What is a ‘safety management system’? A blog by Norman MacLeod

Summary

Healthcare often uses the experience of aviation to set its patient safety agenda, and the benefits of a ‘safety management system’ (SMS) are currently being espoused, possibly because the former chief investigator for HSIB, Keith Conradi, had an aviation background. So, what does an SMS look like and would it be beneficial in healthcare? In this blog, Norman MacLeod discusses aviation's SMS, its many component parts, the four pillars of an SMS, just culture and its role in healthcare.

Content

To begin, you need to understand how regulatory change happens in aviation. The International Civil Aviation Organisation (ICAO) sets standards and recommended practices (SARPS), which are designed to ensure the highest practicable degree of uniformity across aviation in several areas, safety being one of them. All signatory UN states are required to incorporate the SARPS into their national regulations or declare a divergence. 

Typically, States do not like to diverge from ICAO SARPS. The International Air Transport Association (IATA) is the club most airlines belong to.  It has it’s own audit process that requires airlines to conduct a comprehensive review every 2 years. The audit is based on the ICAO SARPS. If you don’t do the audit you cannot be in the club, and if you are not in the club you cannot operate into some airports. Possession of a SMS, then, is an ICAO requirement, but is further backed up by the need to satisfy the IATA audit. This need for compliance is a key driver of the SMS concept.

The implementation of a SMS ran in parallel with the rollout of quality management in aviation, but also supported the move to ‘performance-based regulation’. Historically, aviation has been very prescriptive in term of oversight. The State Aviation Authorities laid down what was required of an airline and teams of inspectors would periodically visit and check that things were being done according to the rules. But Regulators were themselves becoming increasingly resource-constrained, so the philosophy changed. Airlines would be told the intent of the regulation and how to achieve it and the Regulator would now look at outputs from processes. SMS is an example of performance-based regulation. The transition to a SMS was not trouble-free. Quite often the argument for SMS was framed around cost savings on the part of Authorities. Canada is a case in point, where the savings were made ahead of implementation, and a report by the Auditor General of Canada found that safety was degraded during the transition as staff were cut and no one was tracking progress.

The SMS concept is now well-established in aviation, but what is it exactly? In simple terms, it is an organising framework. It is often described as having four pillars:

1. Safety policy.
2. Safety risk management.
3. Safety assurance.
4. Safety promotion.

These pillars pulled together existing concepts while adding some new requirements. The safety policy pillar lays out the management’s commitment to safety, sets objectives and defines the methods and processes that will be applied in the organisation. You might expect ‘just culture’ to be included in this pillar. The ‘just culture’ concept originated in the USA as a response to the prevailing punishment culture that characterised how aviation dealt with failure. It was product offered for sale. You could become qualified as a ‘just culture practitioner’ and the original just culture decision tree was trade-marked. However, the benefits of the approach were recognised and adopted by ICAO. The subsequent SARP required airlines to develop just culture policies and it is not uncommon to find that airlines have separate just culture and SMS manuals. Just culture illustrates how SMS has developed piece-meal over time.

The safety risk management pillar includes hazard identification and risk management. It could be considered the heart of SMS. It includes safety reporting systems as a means of identifying new hazards and evaluating risk. Again, safety reporting has developed over time. With the advent of complex jet aircraft after the 1939–1945 war, reporting systems were used to track the reliability of technology. Lists of types of failure were published and airlines were required to report any encounters. Over time, aircraft became more reliable and more sophisticated. The former prompted a recognition that the industry needed to track failures in other areas (humans) and, in the case of the latter, the list of technological failures to be reported just got longer and longer. Safety reporting (or, rather, why people do not report) is a complex topic, but what has happened over time is that ‘anonymous, confidential’ reporting has emerged as a possible solution.

The safety assurance pillar includes activities that provide analysis and oversight of safety, including periodic safety committee meetings, audits and data analysis.

The safety promotions pillar incudes the provision of findings and feedback to bolster safety, reinforce a positive safety culture and generally increase understanding of safety. Airlines struggle with this. Such is the fear of safety information leaking into the public domain, many airlines limit information sharing internally. But there are other problems. ICAO mandates that States must have an accident investigation capability. Equally, the range of events that falls under the remit of the State investigators is laid down. The complexity of a major investigation is such that the time taken for the report to be published is so long that the circumstances relating to that event have probably changed. And, in any case, few people in that airline would feel motivated enough to read the report. Events that fall outside of the scope of the ICAO mandate fall to the airline to investigate, but they often lack the resources or the skills to undertake meaningful investigations, let alone disseminate useful learning points.

To conclude, SMS is a concept with many component parts. It will stand or fall based on the quality of those parts. It is not a single solution: it is implemented differently in every airline. Would it add value to patient safety? Probably, in some areas. Is it a coherent solution to the problem of patient safety? Probably not.

Further reading on the hub:

• Why healthcare needs to operate as a safety management system: In conversation with Keith Conradi
• The involvement of patients and families in a healthcare safety management system: In conversation with Jono Broad
• Patient Safety Learning – The elephant in the room: Patient safety and Integrated Care Systems
• Error isn’t a problem – the problem is the word ‘error’: a blog by Norman MacLeod

About the Author

Norman MacLeod served for 20 years in the RAF involved in the design and delivery of training in a variety of situations. He stumbled across 'CRM' in 1988 while investigating leadership in military transport aircraft crews. From 1994, he worked around the world as a consultant in the field of CRM in commercial aviation, latterly employed as the Human Factors Manager for a blue chip airline in Hong Kong. Now semi-retired, he is one of the Patient Safety Partners at James Cook Hospital in Middlesbrough.