There has been no shortage of blame for the poisoning of Flint, Michigan's water supply. In March, a governor-appointed task force issued a report that rebuked local, state and federal authorities for their actions — and inactions — that created the public health crisis. Then, in late April, state prosecutors announced the first charges in the scandal, as two state employees and one city official were accused of tampering with water samples and covering up the results. And on Wednesday, the Michigan attorney general announced that his office had filed a lawsuit against an engineering firm and a water company involved in the water crisis.
Yet some of the most serious criticism has been directed not at individuals or government agencies but at the state's Emergency Manager Law, which provided a backdrop for the crisis to unfold. Under the law, state-appointed emergency city managers are charged with bringing troubled municipalities out of financial ruin, report directly to the state treasury, and have no requirement to get input or approval from local elected officials. So when Flint decided, as a money-saving measure, to temporarily switch its water supply to its namesake river, the emergency managers had no obligation to publicly vet its decisions or seek feedback from water quality experts.
As we now know, what might have seemed like a straightforward, purely financial decision at the time turned out instead to be a massive public health catastrophe. The Flint River's water is reportedly eight times as corrosive as that of the city's previous water source, and yet anti-corrosive chemicals were not added to the supply (possibly because the city water plant needed expensive equipment upgrades before it could add corrosion control treatment). The water ate away at the film protecting the water lines, causing lead to leach into the supply, exposing thousands of people to the neurotoxin.
Emergency managers' powers removed "the checks and balances and public accountability that come with public decision-making," the state task force wrote. Even when cities are broke, they added, solutions must take into account issues such as quality of life, economic development and maintaining infrastructure. Yet, "emergency managers charged with financial reform often do not have, nor are they supported by, the necessary expertise to manage nonfinancial aspects of municipal government."
Leaders' Downstream Impacts
Flint's water problems might sound distant from hospital board rooms, but there's much that we can learn from this disaster. One is recognizing how conditions created at the leadership level, even those that may seem unrelated to safety, can create latent risks downstream. In Flint, it was emergency managers' near-absolute powers, together with their narrow focus on financial performance, that may have blinded them to more carefully consider the health impacts of their decisions.
Psychologist James Reason, a renowned expert on human error, explained leadership's essential role in fostering safe organizations. "Only in the upper levels of the system can we begin to get to grips with the 'parent' failures ... that create the downstream 'problem children.' If these [conditions] remain unchanged, then efforts to improve things at the workplace and worker level will be largely in vain."
In health care, the potential patient safety impacts of a leadership decision could be somewhat simple to predict. A proposal to reduce patient care staff may pile even more work onto overloaded employees, making them more prone to omit double checks or proper patient identification procedures. Yet for other decisions, the risks may not be divined unless leaders stop and consider them. For example, when technology investments are made, do we conduct human factors analyses to understand how those products may alter clinical workflow or workloads? Do staff members have the necessary skills to use the technology safely? Do we conduct failure mode and effects analyses before implementation?
We should also consider converging risks. If your hospital plans to go live with a major new system at a time of high occupancy, low staffing and a new batch of residents coming on board, that might be problematic. You have to consider the context of a proposed action.
The scandal in the Department of Veterans Affairs — in which some VA hospitals moved patients off the books to hide their inability to meet wait time targets — might also be understood as the byproduct of conditions created by leadership. In an insightful New England Journal of Medicine perspective in March, Georgetown University’s Gregg Bloche explained how the VA's performance standards were unrealistic given its constraints — its clinical capacity couldn't meet demand. Bloche found similar dynamics in the scandal surrounding Britain's Mid Staffordshire Hospital scandal: Patients suffered as the hospital gamed the system to meet unrealistic quality of care targets and control costs.
In both cases, the resources fell short of expectations. "Yet the gap between the two remained unmentionable amid pressure to make care both better and cheaper," Bloche writes. "Outbreaks of dishonesty resulted, as personnel tried to finesse failures with fakery. The fakery was discovered, and perpetrators were punished. But the truth that trade-offs between quality and cost were embedded in budget constraints remained submerged."
