[MUSIC] Let's analyze healthcare as a high reliability organization. Previously, we discussed these four characteristics of high reliability organizations. They're high risk, high volume, highly safe, and highly resilient. Let's take a look at healthcare. Well, what about healthcare? Is healthcare hazardous? Let's examine it against other industries. In this graph, each of these industries is plotted against the total number of lives lost every year, against the number of encounters for each of those fatalities. And also whether or not they're considered hazardous, regulated, or really ultra-safe. Those high reliability organizations we previously discussed are featured here in the ultra-safe category. Healthcare, on the other hand, is listed as somewhere between the hazardous and regulated areas, up there with driving and hazardous, like other mountain climbing and bungee jumping. This graph, I think, illustrates how far healthcare needs to go to become truly a high reliability organization. When we look at healthcare and medical fatalities by year against the automobiles, workplace, and aircraft, you can see here in another illustration how many lives are lost every year. In the healthcare system in the United States, 7% of patients are believed to suffer from medication errors. On average, every patient admitted to an ICU has an adverse event. Nearly 100,000 lives are lost every year from hospital associated infections. And it's estimated that between 30,000 and 62,000 deaths every year are caused from catheter-related bloodstream infections. And the cost of these hospital-acquired infections is between 28 and $33 billion every year. Other reports suggest that between 44,000 and 98,000 people die each year as the result of medical errors. Preventable harm is considered the third leading cause of death. And up to three in ten patients suffer preventable harm. And up to six in ten patients report that they were not respected or heard during their care. This problem is large. We know that eight countries in addition to the United States have reported similar findings. When it comes to surgical care, these errors, they contribute to significant burden of disease. Despite the fact that it's believed 50% of these complications associated with surgical care are avoidable. And that there's one in a million chance of a traveler being harmed while in an aircraft, in comparison to 1 in 300 change of being harmed as a patient while receiving healthcare. So let's take a look, does healthcare meet these characteristics? Are they high risk? Well, yes I think we would agree and high volume. But are they highly safe? I think the data we just reviewed would suggest no, and also not high resilient. Let's look at aviation as one of the model high liability organizations. Much of their success has been that they've been able to combine technical improvements with improvements in teamwork in the members of the crew. In this graph you see, the Fatal Aviation Accidents per Million Departures, since the late 1950s. Over the last 60 years you can see, vast improvements have been made in driving down fatalities related to aviation accidents. But some of the improvements made earlier on, in the early 60s into the 70s, were very technical in nature. Improvements in the aircraft and how the aircraft work, and air traffic control. More recent improvements while technology continues to advance, but some of the more recent improvements had to do with team work and how the crew and ground crew and the cockpit crew and the flight staff interact with one another. That's an important combination of skills. Let's consider healthcare. We've reviewed many ways in which patients are harmed in the course of their care, but let's explore one harm, and how we even proved it over time. When we look at 103 ICUs across the state of Michigan, we were able to successfully drive down the catheter related blood stream infection rate over the course of 18 months, to nearly 0. And that has been sustained. But how did we do that? Well this is an example of how one ICU has driven down the improvements over time, over several months. It was not a single intervention but rather a series of technical improvements, those depicted here in yellow, and teamwork and adaptive improvements, those illustrated here in blue. This is just one example of success but we have a lot of work to do. There's many more harms that we need to work on.
