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High Reliability Habits

Lately I’ve been thinking a lot about habits. If nothing else, the high reliability mindset describes a set of safety habits that we need to adopt in our own practice, and get others to follow along, in order to achieve the best outcomes for our patients. What got me started thinking about this is a recent review I read (Journal of Critical Care Medicine: January 2013, Volume 41, Number 1, pg. 15-23) by Dr. Tasnim Sinuff and the Canadian Critical Care Trials Group. His group studied the effect of a broad set of active interventions that attempted to change the habits of critical care docs so they would adopt a set of best practices (i.e. good habits) that are known to avoid ventilator associated pneumonias in ICU patients. There were a lot of results in this study, and the authors get an “A” for effort, but I found their conclusion depressing. “Despite a high degree of awareness of best practices, the magnitude of change was 8.0% (2.7% – 13.3%) whereas the goal in any group should be close to 100%. Increasing clinicians’ awareness of best practices over time was not associated with a parallel increase in adopting these best practices and changing habits.” So how do we change our own, and even more troubling, other peoples’ habits for saferhabits1 management of our patients?

A lot of smart people have said a lot of smart things about both good and bad habits. This started way back in biblical times, when the Prophets taught us moral and righteous habits, all the way up to modern times with Steven Covey telling us about effective and successful habits. In between, Alice was most put off by the bad habits of some of her animal friends during her journey through the looking glass. “It is a very inconvenient habit of kittens, Alice had once made the remark, that whatever you say to them, they always just purr.” Cleverly hinting his habits were just fine thank you, Mark Twain was also troubled by habits of those around him and lamented that, “Nothing so needs reforming quite as much as other people’s habits.” But, just as Dr. Sinuff observed, habits—whether our own or others’—are really very hard to change. The problem with habits, Samuel Johnson observed way back in the 1750’s, is that “the chains of habits are too weak to be felt until they are too strong to be broken.”

Mahatma Gandhi

Mahatma Gandhi

So what are habits and where do we get them? Obviously, we do things the way we do because we’re comfortable doing it that way and we don’t want to change for that very reason; we like things just the way they are. Perhaps no one in recent time has had a deeper and more personal understanding of human habits and wrestled with changing our habits more than Mahatma Gandhi. Quoting his profound insights:

Your beliefs become your thoughts,
Your thoughts become your words,
Your words become your actions,
Your actions become your habits,
Your habits become your values,
Your values become your destiny.

The implications of Gandhi’s words for those of us who are adopters and practitioners of high reliability mindset skills are crucial to understand. Maintaining, even demanding, absolute adherence to safety principles with every patient encounter and every procedure defines our own personal values, even our own professionalism, and determines the destiny of our patients. We must adopt these best safety mindset practices in our own approach to patient care, and adhere to these principles every day with every patient encounter, whether it is major or minor. We must never forget, as Dr. Arthur Bloomfield, of the Quality of Healthcare in America Project 2003, said, “there are some patients we cannot help, but there are none we cannot harm.” We must be active and vocal advocates for the use of our high reliability mindset skills and teach these skills to our nurses, residents, and medical students, insisting on their use so that the culture and habits in healthcare will change. Once again, Gandhi said it best, “you must be the change you wish to see in the world.”

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