Surfacing Hidden Risks
Contrast that situation with the ways that high-reliability organizations identify potential errors and prevent them. These organizations, in fields such as nuclear power and aviation, are fixated from top to bottom on how things might go wrong and how we can prevent them. That includes understanding how leadership actions can set the table for safer care.
At Johns Hopkins Medicine, we are attempting to surface the kinds of trade-offs that Bloche describes as part of our journey toward high reliability. So, this year, we began asking leaders to take a structured approach to consider the potential risks of the major decisions that they are weighing. A tool walks them through more than 20 questions they can consider, such as:
- Are production pressures created that may force staff to cut corners?
- Is the staff sufficiently trained to use the new equipment, processes or workflow? How do you know?
- Do the knowledge, skills and abilities of the staff members match the work required of them?
- Have you asked what could go wrong as a result of this decision?
I've been encouraged by the feedback I've received from many of our senior leaders. They say they have become increasingly conscious of their role in creating the conditions for safer care. The exercise may not necessarily cause them to reconsider a pending decision, although that is possible. They may decide that a risk is worth accepting, given the decision's benefits or its financial necessity. But at the same time, they can identify and mitigate the risks that come with it. The exercise also encourages them to seek out the wisdom of those at the "sharp end" of care — to gather feedback from those who might be affected by a decision.
This way of thinking represents an evolutionary step in the pursuit of patient safety. For the past 15 years or so, most patient safety work has focused on identifying and mitigating risks at the bedside, on the unit or in a department. While hospital leaders have mostly supported this improvement work at the sharp end — for instance, by conducting safety rounds in clinical areas — less attention has been directed at their role as leaders in creating latent risks.
Yet often, these local patient safety champions are mitigating the risks created by flawed systems and leadership decisions. They can no more prevent those risks than residents of Flint could keep the poisoned water from running into their homes.
To create the conditions for safety, we need leaders who are always on guard, seek to recognize the downstream impacts of their decisions and understand that they don't know what they don't know.
Lori, thank you for this excellent post. Your comparison to the Flint water crisis is an eye-opening awareness of the latent organizational decisions that impact care delivery at the front line. The collective wisdom at the sharp end of care has only really just begun to have a voice that impacts the leadership decision making. Through your work and many other key thought leaders in patient safety we are making strong progress in the journey toward mindful organizing, toward looking to the experts (frontline) in partnership with key decision makers (c-suite) when necessary adjustments, pivots, or large scale change happens. Leadership accountability for decisions that impact the ability for clinicians to deliver high quality safe care everyday is necessary, and begins with a first step, such as the one you have implemented through a structured tool, guided questions, and reflective inquiry.
Thank you, Rhonda. As you know, our journey the past 15 years has focused largely on assessing risk and improving care at the bedside. Hopefully this approach supports a more balanced approach to risk assessment. I would love to generate more ideas from those in the field about how to identify risk before it reaches the caregivers at the bedside.
This is a great article, Lori. I appreciate this comparison all the more because Flint is my hometown. I couldn't agree more that patient safety is driven by the climate of the institution. The climate is typically shaped by the leadership. I'm grateful that leaders are being challenged to measure their decisions against a risk assessment tool.
Excellent post, Lori. Thank you. And also for the NEJM article- very interesting.
Introducing processing and tools that will guide leadership to recognize "how conditions created at the leadership level, even those that may seem unrelated to safety, can create latent risks downstream" is an important next step in evolving risk assessment. and will require important cultural shifts to really gain traction.
Thank you for an excellent article Lori! I think this underscores the fact that we need to break from the paradigm of stigmatizing failure and emphasize transparency at every level. I continue to be encouraged when I see leaders embrace their role in creating a culture that values the contribution of everyone in the institution in driving better outcomes. I am hopeful that more hospitals will create their own Armstrong Institutes to proliferate best practices and continue advancements in patient safety. I look forward to future articles from you and your team!
Thanks for your comment, Bill. It is important that we open the aperture on our view to the health care system to include the sharp end as well as the blunt end. Significant improvement will require we consider how latent failures set frontline providers up to fail and mitigate those risks. All leaders must see their role as serving the frontline where our mission is realized.