It is simply unfair (and unhelpful) to blame providers for comparable breakdowns in the care-delivery process. They are not “bad apples”; they are dedicated people who have been set up for failure. Errors, especially recurring minor errors, point to system failures. We cannot overcome the human propensity for error through sheer willpower, so it is unrealistic to expect providers to consistently do the right thing simply because they possess the knowledge that the given behavior is important. Perhaps it is no wonder that so many hospitals have avoided creating handwashing policies or fail to enforce them.
So, what can be done to create the possibility for hospitals to expect and build accountability around essential safety behaviors—the behaviors that take place every day and often behind pulled curtains or closed doors?
Getting Patients in the Game
One solution is to create a greater sense that providers are accountable to the patients they serve while also preparing patients to speak up when they observe lapses among their healthcare providers’ safety habits. Now that dangerous infections like Methicillin-resistant Staphylococcus aureus (MRSA, pronounced mersa) are spreading beyond hospital walls and into outpatient settings, as well as the broader community (schools, daycare centers, and gyms),4 the public has good reason to be mindful of whether people walking in and out of patient rooms wash their hands. In fact, there may be no other patient safety issue that stands to gain from urgent and concerted efforts to engage the public.
If patients truly understood the importance of proper hand hygiene, they would be more vigilant about whether or not it happened in their presence. What is needed is a way to raise public awareness, motivate civic action, and offer patients, lay caregivers, and those who visit them in the hospital manageable steps for ensuring consistent handwashing. As you will see in coming chapters, the same holds true for off-the-mark procedures and medication administration errors. That is, the public needs to understand the simple safety habits that can protect them from harm and how to make sure they are used during the care that they and their loved ones receive.
Another Slice of Cheese, Please!
In the 1990s, psychologist James Reason introduced a model that he originally intended to be used for academic purposes by fellow cognitive psychologists who studied large-scale disasters like airplane crashes and nuclear power plant meltdowns.5 This model, which he dubbed the Swiss Cheese Model, turned out to be exceptionally useful for understanding how workplace conditions affect on-the-job performance. It quickly became and continues to be the dominant framework for guiding the development of safety programs across a wide range of high-risk industries, including healthcare.
The Swiss Cheese Model recognizes that human error is unavoidably common. People will make mistakes—it is human nature, a given reality, and a fact of life that we must accept. According to the model, however, we can build safety nets to prevent common and potentially serious mistakes from happening. That is, human error cannot be totally eliminated, but human error can be caught, stopped, or prevented before it leads to major mishaps or disastrous events.
To understand the Swiss Cheese Model, look at the graphic below and think of each slice as being a protective barrier. Using the Swiss cheese analogy, a straw (error) could pass all the way through a stack of slices of Swiss cheese (protective barriers) only if all the holes (barrier imperfections, weaknesses, and vulnerabilities) happened to be perfectly aligned—as represented by the arrow. Tragedy strikes—patients are harmed—only when the straw (error) manages to get all the way through the cheese (when all protective barriers fail). Reason’s model recognizes the need for barriers in depth, meaning that because any one barrier is imperfect, as represented by the holes in the Swiss cheese, generally the more protective barriers we put in place, the safer the system. For high-risk undertakings, barriers in depth are essential for a condition of safety to prevail.
The Swiss Cheese Model of Error Prevention.
Source: Gretchen LeFever Watson.
The Swiss Cheese Model also asserts that most accidents represent system-level breakdowns, not malicious acts by bad people. It turns the “bad apple” mentality on its head. Recognizing that doctors and nurses do not set out to hurt their patients, the question to ask when a mistake occurs is: What led the person involved to believe that what he or she did was the right action at that time? In healthcare, the answer is too often that nobody was there to remind well-intentioned caregivers to do the right thing. In other words, the necessary slice of cheese is missing at precisely the time and place that it was needed most.
Patients will often be the last people to have the chance to remind healthcare workers to use common safety behaviors, and patients have the most at stake when safety precautions are disregarded. This is why we urgently need to equip patients for their vital role in safety. The stakes are too high to continue to work without patients serving as genuine partners in safe care. Using the Swiss cheese analogy, patients and their lay caregivers need to act as a final protective barrier (a slice of Swiss cheese). Ironically, the people who would be the most motivated in ensuring that basic safety tools are used during every patient encounter are the least aware of their existence and importance.
Mastering Safety Habits
While no doctor questions the importance of precision in delivering, for example, radiation to a tumor, the idea that equal attention is necessary regarding handwashing can seem preposterous. This is the crux of the problem: eliminating instances of preventable harm depends on healthcare workers habitually using the very behaviors that can seem too simple to matter. Even among healthcare workers who are motivated to wash their hands consistently, achieving performance excellence can be difficult. Momentary lapses will occur. Equipping patients for their role in safe care has been the missing link in the industry’s attempt to improve patient safety. When we finally prepare patients to speak up, we will sanction them as an important member of the healthcare team, and healthcare providers will have a far better chance of avoiding safety slips and lapses. This will require that providers convey the resounding message: “You are not challenging us. You are helping us.”
