Imperfection is normal and system failures are predictable. In recent days and weeks there has been huge commentary on the Covid-19 pandemic second wave in Victoria – the quarantine failure. To be clear, a quarantine failure does not need to take the form of a glaring deficit in safety – when talking about a very contagious virus, a quarantine failure may be a small deviation or error in a minor process.
It is almost certain that there was more than one process failure – Swiss cheese error models tell us this from everyday clinical problem solving in healthcare. Errors and deviations are common, and only when all the holes in the cheese line up, do we see an impact on the patient. All the other cheese slices, that have no holes, are the processes that protect the outcome. Safety can be ensured by just one of many processes providing the necessary safeguard.
When error occurs, we look at the points of system failure and we search for the cause: in a Root Cause Analysis (RCA). At the moment we see lots of pandemic blaming, shaming and political witch hunts. This is reactionary, anger-based, politically motivated or mischievous. Blaming individual slices for the failure of the cheese maker is not smart.
It’s time to go back to basics; to the simplicity of the root cause analysis – it’s about analysis first, not the ‘hunt for a fall guy’. RCA’s ask lots of questions, the most common one being “Why?” If we continue with the ‘whys’, we arrive at the root cause of the error or failure. The core of management of a disaster or pandemic is the PLAN – this is where to look for the root cause.
Disaster or pandemic preparation all comes back to planning. Define the event and risks. Anticipate the impacts. Plan the mitigations. Test and retest the processes and get them right. Then refine the plan until stress testing can’t break it. If there is a failure in the management of a disaster (pandemic) then it is almost certain that the origins of that failure lie in a weakness of one or more of these components of planning.
The pandemic was totally predictable. Every year health departments all over the world revise influenza pandemic plans, SARS pandemic plans and other health disaster plans. Everyone knew a pandemic was coming ‘sometime’.
So, if there is a failure of management, that will almost by definition be a failure of planning. Too much was done in a flurry of activity at the last minute…not enough done by enacting a well-considered, risk minimising, rehearsed, tested, refined and optimised plan. For example, it is clear that we could have had better designed systems for:
- Border control (when did we stop flights from China??)
- Escalation of protective strategies (masks and isolation)
- Quarantine (developing systems for quarantine after the need has arisen is not a plan)
- Business and commercial restrictions
- Supply chain and manufacturing security
- Care of high-risk, high-density populations (aged care, prisons, schools)
- Healthcare preparation (ICU’s, ventilators, processes, staff training, PPE stores)
Most disaster plans are designed to respond to a large single event which by definition overwhelms our usual systems. In response we swing into action with an extraordinary response, contain the event, treat the cause and implement recovery.
A pandemic is different. It is overwhelming from the start (not like a fire), and it will overwhelm for months (not days, like a bomb or terrorist event). Where most disasters mainly require an ‘emergency services’ mindset to management, pandemics need a predominantly ‘public health’ mindset. As a result, planning is much more important and much more difficult.
Much of our response to the pandemic has been characterised by progressive escalation of reactions and by the development of solutions ‘on the run’. This approach needs review.
Unfortunately, and self-evidently, the plan for this pandemic has not covered all the bases. The question is: where was it inadequate?
The answer may be multifactorial but wherever the failure may be, it’s a safe bet that the core issue will be in the verification and continuous refinement of the PLAN.
If a plan is rigorously tested, exercised and refined one would expect it to detect and plug ‘all’ the holes in the cheese. We need to do it better next time…BTW there will be a next time.
marcuskennedy.net 