Dec 23, 2015
I have frequently heard quoted that 80% of errors are related to system failures. There is no doubt that system failures and the inherent nature of the procedures and processes within an institution can lead to errors, oversights and mistakes. At the same time the skill sets and knowledge of employees fall within a Bell curve. By definition within any given organization, there will always be individuals who fall within the bottom quartile and ultimately those who fall into the bottom 1%. How does one reconcile system errors as a source of problems with the inherent nature of the poor performance of the lowest skilled individuals? Solving the dichotomy has implications for risk management, quality and safety programs.
High reliability organizations rely on full evaluation of the systems failures to adequately address underlying errors. Within that framework the airplane industry though finds pilot error as the most common cause for airplane crashes. The safety systems which are in place are not followed. Those in the safety and quality field are constantly reminded that the safety culture should not assign personal blame and that a punitive nature to any system will undermine its credibility and effectiveness. Some have suggested that a standard of gross negligence or intentional misdeeds are the only basis for personal accountability. This standard is far too high and ignores the underlying nature of the bottom 1% of employees with limited knowledge and skill.
How do we reconcile the use of a just culture and safety culture with the concomitant assignment of personal blame. Are the two inherently conflicted? The basis for accurate assessment of the underlying cause of the problem rests in knowing your systems and doing effective root cause analysis. At the same time each person's responsibilities and skill sets within the framework of the institution need to be clearly defined and need to be monitored and assessed to ensure adequate performance. Some institutions have an ongoing tradition involving employee evaluations where supervisors are expected to check off the box of very good or excellent in all categories. Evaluations of this nature are self-defeating for the mission of high quality safe care.
One particular anecdote involved the performance and monitoring of errors within a subgroup of 100 employees within radiology. All mistakes within that group were tracked for six months. Over this time frame multiple poor design elements in various components of the system were identified. The ultimate analysis of the data was fascinating. While systems errors were identified and corrected, the data also showed that 80% of the errors were the responsibility of 3 individuals working within the department. Further inquiry identified no surprise from coworkers of the poor performance of those outliers. There was actually a culture of denial and cover-up present.
Once again this highlights the dual etiology of many problems within industries. There is a combination of system error and poor design combined with individual performance failure. In order to maintain the safety culture and nonpunitive nature of the just culture one needs to clearly identify within individuals who are underperforming which tasks can be corrected through remediation and system redesign. Unfortunately not all failures of the personnel within the system are able to be remediated. If after multiple attempts to use systems corrections and personal interventions to correct problems those who have consistently underperformed need to be moved into an environment where they can more effectively sustain a high quality of output or reassigned to another task.
Ultimately recognizing the importance of both system assessment and personal accountability will lead to success. Each individual needs a clearly defined skill set and the institution needs to both measure and monitor in an ongoing fashion the maintenance of that skill set and performance. The proper balance of systems redesign and personal accountability is the most likely path to high quality safe care delivery.
Nicolas Argy, M.D., J.D.Health/Business Consultant/Educator, Patient Safety, Quality, Risk Management, Public Health Advocate, Witness Prep