7 Key Lessons from James Reason’s Swiss Cheese Model for Healthcare Leaders

Mayday! Mayday!! Mayday!!! The ‘holes’ in my cheese” are aligning! As a leader in healthcare, would you scream for help when the ‘holes’ in your ‘cheese’ are coming in alignment?

I am not a foodie, nor am I a great fan of any type of cheese but my work has encoded the value of appreciating the Swiss Cheese in the way my mind works.

Prof. James Reason started discussing the famous theoretical framework- the Swiss Cheese Model (SCM) of Accident Causation more than 30 years ago. It can be applied to many sectors but within the Patient Safety space, we use it to understand how accidents or adverse events can occur in complex systems like healthcare.

A Synopsis of the Swiss Cheese Model

The SCM conceptualizes systems as a series of layers (slices of Swiss cheese), with each slice representing a barrier or defense against potential errors. This framework has profound implications in healthcare because of the high stakes of patient safety.

?In a complex system, for an accident to occur, holes in each layer of defense must align [similar to the holes in slices of Swiss cheese]. While the holes in the slices represent active failures, there's a much deeper concept in the model that addresses the factors leading to these holes: latent conditions.

Here are some definitions:

Active Failures - direct and immediate causes of an incident. Active failures are often made by those at the "sharp end" (e.g., pilots, doctors, operators). They are the last set of failures that occur before an incident and include slips, lapses, and mistakes.

Latent Conditions – ‘hidden’ problems within systems that may lie dormant for days, weeks, months, or even longer. They arise from decisions made by designers, leaders, and top-level management. Inadequate training, understaffing, poor maintenance, or flawed procedures are a few examples of these latent conditions which set the stage for active failures and can make them more likely to occur.

Defenses, Barriers, and Safeguards are represented by the slices of Swiss cheese. Our assumptions is that they prevent or detect failures. However, each layer has weaknesses (holes) that can be exploited by active failures, especially when latent conditions are present.

Trajectory of Accident Opportunity: This is the path an error takes as it penetrates the layers of defense. For an accident to occur, the holes in each slice of cheese must align, allowing the error to pass through every defense layer.

Organizational Influences are not always depicted explicitly in all versions of the SCM, there is agreement that latent conditions often arise due to organizational decisions, policies, and culture. Factors like cost-cutting, lack of proper training programs, or prioritizing speed over safety can create an environment where latent conditions thrive.

?Why SCM and why now?

What triggered my decision to write about the SCM? Among other reasons, it is because “It's not what you don't know that kills you, it's what you know for sure that ain't true.” (Mark Twain).

?Notwithstanding my experiences within healthcare systems across the world (spanning over 3 decades), I continue to hold on to the belief that healthcare is ALL about saving lives. But is it also possible that the healthcare system is sometimes ‘a land that devours its own people’?

?Fifty six days ago, on a Tuesday like this one, a colleague fell to her death in an elevator accident – in the hospital where she worked as an intern. She was a victim of the system – the very system that she had committed to serve in. The committee set up to ‘investigate the incident’ is presumably still meeting trying to unravel the ‘mystery’ surrounding that incident. ??Where did we fail her? What could we have done differently to prevent that event? When exactly did we ‘kill’ her? Was it the day the elevator malfunctioned or the many times before that day that we decided we would ignore the telltale signs of a failing system?

?More recently, another colleague slumped from exhaustion, while on a round – he died. The round continued – there were patients to be seen! The system failed him. Was this a case of burnout or of a heart disease that was ignored? Why did we not see it coming? If we saw the handwriting on the wall, were we designed to prevent his death by helping him? Every single day, in every healthcare system globally, people die- patients and provider alike, people quit, people resign without resigning (the pandemic of quiet quitting). Because the systems fail.

?The easier route to take here is to find someone to blame for these incidents. But that is too cheap a stance to take. You will agree with me that LEADERSHIP is anything but CHEAP or EASY.

In the spirit of candor, let us look at seven important lessons drawn from the Swiss Cheese Model that can help us embrace the complexities of healthcare systems. Subsequently, we can choose to use that understanding to our advantage – to navigate the murky waters of leading systems that are safe and that ‘protect their own’.

