Jeffrey Braithwaite: The right way

WHEN it comes to tackling quality and safety, modern health care is often compared unfavourably to the aviation industry.

In the past 50 years aviation has seen a dramatic decrease in passenger deaths with the introduction of standardised protocols and processes. At the same time in our health care system, up to one in every 10 hospital admissions still results in an adverse event.

However, as clinicians at the coalface well know, there is a world of difference between flying a plane and treating a patient. Both are complicated procedures, but while aviation is amenable to applying formulae and analyses of cause and effect, improving health care is a far more difficult proposition.

Health care is a complex, adaptive system. It is multifaceted and constantly changing. Delivering health care is more like raising a child — it takes a community to nurture it and help it grow, and to work together so that it can achieve its best.

That’s a key reason why the billions of dollars spent internationally in the past 25 years have failed to put a dent in the high rate of errors in medical care. We have been looking at things from the wrong angle.

We have traditionally waited for health care providers to make a mistake, then analysed what went wrong and attempted to put in place provisions to prevent it from recurring.

That might be fine for policymakers and managers remote from the clinical front line, who can only imagine how clinical practice is performed and rely on producing policies and instructions, all based on procedural standardisation and rooting out error.

But as every clinician knows, hundreds of clinical guidelines and procedures can be worth very little in the busy environment of a hospital or doctor’s surgery. How many clinicians remember — or are even aware of — the policy documents that are designed to promote consistency and prevent mistakes?

In reality, everyone is self-managing their risk. Surprisingly to some people, clinicians get things right most of the time. Yet, although safe and effective health care encounters are in the majority despite the inherent complexity, we have never studied them systematically.

To focus on things going wrong is to understand only a small proportion of what gets done. Shifting the focus to what goes right as well means we can begin to understand how clinical practice works both when it performs and when it underperforms.

If we can understand how mistakes aren’t made as well as how they are, then this might provide a blueprint for us to start having much more of an impact on quality and safety in health care.

We need to support clinicians who get it right, to study their practices and develop theories about why these work, and then encourage others to follow their lead. Essentially the emphasis would change: we should be striving to make more things go well in the future.

The Australian Institute of Health Innovation, now based at Macquarie University, Sydney, endeavours to understand what clinicians understand about the health system. We want to methodically and rigorously evaluate how clinicians get things right, rather than trying to prevent mistakes from being repeated.

Working with the Australian School of Advanced Medicine, the new Faculty of Medicine and Health Sciences, and Macquarie University Hospital, we have Australia’s largest research group studying clinical governance, health informatics, health services, and systems and safety.

This research can make a significant difference. In some ways it’s more important than splicing genes or developing new treatments for cancer.

After all, understanding how health systems operate and building on their strengths are the best ways to deliver health care sustainably and effectively into the future.
 

Professor Jeffrey Braithwaite is Director of the Australian Institute of Health Innovation at Macquarie University.