–The US Department of Homeland Security (DHS) states “healthcare” is one of the nation’s critical infrastructures sectors, along with others like large-scale water and energy supplies.

Infrastructures, however, vary considerably in their mandates to provide vital services safely and continuously. The energy infrastructure differs depending on whether it is for electricity or natural gas, while the latter two differ from large-scale water supplies (I’ve studied all three). Yet the infrastructures for water and energy, with their central control rooms, are more similar when compared to, say, education or healthcare without such centralized operations center.

What would healthcare look like if it were managed more like other infrastructures that have centralized control rooms and systems, such as those for water and energy? Might the high reliability of infrastructural elements within the healthcare sector be a major way to better ensure patient safety?

–Four points are raised by way of answer:

 (1) High reliability theory and practice suggest that the manufacture of vaccines and compounds, by way of example, can be made reliable and safe, at least up to the point of injection. Failure in those back-end processes is exceptionally notable—as in the fungal meningitis contamination at the New England Compounding Center—because failure is preventable.

When the perspective is on medical error, the patient is at the center of the so-called sharp-end of the healthcare system. But healthcare reliability is a set of processes that includes the capacities and performance of upstream and wraparound organizations. When dominated by considerations of the sharp-end, we overlook—at our peril—the strong-end of healthcare with its backward linkages for producing medicines and treatments reliably and safely.

(2) If healthcare were an infrastructure more like those with centralized control centers, the importance of societal dread in driving reliable service provision would be dramatically underscored.

Aside from that special and important case of public health emergencies, civic attitudes toward health and medical safety lack the public dread we find to be the key foundation of support for the level of reliability pursued in other infrastructures, such as nuclear power and commercial aviation.

It is true healthcare confronts widespread social expectations and demands for high levels of reliable and safe service with potentially high costs for lapses or error. Yet commission of medical errors hasn’t generated the level of public dread associated with nuclear meltdowns or jumbo-jetliners dropping from the air. Medical errors, along with fires in medical facilities, are often “should-never-happen events,” not “must-never-happen events.”

What would generate the widespread societal dread needed to produce “must-never-happen” behavior? Answer: Getting medical treatment kills or maims you unless managed reliably and safely.

This answer may seem perverse but it is not fanciful. Put aside the horror-story medical errors (operating on the wrong eye) and consider only illnesses that arise exclusively in medical facilities and can kill (e.g., hospital-acquired diarrhea). Or consider the wider healthcare system we already have, e.g., rising healthcare costs as a percentage of GDP threatens to consume the entire US economy at current rates of increase (when I started looking at healthcare it was 12% of GDP; now it’s some 18%; note the implication: Change the definition of GDP and you change the context for healthcare and its calculations).

Perhaps the closest we get to something like a healthcare system that kills us unless managed so as not to is the spread of deadly contagious diseases through lapses in quarantine security in the public organizations concerned. But that again is in the public health sector rather than the focus here, which is the healthcare sector as a whole. But this of course raises the counter-prospect of considering all healthcare to be in the public health sector. . .

(3) To mention “the patient” within the infrastructure perspective offered here raises a major question: To what extent is the patient his or her own reliability manager in healthcare?

True, one important role of patients and their support groups is to combat any complacency in patient treatment by healthcare professionals. That said, the patient does not share the same situational awareness that his or her team/network of healthcare professionals may have about the him or her, and even then, the healthcare professionals may not have team situational awareness like that we have observed in water or electricity control rooms.

More, the electricity or water user is a reliability manager typically only during severe water or energy shortages, when their participation and collective mindfulness in rationing is critical. Is a reliable patient necessary for a reliable healthcare system during high demand times (and again not just in a public health emergency) in the same way as energy-conscious or water-conserving consumers need to be during their high use times?

How a reliable and safe healthcare system encourages a more reliable healthcare consumer would be akin to asking how does a reliable grid or water supply encourage the electricity or water consumer to be energy or water conscious. Presumably, the movement to bring real-time monitoring healthcare technology into the patient’s habitation is increasingly part of the calculus.

(4) In all this focus on the patient, it mustn’t be forgotten that there are healthcare control rooms beyond those of manufacturers of medicines mentioned above: Think most immediately of the pharmacy systems inside and outside hospitals and their pharmacists/prescriptionists as reliability professionals. Similarly there have long been efforts to bring “real-time operations centers” directly into the hospital and selected units.

–One response to preceding points is to resist their implications and insist on treating healthcare from the doctor’s or specialist’s perspective as a craft or crafts surrounded by infrastructure elements.

In this view, the doctor and nurse/specialist and pharmacist are craftspeople, while the rest is the support end or business side. Healthcare, accordingly, isn’t nor could it ever be like other “infrastructures.” (I’ll leave aside the fact that control room operators in major infrastructures are themselves craftspeople responsible for far more lives in real time than hospital staff!)

To see healthcare as “all about the patient” is, however, to imply that reducing medical error at the sharp-end is a priority, even when this focus dilutes attention and diverts management from the prevention of key production and distribution errors in healthcare without which patient safety doesn’t stand a chance.

Further, it isn’t just that there may be a “bigger bang for the added buck” in reducing some kinds of error in the strong-end of healthcare than in the sharp-end. It is also that some of the more routine or engineered processes in the infrastructure-end can be enhanced to standards of high reliability while those at the sharp-end cannot.

One final point deserves mention from a high reliability perspective when it comes to healthcare risks. Can we find 12 (or whatever number of) systematically interconnected healthcare providers so critical in the US that they could bring the healthcare sector down as was threatened when the 12 systematically interconnected banking institutions were under threat during the 2008 financial crisis? If so, we would have a healthcare sector in need of “stress tests” for systemic risks just as post-2008 financial services institutions have had to undergo.

Note: I believe much of the above holds for parts of veterinary care and the public health sector, but leave that discussion for another time. I thank Paul Schulman for many discussions, suggestions, and points; the provocations that remain are mine alone.

One thought on “Healthcare

  1. I think an interesting point of contrast re: centralization as potential solution is with the NHS in the UK. Carl Macrae has done really interesting work trying to replicate NTSB to elevate the profile of such events and make more sweeping interventions. Tracking how that plays out seems like a potential (at least partial) test of some of your ideas.


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