In order to change the behavior of healthcare providers, we must influence the behavior of the patients around them. Thinking in terms of the Swiss Cheese Model, protective barriers can include things such as technology aids and training, but they can also involve the use of safety habits and routines. As showcased in recent best-selling books on habit change by Charles Duhigg and Gretchen Rubin, the science of behavior has proven that establishing and maintaining new habits is challenging, but doable. What healthcare has not appreciated is how essential patients are to the process.
Duhigg’s book, The Power of Habit, draws on scientific research and countless examples from accomplished individuals and Fortune 500 companies to demonstrate how identifying a keystone habit can transform lives and organizations; the notion being that changing one critical behavior pattern often makes subsequent changes easier.
In the case of organizations, keystone habits are equivalent to essential routines. The process of forming habits or establishing organizational routines always necessitates that people identify triggers or cues, as well as rewards, that are associated with a desirable behavioral pattern; establish routines to perform in the presence of identified triggers or cues; and maintain a belief that change is possible. As Duhigg explains further, belief is the single most important aspect of the habit-formation process. That is, people must believe things will get better until they actually do get better. And they need a specific ritual, routine, or program to help them get there.6
In her book, Better Than Before, Rubin details why mastering desirable habits in our everyday lives (and work) is easier for some than for others. Nonetheless, she clarifies that everyone benefits when the environment provides signals (cues) that support people in doing exactly what they were already motivated to do. Without sufficient environment
al stimuli, people will simply fail to achieve their desired behavioral patterns. This applies to changing behaviors that are highly individualistic (writing a few lines of poetry or practicing yoga every day) as well as those that have the potential to impact the broader society (reducing water consumption or increasing handwashing).7
Applying the analyses by Duhigg and Rubin to healthcare, there are two things that are not sufficiently abundant in hospitals today. First, belief: many healthcare workers have lost faith in their hospital’s safety programs. In light of the field’s dismal track record we can hardly blame them. Second, cues and rewards: too often the cues are missing that might serve as reminders to execute specific safety habits (or routines) at the critical moment of care. Why should we expect healthcare workers to always remember to use safety habits or routines that can seem too simple to matter when they are focused on a myriad of more complex care-delivery actions, get frequently interrupted, and are often tired from working long shifts? Likewise, there is rarely anyone present who has the wherewithal to acknowledge or express appreciation for (reward) providers when they do the right thing.
Consider that populating hospitals with well-informed patients who are capable of speaking up when lapses in safety protocols are observed would be tantamount to providing much-needed reminders or cues. And imagine how much easier it would be for healthcare workers to believe that success is possible knowing that the environment would be replete with friendly reminders to do the right thing with every patient every day during every encounter, and knowing that they would be reinforced for doing so.
New Use of an Old Tool
To a large extent, the idea of getting healthcare workers to do the right thing every day with every patient is asking them to cooperate with simple routines for the benefit of others. Two Harvard economists and two Yale psychologists recently conducted a review of field studies that examined factors that promote cooperation, noting this body of behavioral science research has a great deal to say about modifying habits for real-world solutions that require long-term behavior modification such as safety habits.8 When it comes to getting people to cooperate to increase desired habits, the Ivy League researchers emphasized that financial incentives and material rewards often fail or even backfire, whereas leveraging social concerns that play on people’s natural desire to be highly regarded by others are consistently effective.
This relates to what Garrett Hardin described as the tragedy of the commons, which refers to shared dilemmas wherein acts that benefit each individual cost the group as a whole. In his now classic paper, Hardin tells the story of herdsmen who were prone to overgraze cattle because each cattle brought them more money. However, each added cow also contributed to the destruction of the land, eventually destroying the land to the point that it was entirely unsuitable for grazing. In the end, everybody lost. The herdsmen never saw the tragedy coming because, for a long time, each received the full benefit of adding one more cow and suffered only a fraction of the cost of overgrazing. So each herdsman felt compelled to add one cow after another without taking stock of the fact that his actions, coupled with the actions of his fellow herdsmen, contributed to the depletion of the land.
Likewise, when it comes to pollution, the cost to the homeowner for purifying waste before dumping it into the river on his property might be greater than his share of the benefits for treating the discharged waste. Predictably, he will muddy the waters and worry about the downstream consequences when forced to later on, if this becomes necessary. It is a calculated risk, much like healthcare providers perceiving it is safe to skip handwashing a time or two or here and there without fully appreciating how their decisions contribute to the spreading of dangerous germs throughout the hospital.
