| | OCTOBER 202319UTLOOKHealthcare Tech Patient Safety in our Post Covid Word--Resilient, not just Reliable SystemsBy Oren Guttman, Enterprise Vice President for Patient Safety & High Reliability, Jefferson HealthWith the COVID-19 pandemic on the decline, US Healthcare delivery is facing a turbulent world.With the "Great Resignation", healthcare lost many of its most experienced clinicians, and their exit, left a lot of nuanced knowledge about how our clinical operational systems really function, the way they fail, our vulnerabilities, and the expertise of how to compensate for the vulnerabilities in our systems of care. Moreover, hospital staff report increasing levels of fatigue & burnout, caring for larger numbers of sicker patients, which has strained the staff's ability to offer the super vigilance historically expected of them. Record numbers of staff turnover further have exacerbated these challenges. Add in regular healthcare supply stock outs, and the loss of watchfulness from visitors and families at the bedside, you have a set up for challenges to patient safety, not seen before. It is safe to say the old playbook seems insufficient to advance patient safety in the increasingly complex systems that define healthcare delivery today. Our patients need us to think differently. Specifically, we need courage to question the assumptions and practices of the past, and not expect to see different results, without a frameshift in our strategy, operations, and tactics on advancing patient safety. Let's start with what perhaps the obvious, but needs to be said. Namely, that nothing will replace necessary people and supplies. But here is the more difficult pill to swallow that will take us longer to unlearn as an industry. That focusing primarily on a "culture of safety' alone, asking more of the people to do better, pay more attention, do more, as though that can be "injected" sustainably into an organization, is a fallacy. According to modern safety science, this mythology about the effectiveness of a focus on "culture of safety" has likely held healthcare back from real improvement work needed to advance patient safety.Modern safety science has shown that it is the operating systems that define the culture of safety. Not the other way around. This is because the reality of care delivery today is it occurs in a system in a socio-technical in nature. The machines (software, hardware, environment, technology) are no longer just our tools, they are our partners and we need to hold them accountable to the same high professional standards we hold our staff to. Our focus on "teaming" needs to move to human-machine interaction optimization, given the incredible impact this has on care directly. Moreover, when the workforce is so unstable, clinician fatigue and turnover is so high, focusing on culture alone just does not make sense. Similarly, the holy grail of process improvement and attempts to standardize in the face of changing socio-technical system contexts, interactions, and external forces out of our control, can lead to reductionism in a system like ours with irreducible complexity, that can be deadly. "Tailorism" instead of adaptability, agility, and flexibility, may make us "feel" more in control of the chaos we are experiencing, but is not the aptitude needed to weather this storm. One possible way to find our way out of this forest is to rethink our philosophy on patient safety and preventing Oren GuttmanCXO INSIGHTS
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