Is quality safety Is safety quality Clarity is a priority' - PowerPoint PPT Presentation

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Is quality safety Is safety quality Clarity is a priority'


Conflating the concepts may implicitly create the belief that if you enhance ... to achieve safety you lose focus on safety if you conflate it with quality ... – PowerPoint PPT presentation

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Title: Is quality safety Is safety quality Clarity is a priority'

Is quality safety? Is safety quality?Clarity is
a priority.
  • Sam Sheps
  • Karen Cardiff
  • Department of Health Care and Epidemiology
  • University of British Columbia
  • Western Healthcare Improvement Network Conference
  • Enhancing Patient Safety Across the Continuum
  • Richmond, BC
  • June 8, 2006

Why are we asking?
  • In health care, quality and safety are most often
    talked about together, as if the concepts are the
    same, or at least, highly overlapping.
  • System safety experts from other industries have
    thought about the same question, and weve
    discovered that they rarely refer to quality, in
    discussions about safety.
  • Our research into the management and regulation
    of high-risk high reliability industries
    aviation, nuclear power and rail led us to
    think about the weakness in using the words

Brief history of efforts to understand the
concepts quality and safety
  • 1930s to 60s
  • The fundamentals of good medical care (Lee and
    Jones, 1933)
  • Hazards of modern diagnosis and therapy (Barr,
  • Diseases of medical progress (Moser, 1956)
  • The hazards of hospitalization (Schimmel, 1964)
  • 2000
  • To err is human, building a safer health system
  • (Institute of Medicine report. Kohn, Corrigan and
  • 2001
  • Crossing the quality chasm a new system for the
    21st century (Committee on
  • Quality of Health Care in America).

In health care.
  • At present, the words quality and safety are
    often used interchangeably (e.g. media, journals,
    educational initiatives, etc)
  • The risk is that people responsible for
    governing, managing and providing health care may
    think these concepts mean the same thing.

Why do we think this is a problem?
  • Conflating the concepts may implicitly create the
    belief that if you enhance quality, you are
    automatically managing safety.
  • We think this assumption is wrong.

Familiar examples
  • Quality of food versus the safety of food
  • Perfectly safe food that is unpalatable and
    unpleasantquality attributes
  • Extremely tasty food that is contaminated
  • Punctuality as a quality issue in the
    transportation sector
  • If you are not on time you will lose a few
    customers, if you are not safe you will lose them
    all (Bob Dodd, Qantas)

  • Even though people talk about improving safety,
    they may, in their directions and actions,
    actually be trying to do something to improve
  • Our central tenet is that in order to make
    progress on safety, it is important and necessary
    to separate the concepts, while not losing sight
    of the overlap.

Defining quality (Wikipedia)
  • Quality refers to the distinctive characteristics
    or properties of a person, object, process or
    other thing. Such characteristics may enhance a
    subject's distinctiveness, or may denote some
    degree of achievement or excellence.
  • When used in relation to people, the term may
    also signify a personal character or trait.
  • When used in relation to management, the term may
    be easily defined as "reduction of variability"
    or "compliance with specifications".

  • Quality can be used as a tool of measurement,
    like metric or Fahrenheit, as it is used to judge
    both subjects that are esteemed as credible and
    agreeable as "high quality" and subjects that are
    viewed as confusing, offensive, unhelpful, or
    incredible as "low quality." But quality is also
    used as a positive word, as in the sense of "this
    is a quality chair." Its antonym can be perceived
    as poorness, incredibility, unhelpfulness, and a
    variety of other words that reflect the concept
    of having low quality.
  • ISO 9000 defines quality as "degree to which a
    set of inherent characteristics fulfils

Defining safety (Wikipedia)
  • Safety is the condition of being protected
    against physical, social, spiritual, financial,
    political, emotional, occupational, psychological
    or other types or consequences of failure,
    damage, error, accidents, harm or any other
  • Risk management is the art and science of
    identifying risks, determining how significant
    they are, deciding whether they are worth taking,
    and recommending measures to reduce or eliminate
    particular risks.

