Synergia has identified three categories of situations that are precursors to significant risks to patient safety (and, to efficiency). These categories are common to all of healthcare, and, indeed, appear to be common to all complex operational settings. In these risk-promoting situations, saving the patient (or ensuring the briefest stay) requires that some members of the team come to understand something that someone else already knows. Lacking the information, some actions go undone, and other actions end up creating conflicts and hazards. But if the important information gets to the right caregivers, it is more likely that they will do the right things as individuals. And, it is far more likely that their individual actions will combine well on behalf of the patient.

For example, the ability of later caregivers to monitor for symptoms and react promptly can be greatly influenced by knowing not only when a medication was stopped, but also the reasons why. This leads others to monitor with the right frequency, prescribe in a consistent manner, and recognize emergent problems. Additional illustrations of the clinical data leading to coordination requirements can be found here.

Saving at-risk patients does not need to be a matter of radical or novel changes in care, delivered by a caregiver with rare insight and just the right skills. Instead, it is a matter of the relevant members of the team coming to see that, for a particular patient, they need as a team to do things somewhat differently than usual. Caregivers can learn to recognize they are in one of the three important categories of risky situations. In turn, each situation can be resolved with its native way of adapting care-as-usual.

We use our methods (Critical Practice Management) to determine how organizational risks express themselves in each particular healthcare organization. In general, the risks embodied in an organization’s practices derive from the degree to which these problematic contexts arise - how they express themselves in the organization, how frequently they tend to arise, and how severe the consequences can be (which depends on features of the patient population). When we analyze the organizational risk we: produce a map of key practices, diagnosis their flaws, create a model of recurrent risks that are ‘permitted’ by practice flaws, estimate likelihoods of the flaws and the magnitude of their consequences, and so create a measure of overall expected costs.

It is inherent in our approach that, as part of the process, we naturally uncover defenses that may impede change - just doing the risk analysis exposes barriers to possible future interventions. With these risks and defenses in hand, appropriate change programs are developed. Our work produces durable organizational change because we help the organization improve not only individual skills but also relationships among skills, and because we attend to given phenomena to the degree that they promote key risks.