Frequilibrium and the myth of patient safety…

Who designed the roof currently over your head? There’s several tonnes of it, dangling there. Who built the roof and how qualified or experienced were they? There are all sorts of designs, materials and ways of putting it together. How likely are you to survive that bloody big thing landing on your head?

To be honest, nobody cares. You’ve probably never given those questions a single thought, ever, despite the number of roofs you’ve been under. Unless of course, you design and build the odd roof, or you’re one of those very rare people who have been under one when it collapsed and survived. Nobody really cares about safety in general and neither should they, because in normal life safety is passive, it’s a hygiene factor at best. Safety is also weirdly context dependent. What’s safe one day is not the next day and nothing obvious has changed. When safety is there, everything is ticketyboo, but in reality is safety, really there? Where is it, hang on, it’s mostly not there, wherever you are. Go on, right now, look at the safety, try to measure it, or even just point at it.

There will be a clever clogs somewhere sat in a car reading this (hopefully in a passenger seat) now pointing at the seat belt. Wrong. Seatbelts are not safe. They will hurt you and if you’re really short, probably rip your head off in a big smash. Seatbelts, are a legislative mitigation to reduce the socioeconomic effects of crashing cars. They are designed to be minimally intrusive, not safe. You want safe, it’s a four point harness and a full face helmet with an integral neck brace. I’m not being sarcastic, the baby gets a harness and if you were really interested in safety, you’d install them in your car today. What this is about is risk, and that is commonly, intellectually and statistically not very well understood. My favourite seatbelt is the one on a plane. If anyone thinks that little belt across your lap is going to protect you in a 450 tonne bullet shaped plummet towards the ground at 600mph, you haven’t thought this through. That belt is to stop your carcass flying out of the seat and becoming its own projectile.

And on that note, the aircraft industry is a pretty pathetic analogy for safety in healthcare and there’s way too much of it being peddled about. A commercial aircraft is a giant machine, designed to work perfectly with many layers of redundancy. Apart from the half a dozen staff, the people on board are little more than cargo, cocooned meat only present for a transitory hour or two. That’s not healthcare, which apart from the odd little machine, is made up of highly volatile and interacting crowds of the walking dead, who hang around for decades. Even the super fit ones working perfectly are dying, albeit really slowly, while the majority of people, are in healthcare because they are already in harm’s way. The only real lessons to be learnt in Healthcare from an Aircraft, is after it’s crashed. The huge fractal network that prevents them crashing into each other is more analogous, but nobody talks about them trolls under bridges.

The truth is, if you’re alive, you are not safe. If you’re not alive, an inanimate object, you’re only safe if you’re not interacting with other objects or natural phenomena like gravity or weather. Even a brick, lying on the floor minding its own business is not safe if it starts to interact. The number of bricks and other heavy shit that has fallen off stuff and killed people while someone is busy building the roof, you wouldn’t believe. In the Architectural business we used to be pretty good at bumping off builders while building stuff: mostly with those inanimate things, sometimes because there’s a bloody idiot on site and sometimes because well, never sleep with a fellow roofer’s other half.

Now we’ve got Alf and Shifty, the hard hatted yellow vested House Elves with the stripy tape and a clipboard listing how much of everything is where and when. But again, most of the safety stuff is passive. We now have to design lots of safety features in to buildings like emergency lighting, sprinklers and fire exists to name the obvious stuff. But what you may not be so familiar with, is that now we also have to design safety into the methods of building. In the most sophisticated designs the scaffolding required to build safely, is absorbed into the structure itself as the building reaches its liminal threshold.

It took 100 years for Architecture to relearn something forgotten. The most powerful tool for protecting the people is the people themselves: well trained, experienced, working in small teams and viscerally and consciously aware of the harm all around them. Some experienced practitioners even think they have a sixth sense for this sort of thing and Gary Klein’s classic Sources of Power is well worth a read. I’d go even further and suggest that clinicians do develop a sophisticated sense of Anticipatory Awareness (a phrase coined by Klein). My mother, an old school Nurse, called it her Radar and “once it’s on, you can’t turn it off”. She walks behind people in the supermarket, spotting the ones who shouldn’t bother with a big shop.

Thankfully and similar to doctors, Architects take 7 years to train, have to pass two professional exams to register with the RIBA and then several years of supervised practice before they can design something to dangle over your head. And even then, there’s a bunch of engineers alongside, working out the maths and most of the other heavy lifting. Ask an Architect what’s 2+2 and they’ll say “somewhere between 3 and 5, go check with the engineer”. The engineer will say “4.0 but we’d better call it 8.0 just to be safe”. That’s redundancy that is, designed into the roof above your head.

