Issue link: https://industrialengineer.epubxp.com/i/777540
22 ISE Magazine | www.iise.org/ISEmagazine I health systems Accept the risk ... or reduce the risk By William "Ike" Eisenhauer In my December ISE column, I lament- ed how healthcare never seems to learn from the past. We are, however, good at learning from other industries. My previous high-risk industry ex- perience is in the nuclear part of the U.S. Navy. The healthcare profession is well aware of the nuclear industry's vast experience in quantifying risk and reliability measures. But applying those measures to improve healthcare delivery processes is not so clean-cut. One effec- tive but underutilized concept in- cludes the risk importance measures "risk reduction worth" and "risk achievement worth." We obviously cannot fix every- thing at once, so the question is what to focus on. The answer is "the most risky issue," but what does that mean? To some, it means the issue with the highest potential overall impact. Under that line of thought, earthquake- proofing a hospital (affects everybody) would take precedence over installing bathroom hand rails (affects only those who are moderately unstable). To others, the issue most likely to oc- cur takes priority. For example, making sure the printer paper doesn't jam, which delays discharge (every day), would take precedence over making sure the pa- tient's discharge medications are filled correctly (less than every day). Neither one will work, and a major- ity of professionals involved in risk man- agement and assessment would point out that risk is assessed through the combi- nation of probability and consequence. The next step is where we need to learn a thing or two. The conventional mindset is to rank those assessed prob- ability and consequence combinations and prioritize. But this is ineffective and plain wrong when dealing with com- plex systems, like nuclear power plants and – you guessed it – healthcare sys- tems. The rank order method is premised on the concept that the risks are fairly independent and not embedded in an interconnected system where weak and strong links form. In short, it ignores the whole systems thinking concept when addressing the risks. Why people use systems thinking principles to come up with the risks and relationships but then completely ignore those principles when dealing with them is a mystery. Using the systems thinking frame- work and looking at which processes these risks operate in can help you ask two questions. First, what is the expect- ed impact change to the overall system (hospital, patient, community, etc.) if this one risk was guaranteed to happen? In mathematical terms, the probability is raised to one and the event is guaranteed to happen. This is the "risk achievement worth (RAW)." Second, what is the expected impact change to the overall system if this one risk was guaranteed not to happen? In mathematical terms, the probability is lowered to zero, and the event is guar- anteed not to happen. This is the "risk reduction worth (RRW)." Note, these are not opposites of each other, and one is looking for the overall change to the system. Viewing the situ- ation this way captures the classical risk dimensions, enhancing them with the dynamics of the systems where the risk is embedded. Issues with high RAW and low RRW pretty much can be avoided. The good news: This technique has been around since the 1970s and used by the nuclear industry since at least 1983. It is well-doc- umented and illustrated. The bad news: Almost no one outside the nuclear pow- er field has heard of it. In high-risk industries, organizations that want to achieve the status of "high reliability organizations" must use all the tools at our disposal and learn not only from our past but from each other. As I have heard others say on this jour- ney, "Steal shamelessly." William "Ike" Eise hauer is a gi eeri g professor at Portla d State U iversity a d atio al director of the Vetera s E gi eeri g Resource Ce ters for the Vetera s Health Admi istratio . His i terests are i tegrati g e gi eeri g a d healthcare professio als to i crease the value of health systems a d ad- va ci g e gi eeri g scie ce to address health- care delivery challe ges. He ca e reached at wde@pdx.edu. Issues with high RAW and low RRW pretty much can be avoided.