Heart surgery is a complicated procedure done on unhealthy patients. Occasional bad outcomes are easy to understand.  On the other hand, a bad outcome that was preventable is less acceptable.  Examples of harm from preventable mistakes include giving a wrong medication because a verbal order was misunderstood, failure to correct an overlooked but important lab value, failing to intervene on a patient that is rapidly deteriorating, forgetting an important step in procedure.  Oftentimes, other clinicians recognize missteps by their colleagues but fail to speak up in time.  Even more disheartening is how rare it is for hospitals to learn from these errors so they can prevent them from happening again.  These types of process and system flaws used to be common culprits of harm in other hazardous fields such as aviation, nuclear power and the military. But 40 years ago these fields all began to adopt the basic tenets of a high reliability organization (HRO).  Once its rigorous methods of communication and teamwork were learned, it virtually eliminated preventable errors.  It is impossible to find a plane, power plant or military team that does not lean on HRO tenets as its #1 guiding principle.  Yet most hospitals –equally hazardous to these other fields – are a long way from becoming an HRO.  Most fail to even acknowledge that errors in patient care are common within their walls.  They do not have a blame free environment for reporting problems, so the most severe errors tend to remain hidden.  They have been unwilling to commit resources to uncover and address system defects.  They do not rank becoming an HRO anywhere near their #1 priority.  The interesting question is why? Understanding how powerful concepts like this fail to spread in hospital is an often overlooked first step towards improving safety.

A major roadblock for becoming an HRO is tension between two fundamentally opposed ideas – whether the #1 priority should be finance or safety.  For the late Paul O’Neil, former CEO of Alcoa, the answer was simple: safety.  When you get safety right, the profits follow.  This mainly happens because of the magic of engaged employees.  Like workers in the aluminum industry, the hearts and minds of those in healthcare are won over when their leaders focus wholeheartedly on safety. That’s because it is a natural rallying point for teams. Full engagement in safety builds a wide array of habits in team members that cross-over to help drive profitability – clear communication, consistent accountability, follow-through, and a deep understanding of processes and system issues.  A company full of engaged employees with all these skills led Alcoa to become the most profitable company in the industry.

As I’ve prosthelytized the HRO/O’Neill vision among others in healthcare, I’ve noted a surprising amount of resistance, particularly from hospital administration.  Their main opposition is that safety as #1 is just not pragmatic.  Hospitals must (at least at times) prioritize profits to pay bills and keep their doors open.  An often-recited mantra of any business is “no margin, no mission”.  They do not mean to ignore safety, but see it mainly as a tool to stay compliant with a myriad of regulations. Errors that are actually preventable are rare so going the extra mile to pursue a systems based analysis is unlikely to yield a good ROI Instead, physicians are trusted to self-police those adverse events that are due to performance issues.  A much more important priority for hospital leaders is to optimize the utilization of resources during routine care (e.g., control costs, avoid waste). Safety initiatives are reserved for when hospitals have finished making nursing and physician practices standardized and more productive.  In a profit first culture, workers that are the most valuable do not report systems issues (e.g. poor staffing ratio, lack of supplies, lack of training). Instead, they become masters at using “workarounds” to get around chronic problems.  Those that do report hazards to their supervisor are criticized as “complainers” and “not team players”.

Much of this debate centers on whether a safety culture can be sufficiently strong even if safety is not the #1 priority above all else.  Isn’t it reasonable that there would be times where the hospital must first consider finances?  To understand this debate, we need to consider what influences a safety culture.  A culture of an organization is the sum of all the prevailing ideas of formal and informal leaders within an organization that address “how things are done here”.  It is unimportant what the leaders say on this topic. Unspoken rules penetrate far deeper and influence the culture far more. It is precisely because these rules are unspoken that makes them so hard to challenge and change.  Such rules emerge from a Darwinian struggle between conflicting priorities.  Based on their training and experience, nurses, doctors and other medical personnel are the ones fighting for safety. In contrast, hospital executives are not clinicians, but businesspeople whose acumen lies in finance, fundraising, development, and politics.  They advocate for cost control and/or profits. Since we know that all hospitals have a track record of safety far more mediocre than other HRO, it is fair conclude that the executives and their ideas won the battle of natural selection.  Many assume that proves the pragmatic financial approach was the fittest in battle of ideas and that O’Neill’s vision (i.e. safety is the best way to a profit) is just not applicable to hospitals.

A medical culture that emphasizes perfectionism is another hang-up exploited by profit advocates.  Physicians have been trained to view the common culprit of safety hazards as the one standing at the front lines.  From this frame of mind, the best response to an adverse event is to eliminate that “bad apple” or provide remedial instruction.  Blame and shame of the culprit is viewed as an effective intervention while efforts to learn from errors and seek out the underlying system defects are viewed suspiciously as trying to avoid individual accountability.  The legal system benefits from pinning the blame on a single individual, reinforcing this “bad apple” theory.  This idea allows administration to wash its hands of the system defects that cause harm, mitigating a potential driver of costs.  Therefore, it is coadopted in lock-step with the idea of profits as #1 priority.  This constellation of thoughts may be at odds with the modern understanding of errors, but it continues to be rapidly adopted because of its roots within the culture of both medicine and corporations.

