Homemade Swiss Cheese: Making (Imperfect) Safety

Published in on Dec 31, 2020

This post is the first of a series about lessons we learned from dealing with COVID that also apply to acupuncture safety in general.

By May 2020, it was clear that lockdown couldn’t last forever, and small businesses that didn’t want to shut down permanently had to figure out how to re-open. For us, the first step was to tackle the creation of COVID safety policies for two organizations: WCA, an acupuncture nonprofit that, pre-COVID, provided over 60,000 treatments a year and POCA Tech, a tiny, low-residency acupuncture school focused on training community acupuncturists. Predictably, the process was messy and weird, and certain themes are clearer in hindsight than they were at the time.

One of those themes -- and also a theme of this blog, obviously -- is that safety is active, participatory, cooperative, relational, and creative. It’s not just about avoiding mistakes.

People are terrified of making mistakes. This became evident when we started trying to write our safety policies. In an organization, even a small one, what writing safety policies looks like is a group of people getting together (in this case, in a socially distanced way), doing research, and trying to decide on some words to cobble together into a document.

Safety work can’t get done when people feel too overwhelmed to do it, and this was the first hurdle to getting safety policies written. In situations like this, being a trauma nerd comes in handy for me, along with years of trying to navigate my life while my trauma history was lurking in the background threatening to pop up and derail it at any moment. The place I always have to start from, with everything, is figuring out how to not get overwhelmed. For me, getting overwhelmed leads to bad places and so avoiding it is non-negotiable. As a result, I have a lot of strategies for circumventing overwhelm and a lot of practice using them.

So I said to our safety working group: just write something. Create a draft. Don’t try to make it perfect, we’re going to need to review it and get other people’s input anyway. Also, new information is coming in so fast, we’ll certainly have to make changes. Just have some meetings and get something down -- if all you do is give our organizations somewhere to start, you’ll be doing something really valuable.

It took me by surprise when some people didn’t want to do this.

It turns out that a sort of default setting for a lot of people -- and I think a lot of acupuncturists -- is to approach safety as something to demand from external sources, as opposed to something to create. Some people wanted to start the safety planning process by appealing to the powers that be to keep them safe. No, that’s not quite right. It’s more like they didn’t see the safety planning process as a real thing; they just wanted the final product, which was safety, nice and solid, and they thought somebody would give it to them if they made their demands loud and clear. Other people felt unqualified to create COVID safety policies; they wanted to know how to do it right, and they wanted us to just tell them already, none of this business about drafts and revisions.

At that point in the pandemic, of course, nobody knew for sure what COVID safety meant (and we still have a lot of unknowns).

Over the course of having an acupuncture school, I’ve spent a lot of time thinking about the difference between consumers and cooperators, but I hadn’t applied any of that thinking to safety. Clearly I needed to. Also there was something important about the expectations that the school was setting for students. Nobody had quite spelled out that a core aspect of a community acupuncturist’s job is to actively create safety in their clinic -- as opposed to just following safety guidelines. And so if we were training community acupuncturists, we had to explicitly describe how to do that. I think this requirement holds true for any acupuncturist, any independent healthcare practitioner, but --as noted elsewhere -- a lot of acupuncturists only come away from their training with a list of don’ts and the hope that they won’t screw up.

Which is obviously not enough when you’re facing an actual safety crisis like COVID, where you have to make safety, in real time and without a dress rehearsal.

Don’t get me wrong, I would also love to be able to demand safety and then get it. I’ve just never had that work at any point in my life. And it clearly wasn’t going to work with COVID, because the situation was so new that everybody was making up everything as they went along, including the public health authorities. Everywhere we looked it was trial and error.

So we muddled along as best we could. And I was thrilled when people started talking about “the Swiss cheese model of pandemic defense”, which recognizes that no single intervention or practice is enough to actually stop the spread of COVID. The point is not to seek one perfect solution, but to create a bunch of imperfect solutions and layer them. More safety is better than perfect safety. The Swiss cheese model represents a “multilayered approach to reducing risk” -- note “reducing”, not eliminating.

Though it’s not part of the model, I would argue that one very important layer of Swiss cheese risk reduction is building a culture of safety, and the metaphor works for that too. Building a culture of safety involves recognizing that safety is process more than product. It can’t be delivered on demand, it has to be made in-house, layer by imperfect layer.

Safety work is gathering information, sharing information, having meetings, arguing, and making decisions; that’s how policies get developed. Safety work is drafting plans, revising plans, and managing uncertainty. Safety work is communicating. And it’s never done.

Safety work can involve advocacy, including self-advocacy, but it can’t be limited to that. As a practitioner, you don’t have to create safety alone, but you can’t expect that somebody else is going to do it for you. Actively making safety is a skill to practice.

My acupuncture career has taught me, and keeps teaching me, that all the good stuff in life requires active participation rather than passive consumption. In capitalism, everything is supposed to be a consumable commodity, but there are so many areas in which that just doesn’t work. Community acupuncture is one; safety is another.