A SHELL FOR SAFETY
Learning from other industries is important, airlines and pilots have been the common sources for healthcare; the oil industry, especially SHELL is also a very good source.
THE CHALLENGE THROWN TO HEALTHCARE
The oil company SHELL has an extremely high priority for safety. When SHELL do any construction work the area is marked 'This is a safe work place'. It is not a warning or an advisory, it is a statement. At the International Forum for Quality and Safety in Healthcare at Amsterdam in 2011, the question and the challenge that was posed was, which hospital actually has a sign that says 'this is a safe hospital' and which hospitals are working towards that explicit goal?
That is very interesting. Would it be possible to guarantee safety in healthcare? As an enthusiast I would argue that it would be possible in many areas, well at least in some areas, but as a realist I know it would be difficult.
Mr. Rein Willems was the Chairman of SHELL and is now a member of the upper house in Netherlands. He has authored the brief but powerful report which is now the basis of improving safety and quality of healthcare in Netherlands. He spoke at the Forum in Amsterdam. I share some of the messages here.
RED LINES AND DISCIPLINE
In Shell, the by-line for 'this is a safe work place' is ''here you work safely or you don't work here at all''. Willems said that there was an occasion when a worker despite adequate warning and training persisted in the unsafe practise of smoking in a non-smoking zone in a production site and the CEO physically escorted that employee out of the premises and the employee was sacked on the spot.
Though it is a dramatic example it illustrates the seriousness with which safety is taken in Shell. What is our equivalent example in healthcare? We may do that for fraud or for smoking near the oxygen tanks – those are important but are general to any facility – what is the example that relates to clinical care delivery?
MANAGING VERSUS SOLVING
Willems went on to use the iceberg analogy that for every single fatality there were 50s of 'lost time accidents', 100s of property damage or minor injury, 1000s of accidents/incidents with no injury and 10000s of small events/breaches. To avoid that single fatality the underlying causes of 'small incidents' have to be fixed. Managing small events without fixing the underlying causes will eventually escalate into major problems.
In healthcare we are very good at emphasising on 'risk management'. As far as I am aware risk management is about identifying and understanding risks and minimising them. Which is at least a bit different from enhancing safety – which is about continuously increasing the standard of practice to the best that is currently possible. In terms of quality, risk management could probably equate to the principle of quality control by checking the products. Safety in healthcare would probably be the equivalent of getting it right as we go along. There lies the difference.
Having said that, it is possible that some of the people who are currently doing governance and risk are also doing safety; hats off to them since they have to cope with varying threads within a concept. I suspect most people may not be doing this.
EVERYONE DOING THE SAME THING
Willems also touched on the concept of uniformity of shared practices. In Shell they have a policy where 'all employees should have one hand on the stair rail when they are going up or down stairs' this was implemented in their sites (oil fields and refineries). On one occasion Willem and his CEO were photographed in the head office walking the stairs with papers in hand without holding the side-rails. An employee wrote to Willem querying if the rule applied only to lower level staff. With a view to leading by example and with a view to having similar rules for everyone in Shell it is now the policy that whether one is on the field/rig/factory sites or in offices that one hand must be on the rails while going up or down stairs.
We in healthcare are no SHELL but to be fair I have seen a senior board director removing her jewellery before entering a ward, though she was there for administrative reasons. That is a good sign.
I think the core idea was that senior leadership has to play a very visible, proactive and hands-on role in the area of shared baselines, analysing data, resolving issues and safety. These concepts are essential for safe healthcare but are not often done in comprehensive or meaningful ways; that is what we ought to get right.
Shell and Willems do have generic lessons for us in healthcare.
NOTE: The writing in italics are my personal views. The normal type is what Mr Willems said or his views.