Adopting the Klein Triple Path Model of Insight for Clinical Quality Improvement

1. Understand the constituents of clinical quality improvement

2. Understand the Klein Triple Path Model of Insight

3. Discover how the Klein model of generating insights can be applied at both personal and organizational levels for quality improvement in healthcare settings

“Insight” can be defined as a change in perception and behavior that leads to better outcomes.^[1] American cognitive psychologist Gary Klein, who popularized the field of naturalistic decision-making, proposed that in real-world settings, performance improvement requires a combination of “error reduction” and “gaining of new insights.”^[1,2] Yet, in many organizations, error reduction is often prioritized at the expense of generation of insights because mistakes are highly visible, costly, and damaging to reputation.^[2] Moreover, while error reduction strategies often have obvious, precise, and measurable outcomes, novel insights into how things can be done better tend to be seen as disruptive to the organizational workflow.^[2]

In the medical profession, reduction/avoidance of medical error is understandably prioritized, as mistakes can lead to serious implications in patient care, leading to significant morbidity and mortality, and eroding public trust in the healthcare system. This has led to the adoption of comprehensive medical error–reduction practices as listed in the Institute for Safe Medication Practices (ISMP)’s “Hierarchy of Effectiveness of Risk-Reduction Strategies,” which comprises high-leverage (forcing functions, barriers and fail-safes, automation and computerization), medium-leverage (standardization and protocols, redundancies, warnings/alerts/reminders/checklists), and low-leverage (rules and policies, educational programs, available information, suggestions to “be more careful”) strategies.^[3] However, in reality, clinical quality improvement is not merely achieved by implementing error reduction strategies through checklists and protocols, but through development of novel insights necessary to actually improve standards of care in clinical settings (Fig. 1). Therefore, this article seeks to review the Klein Triple Path Model of Insight (creative desperation, contradictions, connection)^[1,2] and describe how it can be applied in healthcare settings for clinical quality improvement.

Through a qualitative analysis of 120 cases of “insights”, Klein and colleagues^[2] discovered three major pathways that lead to formation of “insights”: 1) “connections”, 2) “contradictions,” and 3) “creative desperation.” Notably, insights can develop from simultaneous activation of more than one cognitive pathway.^[2]

“Connection” is defined as the process of finding new data elements and using that to add a new anchor to an existing framework.^[1,2] This approach has been commonly adopted in clinical practice to identify poor practices that lead to adverse outcomes, and implement quality improvement and safety interventions.

In the 1800s, Hungarian gynecologist Ignaz Semmelweis studied the troubling phenomenon of puerperal fever, also known as “childbed fever,” which led to many maternal deaths shortly after delivery.^[4] After having developed and debunked numerous hypotheses, his breakthrough came when his pathologist colleague Kolletschka died from the same illness after an accidental scalpel injury when performing postmortem examination on the women who died from puerperal fever.^[4] When he relooked at the cases of maternal death from puerperal fever, he then realized the reason behind why women who were delivered by medical professionals had a much higher prevalence of this illness than those delivered by midwives—because the medical trainees were often performing autopsies prior to examining patients in their obstetric clinics, where their hands were likely the source of transmission of “cadaverous particles” to the women.^[4] This led to the revolutionary introduction of handwashing and hand hygiene practices, which dramatically reduced the rates of puerperal fever, and subsequently nosocomial infections in numerous other clinical settings.^[4]

In the field of anesthesia and perioperative medicine, it had been recognized that anesthesia and air travel bore similarities in both their high-risk nature and general construct—where the three phases of anesthesia (induction, maintenance, and emergence) were likened to those of a flight (take-off, cruise, and landing).^[5] Therefore, many of the currently implemented perioperative safety interventions such as standard operating procedures, operations manual, checklists, and simulation training were developed through studying how the aviation industry manages to keep its in-flight safety incidents to a bare minimum.^[5] A few years ago, Jung and colleagues^[6] further developed an innovative operating room black box to pick up and analyze intraoperative errors, events, environmental distractions, and variability of surgical skills, which was helpful in facilitating timely implementation of safety measures to address identified hazards before major intraoperative incidents occur. The authors were again “inspired” by the rigorous data capturing and monitoring capabilities in aviation, in particular the in-flight “black box,” which allows hazards to be identified before major incidents occur.^[6] On the contrary, they realized that in perioperative situations, changes in safety protocols were still typically implemented upon retrospective analyses of incident reporting or findings presented at morbidity-and-mortality meetings, which are less robust and often subject to recall bias and incomplete information.^[6]

