The Need for "Safety Culture" in Radiation Oncology

I recently had the opportunity to speak with both Lawrence Marks and Lukasz Mazur, who are the authors of a very important new book titled Engineering Patient Safety in Radiation Oncology: University of North Carolina’s Pursuit for High Reliability and Value Creation. During our conversation, I asked them: "Why did you write this book? What was unique about your experiences?" Here are their complete separate responses:

Lawrence Marks: I studied engineering before medical school. I have always been struck by the differences between engineering and medicine; particularly in the way that the workplace in organized, how work in done, and how each address safety concerns. In the engineering setting, it is often acknowledged that people’s actions, and hence safety, are impacted by things such as leadership, workplace/workflow design, and the organization’s safety culture. This lesson has not been widely learned within medicine. As medicine in general, and radiation oncology in particular, have become more complex, it is becoming increasingly important to consider these “upstream” factors.

For the most part, radiation therapy is very safe. Nevertheless, there are recognized risks. Further, the interactive complexity of modern practice makes it challenging predict where problems will occur. Presently, much of the emphasis on making radiation therapy safer is in the realm of technical solutions: medical physics, computer software, etc. These initiatives are necessary and will certainly help to address the safety issues. This approach alone, however, will not bring us to the level of reliability we strive to achieve.

We can and should do better, and the way to do that is to apply lessons from engineering/industry. We must consider the leadership/administrative component, the workplace and workflow component, as well as the people component, to minimize errors. We must use Lean improvement principles to motivate and enable all colleagues to be actively involved in assessing and improving their own systems -- This will increase safety mindfulness and help to create a “safety culture.” It is only through this multipronged approach that we can become the highly reliable organization that our patients deserve. And this is the focus of this book. We provide an honest and heart-felt summary of our journey in applying this approach in our radiation oncology clinic. We hope that readers will become motivated to apply similar strategies in their own clinics. While we did this work in the context of radiation oncology, the lessons described are applicable in any area of medicine.

Lukasz Mazur: Most quality and safety improvement programs in healthcare delivery industry are currently structured to: transform leaders into effective change agents, design efficient and ‘waste-free’ workplaces, and develop people into creative problem solvers. This is perhaps one of the key reasons why continuous quality improvement (CQI) programs based on Lean or Six-Sigma philosophies become so popular and are now being implemented throughout the healthcare delivery landscape. Despite many positive reports in the academic literature, books, and press, however, it is still difficult to determine whether the transformation of colleagues to innovative problem solvers has indeed occurred in the healthcare organizations utilizing CQI programs. One of the reasons for this shortcoming is lack of valid and detailed implementation – the basis for transformation to safety mindfulness. 

This book’s purpose is to fill this shortcoming and provide ample examples of our hard work at transforming our leaders, enhancing our workplaces, and supporting people in their journey towards safety mindfulness. We have an important message to send—that the patient safety and quality concerns within radiation therapy (RT) field are not merely a technical issue, but rather a more global cultural issue grounded in attitude and behaviors. We emphasize a need for leaders to create and nurture a culture that promotes a transformation from quick fixing, conforming, and expediting behaviors to enhancing and initiating behaviors. Leaders must acknowledge that they are responsible for modeling and developing these desired improvement behaviors in colleagues by developing infrastructures that promote these values and, as needed, use their authority to enforce these values as well. 

The broad application of the principles described in our book to healthcare can make healthcare delivery more efficient and safer. At the end, this can benefit all of us – providers, patients, and families. 

What are your thoughts on the application of lessons learned from Lean initiatives in engineering and industry to radiation oncology clinics?