Error-Proofing Healthcare

February 12, 2009


Michael J. Tatham knows a thing or two about safety. As a pilot with over of forty years of experience and the owner of his own airplane, he has been in many dangerous situations. Yet each time he faces a critical scenario, he successfully pulls through by applying one simple principle: the principle of process. In the following story, Tatham recounts how process can improve safety in any industry.

“Three years ago, as part of the routine re-certification for all pilots, Transport Canada required me to put together a formal Safety Management System for operating my aircraft. The federal agency even withheld my private operators certificate until I could prove that I had implemented a system that passed their test. When they finally inspected my system, they said it was the best one they had ever seen submitted by a private pilot in Canada, and they issued my Private Operator Certificate immediately.

Later on they asked me, ‘Mr. Tatham, how did you do it? Most private pilots produce a safety manual that ends up back on the shelf, while they continue flying their plane as they always had.’ I replied, ‘It has taken the commercial airline industry 25 years to refine their processes before implementing a safety management system. It took much longer because redesigning their processes required detailed government investigations into aircraft accidents that often took years to conclude. Still, the result of redesigning their processes was that airline staff had to implement a cockpit resource management system to ensure the pilot and flight crew are on the same page for each flight. This determines the roles and responsibilities before each flight and distributes the authority for decision-making equally between the pilot and the entire crew.

That’s why I didn’t layer a safety protocol on top of a bad process. Instead, I redesigned my flight operations process first and then built safety management principles into it. By building safety and risk management directly into the process, I could ensure there was always a check and balance.

In fact, my safety process was simply a by-product of good process management. I used the Tatham Method to redesign my processes and make them ‘error-proof’ rather than ‘error free’. There is a big difference between the two. ‘Error-proofing’ means creating a way to intercept errors before they become catastrophic. When we error-proof a process, risk management decision-making is built directly into real-time – as we are carrying out our actions. The natural outcome of error proofing a process is to create a checklist – and a perfect place for a safety checklist is, for example, an operating room.

I have just described simple process management principles that we use every day with our clients. Just take the words flight, aircraft, pilot, flight crew and safety management system out of the description above, and insert doctor, nurse, health care practitioner and patient safety system and you have the same approach that will work in healthcare as it does in air transportation. And that’s exactly what we’ve been doing for the past forty years in high-risk, yet high-reliability processes such as in nuclear power plants and military and defense weapons systems manufacturers. It works equally well in financial service companies and in hospitals.

I believe that my vision for healthcare could exist in Canada if the industry applied the Tatham Method across the board, to create error-proof processes and to integrate a strategy for healthcare delivery and patient safety. Medical errors can – and should – be eliminated entirely, but only if the processes are first redesigned to be reliable so that health care professionals don’t need to compensate for bad processes. And wouldn’t it be great if we knew that every time we set foot in a clinic or a hospital?”