What is reliable healthcare? Not what you think!

I

“Healthcare” is considered to be one of the nation’s critical infrastructures sectors, according to the Department of Homeland Security.

Infrastructures, however, vary considerably in their mandates to provide their services safely and continuously. The energy infrastructure differs depending on whether it is for electricity or natural gas or hazardous liquids, while the latter three differ from large-scale water supplies (I’ve studied all four).

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 operation centers.

Which provokes a useful question: What would healthcare look like if it were managed more like other infrastructures that have centralized control rooms and systems? Might the high reliability of infrastructural elements within the healthcare sector be a major way to better ensure patient safety?

II

Three points are offered by way of answer:

(1) High reliability theory and practice suggest that the manufacture of standard vaccines and compounds can be made reliable and safe, at least up to the point of the interface with patients. Failure in those back-end processes is exceptional—as in the 2012 fungal meningitis contamination at the New England Compounding Center—precisely because failure is so preventable.

Yet, under routine healthcare, it is the sharp-end of patient interface with those treatments that receives priority attention. The risk here is this focus dilutes attention, encourages complacency and divert management from the strong-end of healthcare, namely, the prevention of key production and distribution errors in healthcare without which patient safety doesn’t stand a chance.

(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 far more visible and dramatic.

Aside from that special and important case of public health emergencies (think the COVID-19 pandemic), civic attitudes toward health and medical safety lack the widespread public dread we find undergirding the reliability demanded of other infrastructures, such as nuclear power and commercial aviation.

Clearly, 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 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?

One answer: Hospitals, if not managed reliably kill you. “Going to the hospital always means risking your life” is another way to put the dread. Once societal dread over medical error is high, expect to see medical errors of all sorts to be prevented more effectively.

(3) One response to preceding 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 advanced infrastructure elements (think technologies and information systems).

Yes, mistakes are made, even horrible ones, but where would healthcare be without first and foremost the patients’ trust in doctors, staff and their expertise? (I’ll leave aside the fact that control room operators in major infrastructures are themselves craft professionals responsible for far more lives in real time than hospital and clinic staff!)

But in the high reliability management research with which I am familiar, distrust is as core as trust. One reason control room and front-line operators are reliable (that is, safe and continuous providers of services) is that they actively distrust the future will be stable or reliable in the absence of the system’s vigilant real-time management. Their wraparound support units—the experts in system engineering, economics, and modeling—may be telling them one thing and their unique real-time experience quite another.

From an infrastructure perspective, it is not surprising then that a US healthcare system that encourages each patient to be his or her own reliability manager entails a basic shift from the healthcare professionals as the primary wraparound for the patient to the patient’s immediate family, friends, and internet searches as primary support. More, the primary role of the latter is now to combat any complacency in patient treatment by healthcare professionals (complacency being a big risk in routine control room operations). Such tensions, including distrust of what are now seen as complacent medical professionals, are understandable from an infrastructure perspective and not ones to be smoothed over or otherwise “solved”.

III

So what?

Limitations of our analogy are obvious. 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 his or her own 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? Presumably, the movement to bring real-time monitoring healthcare technology into the patient’s habitation is increasingly part of the reliability calculus.

Yet 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.

Note: I thank Paul Schulman for many discussions, suggestions, and points; the provocations that remain are mine alone.