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.
Authors:
 |
| Jennifer, Nigel and Manoj |
Robbie Pearson, Chief Executive, Healthcare Improvement Scotland @rpearson1969
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