The key distinctions
  • Quality is a characteristic of the
  • something the system has
  • Safety is something that the system/organization
  • its proactive
  • Quality is an attribute that we try to enhance
  • Creating safety is something we do to mitigate or
    prevent harm

Quality improvement
  • Embraces a philosophy of meeting or exceeding
    customer expectations through the continuous
    improvement of the processes or producing a good
    or service
  • Posits that the quality of goods and services
    depends foremost on the processes by which they
    are designed and delivered
  • Focuses on understanding, controlling, and
    improving work processes rather than correcting
    problems after they occur.
  • Assumes that uncontrolled variance in work
    processes is the primary case of quality problems.

If you enhance quality you are managing
  • Why do we think this premise is wrong?
  • Its based on what we have learned from other
    risk- critical high-reliability industries about
    making progress on safety.

Unlikely events.surprise
  • In large, complex, dynamic, event driven
    organizations one should expect that the
    unexpected will occur, that unimaginable
    interactions will develop, that accidents will
  • Scott Sagan, The limits of safety, 1993

  • We live in a world of hazardous technologies and
    some risk of catastrophic accidents is therefore
    ever present. We try to keep these risks as low
    as possible, yet in recent years, the names of
    many social and environmental tragedies have been
    etched into our memory
  • Scott Sagan, The limits of safety, 1993

Accidents in technologically complex environments
  • Chernobyl, the Exxon Valdez, the space shuttle
    Challenger, Bhopal, the Titanic and the Queen of
    the North
  • Are accidents like these avoidable?
  • Or, are these the predictable result of the
    widespread use of hazardous technologies and
    would they be addressed by quality improvement

What creates safety and causes accidents in
complex organizations?
  • Two major schools of thought
  • High reliability theory
  • Normal accident theory

  • The ideas are rooted in the organizational theory
  • Different understandings of how organizations
  • Different views on how best to analyze complex
  • Competing explanations
  • Proponents of each school of thought focus
    attention on a specific set of factors that they
    believe contributes to or decreases safety

High reliability theory
  • Optimistic view
  • Extremely safe operations are possible, even
    with extremely hazardous technologies, if
    appropriate organizational design and management
    techniques are followed.
  • Scott Sagan, The limits of safety, 1993

Normal accidents theory
  • Pessimistic view
  • Serious accidents with complex high technology
    systems are inevitable.
  • Scott Sagan, The limits of safety, 1993

Contrasting views
  • High reliability theory
  • Accidents can be prevented through good
    organizational design and management
  • Safety is the priority organizational objective
  • Redundancy enhances safety duplication and
    overlap can make a reliable system out of
    unreliable parts
  • Decentralized decision-making is needed to permit
    prompt and flexible field-level responses to
  • Normal accidents theory
  • Accidents are inevitable in complex and tightly
    coupled systems.
  • Safety is one of a number of competing
  • Redundancy often causes accidents it increases
    interactive complexity and opaqueness and
    encourages risk-taking.
  • Organizational contradiction decentralization is
    needed for complexity, but centralization is
    needed for tightly coupled systems.

Contrasting views
  • Normal accidents theory
  • A military model of intense discipline,
    socialization, and isolation is incompatible
    with democratic values.
  • Organizations cannot train for unimagined, highly
    dangerous, or politically unpalatable operations.
  • Denial of responsibility, faulty reporting, and
    reconstruction of history cripples learning
  • High reliability theory
  • A culture of reliability will enhance safety by
    encouraging uniform and appropriate responses by
    field-level operators.
  • Continuous operations, training, and simulations
    can create and maintain high reliability
  • Trial and error learning from accidents can be
    effective, and can be supplemented by
    anticipation and simulations.

