blame and holding each other accountable, hearing negative feedback about your performance while sitting among peers often feels like punishment. My tongue in cheek response to this concern is a saying often attributed to US Naval officers: “beatings will continue until morale improves”. This makes the point that a debrief only feels like a beating because it is unusual, not because it is. It takes humility to stick with the process long enough to become comfortable with the uncomfortable. When that happens, morale improves because we are appropriately honoring the trust that patients place in us.
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1. Halwani, T., & Takrouri, M. (2006). Medical laws and ethics of Babylon as read in Hammurabi’s code (History). *The Internet Journal of Law, Healthcare and Ethics*, *4*(2), 1-8.
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2. Bratzler, D. W., & Hunt, D. R. (2006). The surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery. *Clinical infectious diseases*, *43*(3), 322-330.
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3. Harris, M., & Tayler, B. (2019). Don’t let metrics undermine your business: an obsession with the numbers can sink your strategy. *Harvard Business Review*, *97*(5), 62-70.
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4. Catalyst, N. E. J. M. (2023). Lessons from Health Care Leaders: Rethinking and Reinvesting in Patient Safety. *NEJM Catalyst Innovations in Care Delivery*, *4*(2).
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5. Caskey, J., & Ozel, N. B. (2017). Earnings expectations and employee safety. Journal of accounting and economics, 63(1), 121-141.
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6. Brindle ME, Henrich N, Foster A, Marks S, Rose M, Welsh R, Berry W. Implementation of surgical debriefing programs in large health systems: an exploratory qualitative analysis. BMC Health Serv Res. 2018 Mar 27;18(1):210. doi: 10.1186/s12913-018-3003-3.
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7. Wachter RM, Pronovost PJ. Balancing “no blame” with accountability in patient safety. N Engl J Med. 2009 Oct 1;361(14):1401-6. doi: 10.1056/NEJMsb0903885.
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## One thought on “THE PROBLEM WITH NONPUNITIVE SAFETY CULTURE”
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