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High Reliability: What’s the role of the Patient, Family, Public, and Community?

High Reliability: What’s the role of the Patient, Family, Public, and Community?

March 11, 2014

(To mark Patient Safety Awareness Week, we will be presenting a number of guest blogs. Here's the third, by Jim Conway, Adjunct Faculty, Harvard School of Public Health)

High-quality, high-value, and high-reliability healthcare is something we all desire and deserve.  For the last 15 years, I’ve studied high reliability and this spring I’ve been asked to keynote a high-reliability meeting.  In preparation, I attended some excellent sessions at the IHI Annual Meeting.  As one session was coming to a close a question was asked - a great question:  What is the role of the patient and family in high reliability? As participants thought about and reached for an answer, I knew I had my keynote topic. 

Many members of the Health Care For All quality community know that throughout my career I’ve been interested in advancing and realizing collectively the power and privilege of partnerships with patients and family in all aspects of health and healthcare.  Children and adult patients and family members have inspired me and taught me so much.  Yet, involving the patients in reliability  wasn’t a question I had thought  about.  Maybe I just assumed partnership—nothing about me without me—in this too.  I embarked on a three- pronged journey: first, to read whatever I could  on the topic; second, to talk to industry and healthcare pioneers in this area; and third, to reflect on what I learned relative to what I knew from other settings.   

The first prong, reading, didn’t take long - there isn’t much written. Further, what I read was focused on doing things to patients or for patients and not with patients and/or their families.   Models and articles didn’t describe explicit partnerships with patients and families.

It is always exciting to interview leaders and the second prong was no exception.   I spoke to leaders in the chemical industry, nuclear power, fire fighting, and many more.   They talked about their early journeys where the consumer was an outsider; it wasn’t their problem, they had enough to worry about, they would get in the way.   Over the years the orientation has moved to partnership, a key customer, the essential ingredient.  From leaders in healthcare high reliability, lean, and other systematic improvement approaches I heard about the same historical perspectives—an outsider, not their role, etc.— and evolution to the essential role the patient, the family, the public, and the community plays.  How can you design a reliable care system that executes effectively 100% of the time without the patient?  We may know how to do A, or B, or C but we don’t have a clue how you get from A to B to C.  Patients and families know how the system connectivity works, and doesn’t, because it’s their world, living it often every day. I was also pleased to find others like Helen Haskell and Carol Cronin asking the same question and offering their learning.

o, what can the patient role look like? There were many suggestions and a lot to consider.   I chose to organize my thoughts around the dimensions of mindfulness leading to high reliability proposed by Karl Weick and Kathleen Sutcliffe:  preoccupation with failure, sensitivity to operations, reluctance to simplify, commitment to resilience, and deference to expertise. 

As I read, listened, and thought about the contribution through this lens, an exciting collaborative list began to appear, examples of which are noted below. 

  • Preoccupation with failure: Staff inviting patients and family to report what they saw, what happened or almost happened to them.   Then, everyone listening to what was said so the system can be improved
  • Sensitivity to Operations: Conducting with patients and families gap analyses on the difference between the system on paper and the system in practice
  • Reluctance to simplify: Probing patients and families on how well what was done do them achieves what matters most to them.  Are they receiving cookie cutter solutions?
  • Commitment to resilience: Whenever things go wrong, we respectfully engage with patients and families to understand what happened, why, and what can be done to prevent it from happening again.  Specifically this would include root cause analyses.
  • Deference to Expertise: Staff respects that often the patient and family  know more about their illness than anyone in the room, and always have an essential view.  It’s about them.

There is so much the patient and family can add.  As a patient, I wondered how the principles of high reliability can be applied where I and most patients receive most of our health care; in our home and in the community.   My mind began to explode with the possibilities.

In the IOM report Best Care at Lower Cost, it is noted that improved patient engagement is associated with better patient experience, health, and quality of life and better economic outcomes, yet patient and family participation in care decisions remains limited.  As we seek and design for high reliability healthcare we can’t let the limited participation continue. 

I’m looking forward to this presentation and the discussions, as well as the learning throughout the meeting.   I also welcome your input.  What’s your answer to the question: What is the role of the patient and family in high reliability?  

Thanks to HCFA for all it adds in service to the residents of Massachusetts and beyond over the year and during Patient Safety Week.