High reliability theory The organization is a
rational actor
  • Organizations, properly designed and managed, can
    compensate for well-known human frailties
  • High reliability hazardous organizations are
    rational ? highly formalized structures and
    are oriented toward the achievement of clear and
    consistent goals (i.e. reliable and safe
  • Richard Scott, Organizations Rational, natural
    and open systems, 1987

High reliability theory Organizational
characteristics and safety
  • Leadership safety objectives
  • The need for redundancy
  • Decentralization, culture and continuity
  • Organizational learning

Normal accident theoryThe organization is not a
rational actor
  • Fits within the natural open systems tradition
    organizations actively pursue goals of narrow
    self-interest, e.g. security, survival, not just
    the official goals, such as profit, production or
  • Organizations are seen as open i.e. constantly
    interacting with the outside environment, both
    influencing and being influenced by the broader
    social and political forces.
  • Richard Scott, Organizations Rational, natural
    and open systems, 1987
  • The garbage can model
  • Cohen, March and Olsen, A garbage can model of
    organizational choice, 1986

Normal accidents theory Organizational
characteristics and safety
  • Structure, politics and accidents
  • Complex and linear interactions
  • Tight and loose coupling

What are the implications for health care?
  • Unlikely eventsadverse events can happen in
    what is thought of as an environment that is
    providing high quality care.
  • e.g. transition care the quality of the
    discharge planning process may
  • be fine, but the nature of transition itself
    creates the potential for
  • unexpected events (that may threaten safety).
  • Care may be considered high quality, but harm can
    still occur.
  • Harm is an emergent characteristic of the system
  • The dangerous accidents lie in the system, not
    in the components
  • Charles Perrow, Normal accidents Living with
    high-risk technologies, 1984

  • Creating quality involves ensuring an acceptable
    standard of care (hopefully, a predictable
    characteristicyou can guarantee quality).
    Quality is an attribute of a normally functioning
  • Creating safety involves asking what if it
    anticipates what could go wrong (the
    unpredictable nature of safetyyou cannot
    guarantee safety). Safety is linked to the
    capacity of a system to handle surprise or
  • Creating safety lies within the realm of dealing
    with things which havent happened yet, whereas
    creating quality involves doing something to
    enhance an ongoing process.

  • Quality focuses on the centre of distribution of
    care. Normal curve ? move the whole curve to the
  • Safety focuses on the tail of the
    distributionyou are trying to truncate the tail.

The normal curve
  • Different methods are used to investigate quality
    versus safety problems.
  • This is another important reason to keep the
    concepts of quality and safety distinct.

Methods.guidelines, standards, patient
satisfaction, outcomes
  • Quality compare characteristics/activities to
    evidence-based, and agreed upon, guidelines,
    standards measure patient satisfaction and
    monitor and evaluate outcomes

Methodsincidents, adverse events, hindsight
bias, and sensemaking
  • Incidents/accidents incidents and accidents in
    complex organizations are usually signs of
    trouble deeper within the system however, a
    large portion of incidents and adverse events in
    health care are still attributed to human
    errorit is critical to understand why people did
    what they did, rather than judging them for doing
    what we now know (in retrospect) they should have
  • Its challenging to reconstruct the human
    contribution to incidents the problem of
    hindsight bias.
  • There are specific methods to mitigate the
    effects of hindsight bias.

  • Quality and safety are distinct concepts.
  • Quality is a characteristic of the systemyou
    enhance quality.
  • Safety is a set of activities that actively
    identifies risks and harms with the goal of
    preventing incidents and accidents.
  • Good quality is necessary, but not sufficient, to
    ensure safety.
  • Safety can be best developed on a foundation of
    quality, but can exist as a system property on
    its own.
  • You dont have a quality system without safety.

  • Safety management systems actively seek hazards
    as a core function surveillance oriented,
    actively managing culture, monitoring it, and
    developing policies to encourage safety culture.
  • The quality model can distort efforts at trying
    to achieve safety you lose focus on safety if
    you conflate it with quality
  • Personal communication with Bob Dodd, Qantas
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