Summary - RCP / FMLM Lilly Lecture 2013: Can Healthcare Change?

Professor Donald Berwick, former President & CEO, Institute for Healthcare Improvement

Sir Richard Thompson initiated the proceedings by referencing the current time of great uncertainty in healthcare, but stressed that a lot can be learned and changed during this period.

Don opened up with a personal example of how, as a junior doctor, he found that systems present in hospital can be confusing, especially when procedures vary from those in nearby hospitals, which can lead to make fatal mistakes being made.

And that, aside from personal examples, it is known that genuine mistakes happen regularly - so how do doctors deal with recognising the harm that was caused by genuine individual mistakes, or by a misunderstanding between professionals, or by not being familiar with the procedures? How many doctors follow up their mistakes? How many doctors raise the failure (system or individual) with the authorities, or those senior to them?

Mid-Staffordshire is a case where the system fell into chaos.

Hundred died, thousands suffered, alarms were rung, but the response was defensive, slow and inadequate.

Why was that?

Why is that we don't take the science of safety and compassion seriously enough?

The human factors that contribute to safety, or conversely accidents, are real and predictable.

Don used handwriting as an example – real examples taken from medical records, that demonstrated how the written word could be interpreted in a variety of ways in a healthcare environment.

So what does the nurse or junior doctor do when faced with uncertainty in the middle of the night? Recognise the potential mistake, phone the consultant or just get on with their job as best they can?

Don believes that the science of safety is crucial to driving up quality standards in patient care, not just the science of treatment.

The mantra 'every patient is the only patient' should be our mantra when it comes to safety.

In fact injury and death produced by medical interventions or accidents in the US are greater than those of road traffic accidents, workplace and aeroplane accidents.

Why is this?

Its not because we don't care as healthcare professionals – it because we are in a people business working in complex systems.

So what is our average rate of failure in everyday tasks in everyday life?

On average, we are 1% error-prone – we know this from research.

This is why just 'trying harder' does not always work.

It is a myth that we can correct and prevent all errors from happening – instead, we have to design systems that will help protect against human error.

Punishing people for making errors will not help prevent more errors.

There are three basic types of error (as described by Professor James Reason, BMJ 2000)[1]:

1. Skill-based = slips

2. Rule-based = mistakes (we use the wrong rule to solve a problem – ie heuristics)

3. Knowledge-based = mistakes

These basic principles apply:

1. Everyone makes errors every day;

2. No one makes an error on purpose;

3. An error is not misconduct;

4. Misconduct is far less common than errors.

The solution is to design ways of working that protect people against human error-proneness and decrease errors by improving systems. This means eliminating complexity wherever possible, such as:

1. Avoiding reliance on memory;

2. Simplifying procedures;

3. Standardising procedures;

4. Using constraints & forcing functions (ie to design equipment that is impossible to use in the wrong way);

5. Using protocols and checklists wisely.

Don is promoting An Ethics of Improvement:

1. Professionals have a duty to help improve the systems in which they work;

2. Leaders have a duty to make 1 logical feasible and supported;

3. No excuses for inaction on 1&2 are acceptable;

4. The duty to improve encompasses safety, effectiveness, patient-centredness, timeliness efficiency and equity. This requires the continual reduction of waste;

5. Those who educate professionals have a duty to prepare them for this improvement work.

His final plea in the Lilly Lecture was for the professions to rise to the occasion.

Peter Lees brought the event to conclusion by thanking the following:

1. The Lilly sponsors;

2. The RCP for their generous support;

3. Don Berwick for the profound impact that the IHI has made on healthcare both in the US and globally.

Peter Lees praised Don for his particular contribution to patient safety and hopes that his emphasis on NOT punishing people for their errors, will feed into the Government's longer-term response to Francis.

Further reading:

Kahneman D. Thinking Fast and Slow (2011).