“Contradiction” is defined as spotting inconsistencies and flaws in currently accepted beliefs, and building on the possibility of an alternative “weak” anchor to be true.^[1,2]

In hospital medicine, isolation precautions are common interventions to prevent spread of transmissible diseases amongst inpatients. However, from on-the-ground observations, it appeared that contact precautions, which were supposed to reduce spread of drug-resistant organisms in nosocomial settings, not only were not clearly helpful in achieving their intended objective, but also had negative implications in clinical care such as stigmatization and reduced clinical review of patients on these precautions.^[7] This has led to larger scale studies to review whether this practice is still warranted in hospital settings.^[7]

“Creative desperation” refers to novel breakthroughs that occur owing to an exigency or impasse, which necessitates an urgent reframing of the situation and replacing an (often weak) anchor with a new form of understanding.^[1,2]

Uncertainty is pervasive in medicine, such as in disease diagnostics, prognostication, and management. This underscores the importance of adaptability, especially in acute and critical care settings, where clinicians would need to be able to think on their feet and come up with solutions to problems in clinical care when there is a lack of availability of certain equipment, therapeutics, or personnel with relevant expertise. Besides, there is also often uncertainty pertaining to the environment in which clinical medicine is practiced. For example, when the COVID-19 pandemic suddenly struck at the end of 2019, it led to novel and drastic changes in the medical field in how medicine is practiced and taught. In clinical practice, there was significant advancement in telehealth services, which will likely remain a permanent fixture in healthcare, owing to identified benefits in chronic disease management, patient empowerment, and healthcare accessibility as well as reduced burden on limited medical infrastructure and logistics.^[8] In medical education, innovative, technologic-driven pedagogical approaches had to be adopted because of social distancing requirements in the pandemic, which turned out to be a major improvement from traditional models of in-person didactic teaching in terms of learner centricity, accessibility, and educational inclusivity.^[9]

To promote the development of insights via the “connections” and “contradictions” pathway, medical practitioners should first be trained to think critically about existing clinical processes and institutional health delivery systems when they go through clinical rotations. In healthcare, Scott et al^[6] recently described three fundamental critical thinking skills, comprising clinical reasoning, evidence-informed decision-making, and systems thinking. In particular, cognitive debiasing strategies are useful not only in avoiding cognitive biases, but also in helping physicians “keep an open mind” when evaluating situations so that they can detect “contradictions” in clinical processes and challenge assumptions that may not be valid.^[10]

In addition, medical professionals must also feel empowered to offer practical feedback and suggestions based on their active observations on the ground, which requires a flattening of the professional hierarchy to encourage input, and removal of bureaucratic roadblocks in healthcare institutions that often stymie innovation and implementation of useful feedback.

At the organizational level, promoting “internal swirl” by actively facilitating interactions and meeting of colleagues of different healthcare subspecialties and disciplines may facilitate discovery of insights through the “connection” pathway.^[2] For example, quality improvement projects should involve multidisciplinary teams comprising both clinical and nonclinical staff not only to harness the knowledge, skills, expertise, and resources of individuals of different professional backgrounds, but also to help diversify perspectives and promote collision of ideas that facilitate the generation of “insights” on the connection pathway.

Promoting “creative desperation” in healthcare, however, is more difficult, short of extenuating clinical circumstances that require either on-the-spot rethinking due to exigencies, or reframing of a clinical approach due to an impasse. However, healthcare hackathons may be helpful in this regard to foster development of new innovative strategies to solve pressing real-world clinical problems under significant time pressure. Furthermore, robust thought processes that promote “thinking out of the box” are also required to facilitate the generation of insights through “creative desperation,” which necessitates a degree of cognitive flexibility to challenge flawed or unwarranted assumptions.^[2]

In summary, the Klein Triple Path Model of Insight is a novel approach that can be applied to clinical quality improvement for better patient care and workplace efficiency.