So, what on earth has put a Bee in my Bonnet about Safety. The new fangled thing called Safety Two! The first thing SafetyII has done is to set up an Aunt Sally called SafetyI to attack and decry. SafetyI they say, is all about fixed industrial notions of inspection and perfection and process control and a binary insistence on right or wrong. And it bloody well is! In fact there are entire institutions whose role is to turn up and count the dead. They all use the ABCDE method typical of all inspections and pantomimes where a load of stripes and epaulettes appear down near the work, just after the painters have left. SafetyI is a description of how hierarchical bureaucracies do safety, not how clinicians do safety, because clinicians don’t do, safety.

Healthcare is not a safety critical industry, mainly because (outside of the US) it is not a bloody industry. It’s a biology and that works differently. Even some of the supposedly great thinking in Safety such as Reason’s Swiss Cheese malarkey, doesn’t translate into Health. We got 75 different cheeses, some impenetrable and some crumbly and only the odd slice of Reason’s posh one, with holes in. Fair enough, if you’re running a nuclear power station, or an aircraft carrier, or nitrating glycerol, you can’t afford any mistakes. Things have to be designed to not break, be robust and that is SafetyI, right there.

Trouble is, that’s crap, even those industries have moved on. Nuclear power stations are not designed never to fail any more, because that design brief had the unintended consequence of making the system inflexible and brittle and they tended to break, catastrophically. Now, power stations are built to a high standard, but they are expected to go wrong. They are designed so that the smallest deviations are picked up and displayed to very clever people who know how to correct the problem when it’s small and easy and of little consequence.

Interestingly this is a feature of complex living systems, called homeostasis or a state of dynamic equilibrium. The system is neither fixed nor completely random, but somewhere in between. In complexity science this is called far-from-equilibrium, where a body attempts to maintain a large number of fluctuating features within a small range, irrespective of the external conditions. This frequilibrium, as I call it, is the normal state of living things and even you right now, are in this state: get too hot you sweat, too dry you get thirsty, stay still too long and you get fidgety. To work, frequilibrium needs entropy (some spare energy to play with) and variety (lots of ways to play).

Inanimate objects don’t have much frequilibrium, but then even the brick, minding its own business will eventually degrade entropically into the environment, albeit very bloody slowly. The most complicated inanimate systems, machines, that have to interact with or augment, the most complex living systems, people, are now designed to be imperfect and simulate this frequilibrium. The latest fighter planes are aerodynamically unstable in normal flight. They have sophisticated sensors and computers that constantly stabilise the effect and provide acute feedback to the pilots. An unstable fighter plane is considerably more manoeuvrable, limited only by the sack of meat giving the obtuse instructions. It’s why increasingly, the meat is now in a bunker with a VR headset and a very cool wobbly seat.

And this is the thing, SafetyII says, we need to move away – from the machine metaphors of manufacturing and the process control mindset of 100yrs ago – to a new paradigm. Then they go on to describe the features of working in complex systems. How on earth can I be upset with that, after all, that’s what I bang on about all the time. Surely they are advocating my favourite thing?

They go right up to the plate glass window that is the paradigm shift they are looking for and then, stop. It’s like the authors can see the complex adaptive system that is healthcare, but it’s all a bit blurred and muted, the other side of the glass. They’ve got their noses squashed up against the threshold concept but can’t quite get through to it. As a result they describe too much of the new world using old world thinking. Kieran Sweeney’s fab book was published 10 years ago and Trish Greenhalgh was publishing on Complexity in Healthcare 5 years before that. Then there is the 70 years of complexity science that goes virtually unmentioned.

I used to manage Maternity, technically the highest risk place in any health system and scarily, it wasn’t so long ago that we’d lose 1 in 10 babies and 1 in 200 women. Thankfully, we’ve moved on considerably. My Maternity Committee that dealt with governance, audit, risk and learning was second to none and our midwives were the most prolific users of Datix (the national incident reporting system). But we were all frustrated by the inflexibility, lethargy and retrospective bias of our own organisation, when we needed to move quickly and creatively. Safety was for fire extinguishers and wet floor signs, whereas we were all about managing the harm, right here, right now, on the shop floor. A Complex Adaptive System is a practice not a theory and in Maternity, we were all too aware that baby doesn’t know the plan. So you have to work in advance of need and deploy resources in proximity to favourable conditions, to make sure as many things as possible went right.

The phrase I coined for this enhanced prescience is a Tactical Exaptive System – it’s like a Complex Adaptive System, but with a brain that knows it’s in one. With this heightened anticipatory awareness, we prepared for and proactively managed in the Amber (above) and occasionally had to be open and inclusive about the rest, when failure was inevitable. An episiotomy, a perineal tear or a caesarian section – preferably none of the above, but you prepare for them all. In Maternity that’s called ‘maintaining normality’ and just in my experience, that was 15 years before SafetyII was even conceived.

