Managing risk in hazardous conditions – improvisation is not enough

This brief opinion paper from Rene Amalberti may be of interest to my S-II network.

It focuses on strategies that can be adopted to protect patients when healthcare systems are under stress but has good info across other industries.

First they argue that healthcare systems are under stress as never before. To meet this stress, workarounds by staff are common. Workarounds may help cope with problems in the short-term, but if pressures continue then poor working conditions may manifest where “the shortterm crises gradually metamorphose into a permanently stressed system with no immediate prospect of recovery” (p1); eventually posing threats to patients.

They argue that while people are resourceful, there is little data on how often improvisations are successful. It’s said that while short-term fixes are adaptive at the time, they can impede the development of longer-term solutions.

Moreover, while the literature on adaptation focuses on managing surprises & the unexpected, they argue that “principal focus should be on expected problems and hazards”, which involve situations quite different from sudden, unexpected crises.

One of their suggestions (among others) for managing risks in difficult conditions is for comprehensive training and strategies suitable for operating in a stressed environment. For executive leaders, the training would involve a main focus on “the management and negotiation between competing priorities, particularly between safety and other objectives, both in the short and longer term” (p3).

They argue that a short-term impact on safety margins in response to other pressures can be acceptable, providing it is “actively managed, clearly expressed and communicated” (p3).

For middle managers, they need to be attuned to real conditions at the frontline and have a portfolio of possible interventions that can be deployed at times of high workload. A critical task they’re said to have is to be clear about which rules are “absolutely inviolate” and those that can be relaxed.

Managed adjustments to pressure and rules is preferable to inconsistent adaptations.

Finally, at the frontline level, training should enable workers “with a range of simple compensatory strategies that may preserve safety when compliance to best standards is becoming impossible” (p3). Healthcare huddles at each work shift and adjusting team roles based on priorities and pressures is seen as an exemplar of a dynamic frontline safety practice.

Organisations should study their types of pressures & degraded conditions & find ways of adapting safety standards to provide flexibility. For instance having common types of pressures and degraded conditions identified and their effects across the organisation is said to be the first priority in developing practical strategies against these stressors.

Finally, they argue that a shift from fantasies of “absolute safety” and targets of zero harm towards the active anticipation and management of risks may be uncomfortable shifts to take but likewise giving them up may be a “certain relief” for the clinicians operating within the daily reality of stressed systems; targets of absolute safety which may actually be an obstruction to progress.

Authors: Rene Amalberti, Charles Vincent, 2019, BMJ