On closer inspection, there flaws in the reasoning of these last two assumptions.  For one, surviving a battle of the fittest is not proof that an idea was best.  Sometimes wrong ideas win. Many people have the idea to consume alcohol, junk food and even illicit drugs even though it clearly is not healthy in the long run. History is replete with wrong but prevalent ideas rapidly infecting a culture like a virus of the mind. Second, the success of an idea is heavily influenced by the political power of its advocate.  The hallways of hospitals are filled with the ghosts of physicians, nurses or other clinical staff that have been fired for being overzealous about safety.  Being fired this way means that the advocate (and others watching in fear) no longer contributes to the development of a culture.  The administrator lives on and gets to select a more compatible nurse or physician. This battle is not a fair fight of ideas between equals but better characterized as one between predator and prey.

Now turn to the relevance of O’Neill’s vision about safety in hospitals. His safety-first idea was fiercely advocated by Alcoa leaders, not just followers. Hospital leaders can’t do that because most would not know where to begin. They have a chasmic gap in their knowledge about how safety could improve the bottom line.  If executive and clinicians were willing to learn from each other, their separate priorities might coevolve, merging into O’Neill’s view.  However, coevolution requires two competitors that start out on equal footing, which is rarely the case in hospitals.  In predator-prey interactions, the need to change and adapt is asymmetric with prey having to change more. Consider the Rabbit and the fox. The laws of natural selection guarantee that over time the average rabbit evolves to become faster than a fox, yet the fox doesn’t have to change at all. This is because their stakes are different: a rabbit that is slower loses its life while the slower fox merely loses its dinner.  Physicians that push too hard on the safety agenda are like the occasional a slow rabbit – they become the prey that get eaten.  This leads to a culture that may not ignore safety completely, but achieves the same lackluster levels of success seen in the aviation and nuclear power industries prior to their transformation into an HRO in the 1980’s.  It certainly does not see safety as a key to profits like Alcoa.  Mr O’Neill himself resigned from his position on the governing board of a major hospital in Pittsburgh after it showed no incentive to listen to their rabbits.

One thing changes the dynamic with predators – dangerous prey.  The ability of prey to fight back forces natural selection onto predators, causing coevolution. Physicians will counterattack executives from time to time, mostly with poor results.  The politically savvy and successful clinicians often employ the stealth tactics of a virus.  Under conditions when the host is healthy, a virus is content to spread at a low enough rate to avoid provoking an immune response.  However, once the host starts to shows signs of deterioration, it rapidly attacks and overwhelms the host. Likewise, wise clinicians lay dormant until a crisis occurs, like a sentinel event (e.g. wrong site surgery, accidental overdose, death of a low risk case).  These events are most often caused by system errors/defects like poor communication, ineffective leadership and/or bad planning, thus providing a ripe opportunity to make the case for safety.  They are also a rare chance to point fingers at the executives who are responsible for keeping these system defects in check.

The ultimate irony is that profits and safety are never mutually exclusive in any business.  Once safety is prioritized, profits inevitably follow.  Hospitals have twice as many reasons as Alcoa to be concerned about safety.  Preventable errors cause harm to both their employees and customers (patients), which make O’Neill’s vision and its potential to drive engagement/profits twice as applicable to hospitals. In addition, a strong culture of safety prevents the wide array of hidden costs.  Less preventable harm translates into reduced hospital costs, less risk for legal or regulatory sanction, higher staff morale/lower turnover and improved reputation in the community.  The problem is that hospital leaders without a clinical background have no way of measuring costs that are hidden.  The ease of measuring profits is why finances are the top priority.  However, choosing to prioritize profits just because its easier to measure is called the “lamppost error” and causes neither profits or safety to be realized.

Constructive discussions over how a hospital ranks its most important priorities could not be more important. It is in the interests of the hospital community as a whole for this debate to be seen as credible. The tendency to use political discourse as the platform has most definitely been seen as unfair, unbecoming and lacking in legitimacy, mainly because the opposing sides do not enjoy equal political power. When governing board ranks safety as its number #1 priority, that dynamic changes immediately. That one decision would force hospital executives to stop paying lip service and find a real way to collaborate with clinicians and others who are the best position to create an HRO. Safety is not about motivation but about priorities: what is ranked at #1 is what gets done and only one idea can be #1.  There will be plenty of ideas about safety that don’t work out, but the key is to develop dyad relationships across the divide that are able to quickly figure out the ideas that do. We don’t need Darwin to tell us which side wins in the long run once the fight is fair.