Welcome to Episode Four: Systems Reengineering. Systems engineering or reengineering refers to the process of analyzing, designing and managing complex systems with the goals of optimizing efficiency, reliability and productivity. Systems engineering engages knowledge and skills from many disciplines including sociology, psychology, engineering, statistics, logic, healthcare and many others. Systems engineering is also a team effort often requiring a number of different disciplines, implying that these teams that engage in reengineering should include individuals of varied backgrounds and experiences. Most countries including the US have been slow to fully institute systems engineering into building safer patient care systems. A report to the president of the United States called Better Health Care at Lower Cost: Accelerating Improvement Through Systems Engineering provided recommendations to better support the application systems and engineering to healthcare. These include first, accelerating alignment of payment systems with safe outcomes. Secondly, increasing access to relevant health data and analytics. Third, providing technical assistance in systems-engineering approaches. Fourth, involving communities in improving health-care delivery. Fifth, sharing lessons learned from successful improvement efforts. And finally, training healthcare professionals in new skills and approaches related to system design and engineering in healthcare. Systems engineering begins with creating a deep understanding of how errors and harm emerge from within a system. The search for information needs to focus on all systems and subsystems that feed into a particular problem. For instance, if you consider the medical laboratory as a system. And if laboratory results are not readily available when needed, the problem could be related to a subsystem such as the deliver of specimens or how the specimens are transported to the lab. Model developed by James Reason is referred to the Swiss Cheese Model of Safety, because of how it illustrates that errors occur when a number of potential areas that can fail within a system align in a way that allows the failure through an entire process. Sort of like the holes in a block of Swiss cheese. In this model, Reason identifies four major categories that give rise to these potential failures including organizational influences, supervision, preconditions and specific actions. The Reason model also includes the concepts of latent and active factors. Latent factors are factors that exist, but are not recognized until an incident actually occurs such as a lack of free and open communication about potential hazards or recognized problems in an environment. Active factors include direct actions that lead to a failure or an error such as giving the wrong medication to a patient. The most interesting aspect of reasons model is understanding that in safety problems, a number of potential areas subject to failure actually line up and create a hole that runs through the entire slice of cheese and in the case of healthcare, an entire process. This actually happens frequently when systems are poorly designed. In this model, a large hole can be thought of as a fairly high risk failure while smaller holes represent processes at lower, but still some risk of failure. The number of holes is a representation of the overall probability of failures. The alignment of holes through multiple layers can be thought of where processes have few or no checks or redundancies that can block or check a failure that has occurred. For example, a failure where a medication is sent by the pharmacy to the wrong patient can be interrupted before it causes harm by a recheck of the medication. The label and the patient identification band by a nurse or other provider. Another example is when there is harm to a patient, because a physician entered the wrong dose for a drug. The pharmacy didn't catch the error and the nurse administering the drug didn't question the dosage. In this case, all of the failures were holes lined up produce a drug error that may cause harm or even death to a patient. In the Lewis Blackman story, there were many failures of the system that aligned to result in Lewis's death. Using Reason model, consider the latent, for example, system design flaws that allowed the event to occur and the active factors, for example, actions taken or not taken. What were these factors and how would the identification of these factors inform potential improvements? Based on a careful analysis of errors, we can better understand specific factors that lead to harmful events and work such as that of reasons leads us to greater understanding of how adverse events evolve. In addition, there are a growing number of processes that have been developed to guide reengineering efforts. These approaches include lean, six sigma, total quality improvement, the PDSA cycle, and others. All of these models have the significant overlap in the core processes that they use to identify potential or observe flaws in the systems and to fix them. Most of these were developed outside of healthcare in areas like aviation or manufacturing and only recently applied to healthcare. While used extensively in safety reengineering, they also address quality concerns beyond the realm of safety. We will examine some of these processes in more detail in a later module. In addition to these approaches to safety, there are also other tools and technologies that can help in developing specific interventions to address identified problems in either safety or other areas of quality. These tools include checklists, time outs and a variety of tools address to specific areas of care and care processes. You're resources include additional information to guide further exploration of the many different models and tools that can be applied to the design, and implementation or patient safety interventions. Both exploration of why a harmful event has occurred, as well as systems design and redesign require close teamwork. Teamwork requires both formal and informal interaction between those involved in the exploration. Remediation or redesign and those involved in day to day care to effectively make, and maintain changes that make care safer or of higher quality. In the next episode, we'll discuss in greater depth the role of teamwork and other human factors in patient safety improvement.
