Let’s suppose for a moment that you are an “outdoors” type – into hiking, cycling, orienteering, and generally exploring the world. You decide you would like to travel on the Danube, from its headwaters in the Donaueschingen region to the Black Sea. Before you hop into your kayak, I hope you will at least obtain a map to learn how long your trip might take. And I hope you will gather other information about weather patterns, the kind of river traffic you might encounter, the river currents, any natural or artificial barriers you might encounter – in short a host of important contextual matters that will influence your planning and implementation. And perhaps you will also consult various media sources to learn about socio-political issues – will the conflicts in some areas or the immigration policies in others have a potential impact on the possible success of your endeavour. In short, as a 21st century citizen of the world you will prepare yourself for a dynamic, sometimes unpredictable, constantly evolving adventure, recognizing that this will be far from a straightforward trip from Germany to the Black Sea.
The preparations described above are analogous to what SNAP! (Systemic Nonlinear Analysis Protocol) has been designed to do for patient safety practitioners charged with reviewing and understanding adverse events and critical incidents in healthcare. Why bother, you might ask? In most industrialized societies with relatively “advanced” healthcare systems, the level of unintended harm experienced by patients has been consistently shown to be in the range of 5-15% of all acute care hospitalizations. This represents a major (albeit often unrecognized) public health crisis. For instance, in Canada, where I have been involved in patient safety efforts for more than 20 years, every day, 100 patients will die as a result of a breakdown in the way care is provided. This is quite simply not acceptable.
For several decades, these events of unintended harm and patient death, when they were reported, were analyzed using linear analysis techniques that had been shown to be effective in many industrial settings. After years of making little or no progress using linear methods, such as RCA (Root Cause Analysis), or modified linear approaches (such as the London Protocol based on the Swiss Cheese model) it became apparent that techniques adapted to the nature of the healthcare system were needed. This required some understanding of the fact that healthcare is a fairly typical complex adaptive system (CAS) which would require techniques or approaches appropriate for such a socio-technical system. These include systems thinking and nonlinear causation as two basic principles.
SNAP! promotes an understanding of nonlinearity, not only with respect to the concept of causation of accidents but also to the way in which the involved parties (patients, families, healthcare providers) are engaged in the analytic process; how the chronology of events is constructed; the way in which recommendations are developed; and even the way in which the course is presented – nonlinear approaches to adult learning are more effective for this kind of workshop. SNAP! is embedded in the broader SPHERE (Shifting the Paradigm in Event Review and Evaluation) workshop which examines the way in which CAS evolve and self-organize and therefore how they can be influenced. SNAP! applies to retrospective analysis of events. The underlying systemic nonlinear principles are equally effective in prospective risk assessment.
Posted in the REA (Resilience Engineering Association) newsletter, February 2020