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Risk Management: Alter Mindset, Reduce Errors?

by Elizabeth Hofheinz, M.P.H., M.Ed., September 19, 2019

A perennially hot topic, risk management in healthcare is often viewed differently than in other settings. Michael Shabot, M.D. wants to change that. The Former Executive Vice President and System Chief Clinical Officer of Memorial Hermann Health System and Founding Partner, Relia Healthcare Advisors, Dr. Shabot has recently published his related work, “Zeroing In on High Reliability in Healthcare,” in the July-August edition of the Journal of Healthcare Management.

Dr. Shabot, who retired from Memorial Hermann Health System (MHHS) in June 2019, told OSN, “About 20 years ago I became aware that changes in the process of care could lead to improvements in outcomes, including avoidance of the well-known hazards of medical and hospital care. I became convinced that patient harm was preventable, in the same way that commercial airlines fly billions of passenger miles without fatalities, and many other industries operate for years without mishaps.”

Expectations, expectations…

Aiming for zero harmful events is possible and critical, says Dr. Shabot, and can yield improved patient care, a reduction in the cost of harm, and a robust culture of safety. “In commercial air travel and nuclear power plants, everyone expects zero harm as these sectors operate as high-reliability organizations (HROs),” says Dr. Shabot.

He cites a hypothetical example:

“Let’s say that after an entire planeload of people are on board and the flight attendant announces that they need extra time for a mechanic to come and fix something. 30 minutes later it is announced that all is well, and you will leave when a bit of paperwork has been completed…probably another 15 minutes. Although it is a frustrating situation, and some passengers are concerned about missing connections, is it an HRO safety process in which two licensed professionals, the captain and the mechanic, agree that the problem has been resolved. Without such a process, there is a risk that the pilot and mechanic misunderstand one another, and the flight takes off, only to crash and kill everyone aboard.”

Dr. Shabot told OSN: “By publishing results showing that zero harm is possible, healthcare providers and executives can move forward knowing that their efforts could indeed result in vast improvements in patient care and cost savings.”

A party for “zeros”…

“In 2011 MHHS decided to officially recognize the years of zero harm events that they had under their belt. They created the high-reliability Certified Zero Award—“certified” because most harm events are reported to CMS and then certified by the hospital.”

A big non-event…

“The most critical aspect is changing the mindset and then the culture. This takes years, it doesn’t happen overnight. Even if processes are changed to make them more resilient and ‘harm-proof’ in spite of human error, it still takes years to appreciate that harm isn’t occurring. High reliability has been called a ‘dynamic non-event,’ because the prevention measures are always running and then nothing (bad) happens.”

Asked how one might change the mindset/culture, he noted,Achieve small wins that lead to larger wins. If a certain type of hospital-acquired infection occurs often, and then after preventative measures are put in place it doesn’t occur for 3 months, celebrate that. If it goes 6 months, celebrate that. I can tell you that after countless process improvements for hip and knee arthroplasty, including some initiated by our orthopedic surgeons, Memorial Hermann began seeing hospitals go for years at a time without an arthroplasty SSI [surgical site infection]. We actually had to invent a new Zero award for this. It’s very important to celebrate the achievements for physicians, staff and executives to begin believing high reliability ‘Zeros’ are actually possible.”

Lessons from a theme park?

“I think the largest block to this change is the belief that health care is different, and that harm cannot be prevented. Patients can be sick and sometimes don’t follow instructions, so some doctors and facilities may believe they are off the hook for adverse results. The fact is that many high reliability industries involve very high risk – like nuclear power plants, nuclear aircraft carriers, nuclear submarines, zoos and major theme parks – and yet you almost never hear about an injury or death.”

Dr. Shabot emphasizes, “It’s time to get onto the high reliability bandwagon. Many hospitals and health systems are already on this journey, which not only reduces harm, it also reduces costs.”

Josh Sandberg

Josh Sandberg is the President and CEO of Ortho Spine Partners and sits on several company and industry related Boards. He also is the Creator and Editor of OrthoSpineNews.

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