Interview with Dr Dan Cohen on human performance

Summary

Dr Dan Cohen, former military officer in the United States Air Force and international consultant in Patient Safety and Clinical Quality, talks to Patient Safety Learning about how he became involved in patient safety and why he thinks human performance is an area that deserves more study. He feels strongly that leaders must stand up and share their own stories and mistakes to encourage others to start talking and sharing more openly.

Content

Q: Dan, please tell us about yourself?

A: Well, if I had to describe myself, I guess I would say I am an iconoclast of sorts.  I tend to look at issues intellectually from multiple directions and maintain a healthy scepticism about generalisations and issues not supported by sound data.  This leads me to ask questions, to think outside the box and to work to modify for improvement any traditions or embedded concepts that no longer serve a purpose.  I am a collaborator and always open to listening and learning from people I work with, those who have worked for me and those I have worked for.  My philosophy is that one never really knows where the best ideas will come from, listen and learn from everyone, and acknowledge that the universe has provided us with the tools of biostatistics for a reason.  

I am also compassionate and empathic, having seen much suffering and horror during my military career, always striving to understand and support those in need as best I can. I am married to an incredible bright, wise and sophisticated woman who complements me in many ways and enhances my life immeasurably.  We maintain homes in both the US and UK where we have adult children and grandchildren to enjoy.  

Q: What got you involved in patient safety?

I have always recognised that providing healthcare services encompasses a complicated calculus of variables, some of which are commonly referred to as the structures and processes of healthcare.  Sixty years ago, Professor Avedis Donabedian established the paradigm that structures and processes are the key components that can result in high quality healthcare outcomes.  Well, some structures and processes are sufficient and work well, others not so sufficient and do not work as well.  Because of this complexity, the healthcare environment is inherently dangerous.  

As CMO for the US Department of Defence health plan, I played a substantial role in supporting management and implementation of a US Congress mandated patient safety programme as this programme resided within my portfolio of responsibilities.  I had enormously capable staff that designed and managed the educational and monitoring/reporting functionality of this complex programme, based on a non-attribution model for reporting and analysing patient safety incidents. They deserve all the credit really, because my role as the Director of the office was supervisory, directional and supportive of their efforts primarily. 

Q: Human factors has a key role to play in patient safety and, while we often talk about improving systems and processes, less is said about personal performance and responsibility.  Why do you feel this is so important and should be highlighted more?

Really good question. Part of this has to do with my own professional liabilities and holding myself responsible for some mistakes I have made, none catastrophic fortunately, and also with my experience with aviation medicine while in the US Air Force, where my role was to assure the aviators were fit and ready to fly and fight. In this capacity I became intimately aware of human liabilities and frailties and, of course, the value of studying ergonomics in order to improve human technology interactions. But human factors impact goes way beyond ergonomics. Understanding the parameters that affect human performance is an area that deserves more study. The impact of structures, especially leadership and institutional culture, are well understood, but not as easily addressed and remedied are the personal factors that can influence performance such as fatigue, workplace and workload stressors, physical and psychological factors, family economic and social factors; none of which are actually ‘left at home’ when individuals come to work, and no one wants to talk about these seemingly. 

Q: No one goes into work wanting to make a mistake but mistakes do happen. What would you say are some of the key influencing factors that can affect performance?  

A: I think that professional complacency is the pernicious undercurrent, and this is unrecognised by most individuals; well-meaning and highly trained though they may be.  Clinicians do not see themselves as being dangerous, as being part of the patient safety risk calculus. It is counterintuitive to their professional mind-set and for many years it was counterintuitive to my professional mind-set.  I never viewed myself as a potential part of the problem, but I was, most assuredly.

Clinicians look around ourselves and point to insufficiencies in culture and leadership, flawed ways of doing things, lack of funding and all the other components in the ‘structures and processes, leading to outcomes’ paradigm that Donabedian described in 1966.  Yet, we do not take enough time to examine our inherent responsibilities.  We do not pause and reflect on the reality, that we do and will make mistakes.  We are responsible for enhancing patient safety but to do so we need to spend some time and some science understanding how we can improve our personal performance. The biggest dimension that we need to improve on is in the realm of enhancing diagnostic accuracy and timeliness, and this requires delving deeply into understanding how we think and make decisions. Diagnostic inaccuracies, all of which are in fact delays in accuracy of diagnoses, are major confounders of risk management, may cause considerable harm, and for the most part reside on the shoulders of clinicians.  There is much to be learned here and we should be morally driven to do so.

Q: People find it difficult to admit to mistakes in all environments, but particularly in healthcare. How can we encourage those in health and social care to start discussing this more honestly and openly?

Another great question and there are two elements (at least) that should be part of any institutional culture. Firstly, clinicians must be treated fairly and must be supported when they make mistakes. They must never be chastised in public (and only rarely in private) and thorough competent human factors evaluation of why mistakes occur should be part of any investigation.  Support must be provided for clinicians after something goes amiss, and this is a leadership responsibility.  The goal of any investigation should be to learn from the mistake and to prevent the mistake from happening again. If clinicians are treated harshly and unfairly then morale degrades, and in my view this may lead to even more mistakes.  So, a culture of just treatment is key and the provision of resources to support clinicians who have made mistakes needs to be in place.

The second element is sharing stories and this is where clinician leaders need to stand up and be present and ‘authentic’.  Everyone has made mistakes, most minor and inconsequential, but some not so minor and certainly not inconsequential. If leaders talk about their mistakes (chief medical officers, division heads, clinic chiefs, nursing leaders, and so on) then the willingness to talk and share may well filter down to the trenches, to the front lines where things matter most. 

Q: What roles do managers and those in leadership play in this?

It is the key role of managers and leaders at all levels to set the standards for human and professional behaviour.  Leaders and managers must be ‘authentic’ and by that I mean they must be individuals that all can look up to with ‘earned’ respect and admiration.  They must truly understand the challenges that clinicians (and non-clinicians for that matter) face, day to day, and they must respond to those challenges appropriately.  If they share their own stories and discuss their own mistakes they will permit their own experiences to contribute to learning and to enhance sharing by others.  

Q: Finally, how do you envisage patient safety in the future, and how are you playing a part?  

A: Well, now as a consultant for a risk management/professional liability insurance company I hope to enhance educational efforts primarily.  Most clinicians have little training, if any, in clinical risk management and that must change. Clinicians must learn and appreciate their roles in improving care and providing a patient safe environment.  Call this self-awareness training if you wish.

My efforts as a member of the Board of Directors of Patient Safety Learning really will be to help guide the organisation towards its creation of the hub by helping to add texture to the topics already designated for inclusion and also by broadening the range of topics and issues that the hub may address.  

About the Author

Dan is a physician, a paediatrician and haematologist/oncologist by training, a retired Fellow of the American Academy of Pediatrics and the Royal College of Paediatrics and Child Health. He received his training at the Boston City Hospital (now Boston Medical Center), affiliated with Boston University; and the Children’s Hospital and Dana Farber Cancer Center and Harvard Medical School in Boston, Massachusetts.

For almost 30 years, Dan was a military officer in the United States Air Force where he served as a paediatrician caring for children of service members and as an aviation medicine physician in military operational roles.  He spent 14 years in the UK serving with the US NATO contingent and during much of that time became closely affiliated with Cambridge University School of Clinical Medicine and Addenbrooke’s Hospital.  

After retirement from the US military, Dan became an international consultant in Patient Safety and Clinical Quality, managing a variety of clients and primarily serving as Chief Medical Officer for Datix, Ltd.

Currently retired, though still providing some consulting work in the realm of malpractice liability insurance and risk management education.