Healthcare Improvement Scotland supports continuous improvement in health care and social care practice and this event is part of their QI Connect WebEx series connecting health and care professionals with improvement expertise from all over the world.
This event took place on 8 November at the Planetarium within the Glasgow Science Centre, with more than 120 health and social care colleagues in attendance and many more attending virtually by WebEx.
“This is always a difficult presentation for me, but it is one of hope. The hope is that the people who hear it will tell the story and spread the word. The similarities in what we did, in terms of understanding, mitigating and minimising risk is as much as part of your everyday job in caring for your patients, as it is mine. To me, I owe it to the next generation of people who climb into the next space craft. I don’t want them to end up in the same situation as my friends, the crew of Space Shuttle Columbia.”
|Dr Nigel Packham|
On 16th January 2003, Space Shuttle Columbia (STS-107) embarked on her 28th orbital flight which was to be a 16 day science mission. At 81.7 seconds into the flight, a piece of foam detached from the external fuel tank and collided with the left wing of Columbia causing significant damage. Whilst in space, Columbia was able to perform what appeared to be as normal and the crew of seven completed their scheduled experiments successfully and without any cause for concern.
On 1 February 2003, Columbia deorbited and reached the entry interface to the Earth’s atmosphere (around 400,000 feet in altitude) travelling at 24.5 times the speed of sound. The planned touchdown at the Kennedy Space Centre, Florida, was at 14.15 pm GMT. At 13.58pm GMT, Mission Control reported an issue with the inboard tyre pressure on the left side of the Shuttle and by 13.59 pm GMT, they had lost communication with the crew.
“In the space of 10 seconds we went from being in control to being out of control.”
The tragedy of the last moments prior to the disintegration of Space Shuttle Columbia was graphically shown through different perspectives. Through those watching on the ground; a video simulation depicting a vehicle out of control; and the impending disaster through the eyes of the crew who bravely battled to re-gain control.
Each of these perspectives show the same tragic events unfolding but from different viewpoints. The story of NASA’s learning from the Columbia disaster has learning for health and social care.
Is it safe?
The simple fact, as Nigel explains is that space travel is not without risk and, as in health and social care, we need to, instead, ask the question: ‘is it safe enough?’ How we manage risk is key. We must identify and understand the likelihood of any risk and mitigate to minimise the potential impact.
But, who ultimately accepts these risks? In space travel, this would, of course, be the astronauts themselves. Within health and social care, we have a responsibility to ensure that people are supported to make an informed decision about their own care and understand the risks they are ultimately facing. The principles of ‘Realistic Medicine’ now apply, not only globally, but also universally.
The consideration and interpretation of risk changes with the accumulation of knowledge. The risk of a disaster at the outset of the Space Shuttle Programme in 1981 was estimated between 1:1,000 and 1:10,000. By the time of the completion of Shuttle Programme in 2011, 135 flights later, the modern tools estimated the risk for the first flight was revised to 1:12. New data and the accumulation of learning made NASA radically re assess their quantification of the risks of space travel.
So what about health and social care? How should we systematically interpret our perception of risk based on our experience of incidents, both locally and nationally? How do we share our knowledge and learning so that we can prevent further tragedies?
“These were our friends"
Following the Columbia disaster, NASA has carefully considered its culture and leadership model. Their decision to publically share the final investigation report would, in no doubt, have been a difficult one, due to the sensitivities for the families and loved ones of the crew but, also, for NASA staff who were responsible for guiding the Shuttle safely back to Earth.
As part of their commitment to continuous improvement, NASA now routinely collect and share examples of real and potential adverse events at different stages - from blast off, to orbit, re-entry, and landing. Each stage is described as well as the implications for improved and ultimately safer systems. Sharing this internally to improve their own safety procedures is one thing, but NASA goes a step further by pro-actively sharing with other space faring nations so that they can also learn and avoid making similar mistakes.
Ensuring that we too create a culture within health and social care which supports openness and learning is essential so that we can continue to make care better. The events in Mid Staffordshire NHS Trust highlighted the fundamental difference in perspectives of the Trust Board, the regulators who oversaw that Trust, the staff and those families caring for their loved ones. The voices of the weakest - the junior doctors and the families - were not heard until it was too late. From the bed side to the board room, there was a deep and fundamental failure to listen and to act.
Lessons for Healthcare
There is much that we can learn from NASA as well as other high risk and high reliable organisations. Specifically, how they have continued to develop processes to support learning and improvement following close calls or poor outcomes. Though there are inherent differences between health care and space flight, it is evident that success in outcomes in both these fields is ultimately dependent on the interaction between systems, people and environment.
The key is to have a better understanding of these interactions within a complex systems and its relevance when things do go wrong. Often when reviews of ‘incidents’ or adverse events are performed in healthcare, there can exist disconnect between reviewers and individuals or teams involved with the care of the patient. This includes differences in understanding of the challenges faced at the various levels within the overall system meant to support provision of good care. Feedback from reviews may be delayed or even not shared. This highlights the significance of the concept of Work-As-Imagined versus Work-as-Done in healthcare which often contributes to constraints in conducting effective reviews. This inevitably leads to a lost opportunity in understanding weaknesses within the system, possible incorrect focus on what is deemed to be the required improvements as well as in difficulty in capturing and sharing learning.
We believe a significant opportunity does already exist in health care to address these challenges and we are working on optimising this process for NHS Scotland. Mortality and Morbidity Review (M&M) or similar peer review meetings and process describes a systematic approach that provides members of a healthcare team with the opportunity for timely peer review of complaints, adverse events, complications or mortality. This facilitates reflection, learning and improvement in patient care. Importantly, such peer review processes also provide the opportunity to explore and inquire the significant majority of good practice that occurs daily in patient care.
When carried out well, structured M&Ms have added advantages compared to other review processes, including being as near to the event or patient experience as possible and helps promote a culture which support openness and learning in organisations. It provides an opportunity for teams to seek multiple perspectives, describe and discuss complex systems issues and interactions which may have contributed to the event. These factors can be missed when carrying out case note reviews or audits of care. M&Ms also facilitate sharing of learning and immediate feedback, ensuring concerns are addressed immediately thus helping mitigate against errors recurring whilst a relatively lengthy review process is undertaken. This process brings Work- As- Imagined and Work-As-Done closer and provides an opportunity for a better understanding of risks and sharing of learning from frontline to board to improve care.
|Jennifer, Nigel and Manoj|
Robbie Pearson, Chief Executive, Healthcare Improvement Scotland @rpearson1969
Jennifer Graham, Clinical Programme Manager, Healthcare Improvement Scotland @jennigraham8