Mr. Isaacks' Insider: March 2022 HRO Theme of the Month is “Reluctance to Simplify.”

"Reluctance to Simplify"

Dear Colleagues,

The HRO Theme of the Month for March is “Reluctance to Simplify,” which is a reluctance to accept the simple answer, to not assume the person or equipment closest to the error is the problem. It is about encouraging questions and the expression of different views. This principle involves embracing a detailed look into processes and procedures, digging down to the root cause to identify the weak point in the system causing the issue.

Because healthcare organizations are especially complex, there are tools we can use to help us dig down past the initial reaction to discover the hidden layers:

1. ?The Five Whys: This tool starts at the adverse event and questions “why” that event happened until a system issue is revealed. Get used to using this method when close calls and/or adverse events occur.

For example, a wrong medication was given. Why was the wrong medication given? It was not scanned, which is one of our safety mechanisms. Why was it not scanned? Because it was an emergency situation and there are no scanners in the room. Why are there no scanners in the room? Because medical/surgical units do not have computers at bedside. Why not? Because the rooms are too small. And so on…

2. Fishbone Diagram: This visual tool examines categories of causes and drills down within each category until a cause and effect develops.

3. JPSR: One of the most powerful tools at our disposal is the JPSR or, the incident reporting system. These reports allow patient safety personnel to monitor for issues and trends. Entering a JPSR is often the first step to solving a problem and can lead to more formal reviews.

If you have not already taken our HRO Baseline training, we discuss James Reason’s Swiss Cheese Model as an example of how a systems issue, far removed from the patient, can lead to an adverse event. The model explains how holes in our systems can align and bypass existing barriers to allow adverse events to reach a patient.

?Last month I talked about the RCA process and its focus on the “what,” “how,” and “why.” The focus is never on the “who.” An RCA examines how the barriers to prevent harm failed and allowed the issue to make it through to the patient. There may be multiple Root Cause Analyses (RCAs) going on at any one time, each one focusing on issues within the system. At the conclusion of an RCA, action plans are developed, shared, and implemented with responsible services. Finally, the results of the RCA are shared with the staff, allowing all of us to learn and understand why or how the event occurred. An RCA gives us the opportunity to redesign our system to further reduce the opportunity for error and continue to improve patient safety.

?Lastly, you may notice that the Themes of the Month seem to blend in with each other. This highlights the fact that the principles and values of a High Reliability Organization are all tied together and are interdependent. However, they all reflect at least one of the three basic High Reliability Pillars: Leadership Commitment, Culture of Safety, & Continuous Process Improvement.

DAVID ISAACKS, FACHE

Executive Health System Director

Follow the North Florida/South Georgia Veterans Health System