So, I think to myself while reading through it all, SafetyII is absolutely a step in the right direction and the work that the proponents are doing to drag the SafetyI people out of the 1920s is brilliant. Then they go and shoot themselves in the foot with that poxy SafetyI bellend curve of a normal distribution. Most phenomena in healthcare follow a power law distribution. Then that little semantic clue to the lack of insight into practice within complex systems described as Work-as-Imagined versus Work-as-Done. Now that distinction, certainly exists and I wish I could go back in time to give Taylor a square kick in the nuts. But imagination, is a key component of working in a tactical, anticipatory way. I think the sentiment is better described by the phrase Work-as-Idealised versus Work-as-Done.

Now the authors are not dull, they know their stuff, so I assume the gentle shift towards complexity is deliberately designed not to scare the SafetyI brigade too much and temp them up to the glass for a look. My fear is that SafetyII is offering the idiots all the new words that they need to appear like they’ve moved on. Meanwhile, they will continue to advocate the same old counting the dead industrial process control nonsense of inspect and blame. I can already smell the slightly shinier set of platitudes they’ll use to conceal their ongoing failure to appreciate the inherent frequilibrium of healthcare.

So in short, I’m just being really grumpy. My frustration is that SafetyII is being pitched way too close and in the familiar language of SafetyI. But, this rant is not about semantics. More importantly, clinical practice has already moved on and the engineering, the systems of support and sophistication required to nurture the frequilibrium, needs to exceed that of the fighter pilot and be pitched directly at the business end of healthcare.

And on that point, Healthcare is in the business of harm, not safety. The word patient itself, is derived from the Latin ‘patior’ which means, I am suffering. Across my little career it took us ages to embrace ‘Harm’ and talk about it openly, intelligently and all too often, unnecessarily courageously – because of the media penchant for blame and a root cause. Ironically the sorts of situations that typically triggered a Root Cause Analysis, by definition had no root cause.

To get into healthcare, you are already in harm’s way. You got harm and we’ve got the knowledge and skills to fix most of it. We do that in a real, live negotiation about harm. You got a crippling pain in your belly and we’ll work out if it’s raging appendicitis, because that can kill you. So we’ll offer to scan you #harmful knock you out #harmful cut you open #harmful lop it out #harmful sew you up #harmful bring you round #harmful give you drugs #harmful and plonk you in a bed surrounded by other broken people #harmful. And typically, society takes it for granted that all the harmful stuff we do, equates to less than trying to live with a burst appendix. Mainly because we also have some experience and evidence about appendicitis.

Like Architecture, Medicine seems to have forgotten something. Primum non nocere does not mean, do no harm. It says, “first, do no harm”. It means to be ethically and consciously aware of the harm and the attention to context required to see every situation holistically and in balance. A cantankerous Geriatrician I once worked with, used the term “masterly inactivity” when that equation was out of balance. That’s frequilibrium right there.

In the 90s we didn’t get the Harm conversation right and it arguably resulted in that ‘To Err is Human’ cognitive fallacy, making out that everyone is just one distracted glance away from idiocy. First time around we were still fighting the SafetyI bureaucracies of inspect and blame. SafetyII does offer us a much better context within which to take that conversation forward and this time, with the patients and society at large, as partners. Healthcare is a bloody dangerous place and you don’t want to be in here, unless you absolutely have to. Switching the conversation back to Safety feels like a rebranding exercise to avoid the tough conversations and even tougher decisions. Fighter planes or Healthcare and they are not compatible.

I’ve got a watch that checks my heart rate, temperature and respiration and a phone that can share it with the world (even if I don’t want it to). Yet in most healthcare settings this basic feedback on our natural frequilibrium is done every now and again with 1960s technology, a pen and a visually indecipherable sheet of A3 paper! Recus or ITU are probably the exception, but fighter pilot levels of real time feedback should be the rule, not the exception.

The patient’s are our greatest source of information about harm and live sensory feedback to help us make decisions in real time. With that feedback we’ve already got nurses that can spot problems way before they happen, but they have no real time mechanisms to display these judgements when the problems are small, like in the power station. Worst of all in many cases, there are not enough nurses to fly all the planes in the air, at the same time. That’s enough of the analogies. The notion of patient safety seems laudable at first glance, but the moment you get into the real grit of delivering the business of healthcare, it quickly becomes little more than a political distraction or worse, a spin filled exercise in social marketing. Most of the Safety proselytes have spent too long, too far away from patients.

I do appreciate the motivation for SafetyII but semantically, etymologically and philosophically speaking: safety culture, my arse! I want an open, intelligent, responsive and feedback rich, living system that is sensitive to Harm and filled with Anticipatory Awareness.

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