Lesson #1:Multiple Barriers

By design, to foster safety, the integrity of the healthcare system is typically maintained by multiple layers of defense. Just as a slice of Swiss cheese has holes, each barrier in a system might have vulnerabilities. It's only when the holes align that an error can penetrate all the defenses and cause harm. Know this and know peace. Ignorance, in this regard, is not bliss. ?Know your ‘barriers’ and groom them well.

Lesson #2: No Single Point of Failure

Life is rarely ever linear. Do away with the false thinking that a single ‘cause’ is responsible for the failures you see in your systems. Rarely does a single error or failure lead to an adverse event. Instead, it is often a sequence of failures across different barriers that culminate in a negative outcome. This highlights the importance of addressing vulnerabilities at multiple levels rather than relying heavily on one defense mechanism. We apply the multi-pronged approach to treating Malaria, MDR bacteria, HIV, TB, and many other conditions. We must apply the same to system architecture and management for safety.

Lesson #3: Importance of Reporting Near-Misses

What is the true value of a Near Miss? You would never know unless you use the knowledge and insight it affords you in the best possible ways. A Near Miss provides us with the opportunity to ‘solve problems before they arise’. Even if an error does not lead to a direct adverse outcome, it can reveal vulnerabilities in the system. Reporting, analyzing, and acting on near-misses can help identify and rectify potential weak points before they result in harm. Look at the Root Causes Analysis and Action RCA2 tool from the Institute for Healthcare Improvement (IHI) for more on this principle.

https://www.ihi.org/resources/Pages/Tools/RCA2-Improving-Root-Cause-Analyses-and-Actions-to-Prevent-Harm.aspx

?Lesson #4: Systemic Approach to Safety

Well, pointing accusing fingers did not start with us. It is inherent in our nature. But that is not a good enough excuse. None will be. DO NOT NAME, BLAME, OR SHAME. While it's easy to blame individuals for errors, the Swiss Cheese Model underscores the importance of viewing errors as consequences of SYSTEMIC VULNERABILITIES. You can do better. Please, focus on strengthening systems instead of merely attributing blame.

?Lesson #5: Continuous Improvement (or is it really Disruptive Improvement?)

Did you see that video? Well, see it again here { https://youtu.be/twsA3z3xFVE?si=NTwvuoU8KwutyJic}

Systems evolve, and new vulnerabilities will emerge. Therefore, there should be a continuous effort to monitor, learn from errors and near-misses, and refine the system defenses accordingly. Business as usual is the sure recipe for calamity! Get obsessed and preoccupied with failure. That’s how High Reliability Organizations (HRO) roll!

?Lesson #6: Human Factors and Ergonomics

Our estimation of human capabilities are rarely accurate. We need to recognize that humans are fallible and can make mistakes. Hence, it is essential to design systems and processes that are intuitive, reduce cognitive load, and minimize the chances of error. This can involve training, but also redesigning equipment, software, and workflows to better align with human tendencies.

Lesson #7: Organizational Culture Matters

If you agree with Aristotle that “the whole is greater than the sum of its parts”, then you will better appreciate the value of creating an organizational culture that can serve as the glue for all these layers and systems to work effectively - the culture of safety. This involves encouraging open communication, creating a non-punitive environment for error reporting, and emphasizing the shared responsibility of ensuring patient safety.

?In conclusion, as healthcare leaders (or leaders of any system at that), when we understand the interconnected nature of defenses and errors, we give ourselves the edge required to build more robust systems and foster cultures that prioritize the well-being of patients, and healthcare workers.

If you think you do not have the power to cause positive change in the systems where you lead, think again. Ask for help if you need to. But do not sit by the sidelines and watch the ‘holes’ in your ‘cheese’ align. Your work, our work, is to build lands (systems) that ‘preserve their people’ and the Swiss Cheese Model has equipped us with more insight into how we can.

Rest in Power, Dr. Vwaere Diaso. I hope we will learn from how we failed you to save those who are still with us. Adieu.

#PatientSafety#? ?#SwissCheeseModel# ?#Healthcare#? ?#Leadership# ?#IHI#

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