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As Cardiothoracic Surgeons we have a long and proud tradition of honest self-examination and quantitative outcomes analysis. Our national database is a model for other specialties and has proven its value in process improvement on a grand scale. With the CTSRS near-miss reporting site we have taken the next step in advancing ourselves as a High Reliability Profession.
What is meant by the term "High Reliability" in this context? High Reliability Organizations (HROs) are organizations that function in "high consequence" environments in which failure is visibly catastrophic. Accordingly, they have, of necessity, evolved to perform reliably despite the occurrence of "normal errors" (Normal Accidents: Living with High-Risk Technologies, by Charles Perrow, Basic Books, NY, 1984.) - errors that occur as an inevitable consequence of the complexity of operations that are tightly coupled and highly interactive with human beings at technological interfaces. HRO's are masters of "error management," including error capture and recovery, as well as prevention. Examples of such industries are nuclear power, air traffic control, and naval aircraft carrier operations. While our failures in Cardiothoracic Surgery are less visible, they are no less catastrophic. This is particularly so against a background of truly remarkable outcomes today despite increasingly fragile, elderly patients with multiple co-morbidities. An avoidable patient injury or death is not only devastating to the family, but to us as care providers as well for whom "defeat may be snatched from the jaws of victory" after a long and complex procedure or hospitalization. We all share such experiences. So is there something we can learn from others involved in complex activities?
Because of their impact in the world of business, HRO's have been the subject of academic study (Managing the Unexpected: Assuring High Performance in an Age of Complexity, by Karl E. Weick and Kathleen M. Sutciffe, John Wiley and Sons, NY, 2001). A number of common characteristics have been identified among these organizations as they have evolved over time: HROs are characterized by mindful management of operations through (1) a preoccupation with failure, (2) a reluctance to simplify interpretations, (3) a sensitivity to operations, (4) a commitment to resilience, and (5) deference to expertise. We believe that these same principles are applicable to Cardiothoracic Surgery; indeed they are already operational to at least some degree in our daily practice even if we have not labeled them so. The CTSRS supports these very characteristics already a part of our culture on a global scale and so can help take us another step toward realizing higher reliability - but only if we use it.
It could be said that no other characteristic of HRO's is already manifest in cardiothoracic surgery more than a "preoccupation with failure." We are trained to constantly anticipate potential pitfalls, and to maintain a high degree of alertness. The question is, however, "do we engender that attitude in our teams?" In the context of HRO's, "preoccupation with failure" refers to a mindset that guards against complacency and automatic activity by encouraging reporting and discussion of errors. Importantly, this includes near-misses, which are taken as signs of vulnerabilities or, in the language of Reason, "latent failures"(Managing the Risks of Organizational Accidents, James T. Reason, Ashgate Publishing Limited, Hampshire, 1997). If identified, these potential gaps in the process can be corrected. Many such gaps will be unique to the specific practice setting; however there may also be common themes that reach across organizations. We believe that by sharing stories revealing such gaps openly through the CTSRS, readers may be better able to identify similar failures in their own practice settings.
Beyond error reporting, HRO's typically reinforce a general attitude of "resistance to simplification" of the mental model of a situation or circumstance. While simplicity in the conduct of an operation is an important means of reducing error, simplification of one's mental model tends to degrade situational awareness. Instead we must insist on continual reassessment and refinement of our understanding of the situation as data continue to come in. We must encourage the rest of the team to do so as well.
The best clinicians seem to do this updating spontaneously, but if we are to teach the skill to the next generation, it is advantageous to label it and understand it. With shortened work hours, they will be less able to learn these skills by "osmosis." We must constantly challenge them to build ever more nuanced mental models.
How best can we cultivate such understanding? Surely it must be by broadening our base of experience. And what better way to do so than by learning from each other just as we did in residency when listening to one another's disasters and near-disasters? The CTSRS provides a forum to do just that.
The third characteristic of HRO's is "sensitivity to operations." This refers to a focus on what is really happening on the front lines of care. Again the CTSRS has the potential to help us realize this aim. This may seem trivial to us as surgeons, intently on the front lines and by nature detail-oriented. But we must take care not to be egocentric. Sensitivity to operations means sensitivity to all operations and all caregivers on the team. This demands open communication and active reporting from everyone involved in the care of the patient as each has a slightly different view of the landscape. Surely by reading near-miss reports authored by other members of the team we can gain insights into their perspectives and experience its value. It is not an accident that the CTSRS is open to entries from all CTSNet members, and not only surgeons.
The fourth characteristic of HRO's, "commitment to resilience," is also familiar to cardiothoracic surgeons although we may not have labeled it as such. Again, this is a skill to which the CTSRS can contribute. We are taught from our early years to consider "what are the dangers and what are your options" throughout the operative case. Indeed, if there is a hallmark to our specialty, it is the ability to improvise on the fly. The CTSRS was conceived as a forum in which modes of recovery can be shared and learned. The means of recovery is surely just as valuable a lesson as the mode of failure.
The fifth characteristic of HRO's is one that may, at first blush, appear to run counter to some of our training and, one might argue, challenge our culture as surgeons. "Deference to expertise" refers not to academic station or temporal seniority, but rather to actual operational expertise. For example, in a circumstance in which there is inadequate venous return on CPB, the highest level of expertise in running the pump should reside with the perfusionist - not the surgeon. In that instance, the surgeon should, in theory, defer to the perfusionist. This may challenge our notion of what it is to be "captain of the ship," and the responsible party, however, in an HRO's such as an aircraft carrier, a landing signal officer (LSO) has authority to grade and if necessary abort a landing by a pilot who may formally "outrank" them. While this may sound an awkward arrangement, it is a practice focused on the outcome desired as the primary focus and in the end it serves all involved, including the pilot. In our field, this does not mean turning control of the operation over to the perfusionist, but rather working with them in a cooperative manner to troubleshoot the problem rather than dismissing their concerns. Again, it is our hope that through the CTSRS, surgeons will learn from other providers, seeing matters from their perspective and vice versa. For all this potential, the CTSRS will only be a useful tool if events are shared by the readership. This is common practice in aviation today, and while analogies between medicine and aviation may have worn a bit thin, surely we are able to learn from other professionals engaged in high consequence activities in complex environments. Indeed, if we are to argue that our work is vastly more complex and unpredictable, surely this argues even more strongly for us to learn from one another. So please contribute to the CTSRS as we advance to the next level as a learning community once again leading the way in medicine.