What Cheese & Veterinary Clinics Have in Common

I’ve been thinking a lot about cheese lately—Swiss cheese to be exact. I first heard about the “Swiss Cheese Model” from my husband. This model is used by his workplace to analyze outcomes with unfavorable or even deadly results. Unfortunately, I also see this model in action more frequently than I would like to in my own clinic.

So how do you relate cheese to organizational management? If you take a block of Swiss cheese and slice it, each individual slice is filled with holes. However, put together as a whole, the block is generally free of holes. In order for there to be a hole that penetrates the entire block of cheese, holes from every individual slice of cheese must be lined up.

In most organizations, there are a certain number of actions that must be taken by multiple people in order to achieve the goal of that organization. Each action by each individual can be considered an individual slice of Swiss cheese. A mistake made by one person can create a hole, but often these mistakes aren’t significant enough to cause a negative outcome in the overall process. The other pieces of “cheese” patch the hole. It is a series of mistakes that build on one another that end up creating a hole in the entire block of Swiss cheese, often with negative consequences. No one person can be blamed entirely for the end result, although the last piece of cheese often gets the most scrutiny.

Let me give you an example. Mr. O’Brien calls the office to schedule his dog, Max, for a cranial cruciate repair. The receptionist promptly schedules him for the following Friday but does not pull Max’s chart or check with Dr. A (who evaluated Max’s leg four months ago). Max arrives on Friday morning for his surgery and is admitted by a technician. The surgeon, Dr. B, does not meet with Mr. O’Brien before the surgery. Although presurgical blood work was performed on Max, Dr. B does not read Dr. A’s notes from the original exam, nor does he perform his own orthopedic exam. Dr. B opens Max’s stifle joint and finds a perfectly intact and healthy cranial cruciate ligament and no evidence of degenerative joint changes. Mr. O’Brien is understandably upset when Dr. B tells him that Max did not need a cruciate repair but has undergone the arthrotomy anyway. Mr. O’Brien demands a copy of Max’s records and states that he is never bringing Max back to the practice.

The first hole in the Swiss cheese is the receptionist not verifying the necessity of the surgery when Mr. O’Brien called to make the appointment. By looking in the chart or asking Dr. A, she would have learned that Dr. A had stated that Max’s lameness had improved and that he did not recommend surgery. The original “diagnosis” of a CCL rupture had been made at a different hospital.

The second hole is the technician who admitted Max on his surgery day. Having Dr. B meet briefly with Mr. O’Brien would have ensured that everyone was on the same page before Max went into surgery. This is something that should be standard procedure for all surgeries and also would have been a more focused opportunity for Dr. B to read the chart.

The third hole in the cheese is Dr. B. He did not take the time to be sure he knew his patient’s history or to perform his own exam.

All of these smaller holes lined up and created a much deeper hole that resulted in unnecessary morbidity for Max, expense for the practice, and the loss of a client. Being vigilant and making sure there is a system of checks and balances in place can help to plug these holes. Also, analyzing situations such as these can be a great learning tool that does not pinpoint any one person as being the problem, but looks at the overall system and focuses on how it can be improved at every level.

I try to look at every negative outcome in patient care and/or client communication using this model. It helps me move beyond the immediate stress, guilt, and anxiety that often accompany these situations and assists me in dealing with these emotions in a more productive manner. It also helps me avoid similar errors in the future.

What experiences have you had at your clinic that fit this model? How do we implement a more organized way of debriefing the more serious mistakes that occur so that history does not repeat itself? How do we make our entire staff more aware of how their decisions and actions affect the overall service of the practice? Maybe we can start by giving everyone their own block of Swiss cheese as a reminder….