As Hardin explains, when we are trying to get people to consistently do things that are in the best interests of the common good, more than they appear to be in our own best interests, it is foolish to expect a good outcome without somehow wiring the situation for compliance. Two things that help are observability and social norms. First, we can help establish compliance by making the desired action known to the people who would be most affected by the lack of it. In the case of healthcare-associated infections, then, patients must come to understand the risks they face when healthcare providers don’t consistently wash their hands. But sometimes this is not enough.
In her 2015 book Is Shame Necessary? Jennifer Jacquet makes the case for why sometimes honor and shame must be invoked to motivate people to do the right thing. Although we tend to think of shaming as a deplorable act that is best left behind in the days when public hangings were in vogue, Jacquet shows how exposing people for deviating from established or desirable norms can be incredibly effective but only if it is used sparingly and in the right way. In proper form and measure, shame can be retrofitted as a powerful tool for bringing about the conformity that is essential to better long-term performance. When our own private guilt is not sufficiently strong to compel us to do the right thing, public exposure, or the mere fear of public exposure, can shame us into doing the right thing.
Retrofitted shame doesn’t need to be too painful. In fact, when used properly, it focuses on the bad practice rather than a person’s character. Done right, socially engineered shame simply and softly nudges people’s behavior in the right direction by awakening a person’s sense of moral obligation without inflicting undue humiliation. In the end, it helps us achieve our desired social norms. Moreover, in cases in which it is not possible to consistently punish transgressions in the usual ways, strategic use of retrofitted shame may be the only tool at our disposal.9
In the case of handwashing, it would be totally unfeasible to hire enough personnel to monitor providers’ day-by-day and hour-by-hour bedside behavior to enforce compliance. The same is true for the safety behaviors that can avert or reduce off-the-mark procedures and medication administration errors. It would be much more pragmatic to prepare patients to recognize seemingly minor safety breaches and empower patients to nudge their providers to do the right thing. This also makes sense because the personal safety of patients is most at risk. Strategic use of soft shaming can be a particularly effective tool when dealing with behaviors that involve breaches that are so common people think of them as quasi-acceptable practices/quasi-errors—the “violations” that have been normalized because “everybody does it.”
Logically, letting healthcare workers know how many of their peers signed a pledge to use specific safety habits, and to show appreciation when receiving reminders during momentary lapses, would represent a powerful use of “retrofitted shame” to establish more desirable safety norms. For shaming to work, it must hit the sweet spot, meaning it can be “too weak or too strong, too brief or too permanent.”10
Sometimes all it takes to establish a more desirable norm is for people to know they are being watched. The audience effect might have a more powerful influence on human behavior than we give it credit, especially under circumstances in which the visual attention is coupled with a consequence for violating the social norm.11 In fact, research has demonstrated that providers are more likely to comply with safety practices such as proper hand hygiene when they know their patients are watching them.12 Furthermore, plenty of research has demonstrated the conditions under which patients are more likely to take action. Consistent with the Health Belief Model, patients are more likely to speak up for safety under conditions in which they perceive a threat to their health is serious, know what to do to help prevent being harmed, have confidence in their ability to do what is required, and believe the costs of speaking up are worth it.13
Bottom line: we cannot achieve the desired norms for patient safety unless the public becomes engaged in the process.
Botched Attempts to Engage Patients
Effective public or community engagement refers to the process of involving citizens in the decisions that affect their lives and mobilizing them for the purpose of undertaking act
ivities to improve the conditions that affect them.14 Within the healthcare arena, there has been growing appreciation for the idea of engaging patients to improve patient outcomes and satisfaction.15 As noted by physician Donald Berwick, one of the pioneering and most renowned leaders of the patient safety movement, adopting a more patient-centered view of healthcare is essential; although, at first, it will necessitate some shifts in power and control from those who give care to those who receive it.16 This process must begin by engaging with patients to understand how they view and value their role in the delivery of safe care.
Patient engagement refers to the idea that people must be invited to take action to obtain the greatest benefit from the healthcare services available to them.17 To meet the Joint Commission’s patient engagement goal, hospitals must “encourage the active involvement of patients and their families in the patient’s own care as a safety strategy,” and compliance is measured by whether or not hospitals define and communicate a way for patients and families to report concerns about safety and whether hospitals actually encourage them to do so.18
Initially, a lot of people in healthcare dismissed the idea of engaging and empowering patients to improve safety as a misguided and politically correct agenda.19 They thought of it as a mere fluff-and-puff, touchy-feely strategy that had no real potential to improve outcomes. However, the evidence to support this idea exists and continues to grow.
Your Patient Safety Survival Guide Page 5