High Reliability in Healthcare: Trust, Reliance and Listening to the People in the White Space

The fourth characteristic of high reliability organizations is Deference to Expertise – leaders listening to, and seeking advice from, frontline staff who know how processes really work and where risks arise. If you want to understand how the machine works you should ask the nuts and bolts and gears because without them the larger bits and pieces can’t work efficiently and will predictably fail…, repeatedly!

Standard wire diagrams, with boxes and connecting wires, are often used to portray the relationships of authority and responsibility in hospitals. Typically missing from these diagrams are the people who sit in the White Spaces beneath the labelled boxes or adjacent to the wires, the front line people who are continually crossing and communicating, those who provide the most pragmatic aspects of work in the hospital; and the people who touch the patients and hold the hands of family members.

Our industry is different than many purported high reliable industries because patients are not simply passive passengers receiving services provided by airline pilots and their highly engineered and failsafe designed airplanes. They are actual components, the most important, highly variable and unpredictable components, of the healthcare system. Highest quality and safe outcomes cannot be achieved without considering patients as part of the entire system of care. Failure to do so will result in poor outcomes and harm…, repeatedly!

Achieving safe outcomes is enormously complex, especially when treating the elderly, individuals with multiple comorbid conditions and the desperately ill. Healthcare is far more complex than building cars. Yet in the Toyota culture all workers are encouraged and expected to “stop the line” when they see something unsafe or when their specific task cannot, for any reason, be completed within the expected time frame. In the healthcare industry, sadly, White Space workers are commonly not encouraged, yet alone empowered, to “stop the line.” Trust, reliance and listening to people who work in the White Space, those who are the healthcare subject matter experts, will serve to improve patient safety; and not listening to them can have catastrophic consequences.

A friend of mine is an experienced pulmonary ICU nurse with 8+ years under her belt. She really, really knows how to do her job and she loves her job. Last year, during the early and rigorous influenza season, her ICU was overwhelmed with patients requiring ventilator care. She and her colleagues were working heroically long hours to keep up but patient and staff safety were both impaired; and two serious near-misses occurred within a brief time frame.

My friend brought her concerns to senior ICU management with a summary of the near misses, a prediction of the harmful outcomes if the near misses had not been identified and a logical proposal for how staffing might be adjusted in the short term; essentially limiting non-urgent surgical admissions during the period of influenza surge, expected to last three-four weeks, and bringing in one additional nurse that would be available as a result of cutting back on non urgent surgeries. She supported her proposal with hospital census data, international staff resourcing data, influenza prevalence curves from a variety of sources and also expressed the shared sentiments of the other nurses.

The senior manager listened to her concerns, calmly and substantially disregarded them, and referred my friend to occupational health for stress related impairment. One week later a patient died after receiving a medication intended for another patient, the typical kind of error that occurs when staff are overworked in a high acuity setting loaded with environmental distractions and task saturation; normal human factors stuff and easily completely preventable! Likely, one particular nurse will be held accountable, not the system. A regrettable statistic in management’s book, one more mother who will never attend her daughter’s wedding or hold a grandchild in her arms, listed on the first page of a much more important book.

When you undervalue the contributions of subordinate staff, those who work where the rubber meets the road, the White Space people, you undervalue the entire system, and in healthcare that means undervaluing patients; the most important people in the White Space!

Daniel Cohen

Dr. Cohen was formerly Chief Medical Officer and Executive Medical Director for the United States Department of Defense (DoD) health plan. Dr. Cohen was initially trained in paediatrics and haematology/oncology at the Boston Medical Center, Boston University, and the Boston Children’s Hospital, Dana Farber Cancer Institute, Harvard Medical School. He is a Senior Fellow of the Royal College of Paediatrics and Child Health and a Fellow of the American Academy of Pediatrics. Dr. Cohen retains a faculty appointment in the Department of Pediatrics at the Uniformed Services University of the Health Sciences, F. Edward Hébert School of Medicine, Bethesda, Maryland, USA, where he once served as Dean for Student Development. He has also previously held appointments at the University of Cambridge School of Clinical Medicine, UK and the Eastern Virginia Medical School, Norfolk, Virginia, USA.

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