“This department has worked [X] days without accident or injury.” Such signs are uncommon outside of industrial sites, but it doesn’t mean responsible parties aren’t counting. Even minor errors in organizations and industries can result in disastrous consequences and heavy cost to human life (think: nuclear power plants or air traffic control systems). And in the healthcare industry, mistakes and process failures unfortunately do result in approximately 250,000 deaths annually, despite an increased emphasis on patient outcomes and safety.
High-reliability organizations (HROs) successfully avoid catastrophe despite a high level of operational risk and complexity. They set themselves apart from the rest by delivering consistently high-quality, safe results over long periods of time. In health systems, that requires establishing a safety culture focused on process improvement. Medical errors are viewed as challenges that must be learned from and overcome to the extent possible. Patients benefit, but so do the providers and staff working in these health systems.
Why is high reliability important in the healthcare industry?
High reliability is essential to improving patient safety and care quality. Unfortunately, healthcare organizations historically haven't delivered safe, reliable, evidence-based care as often as they should. That’s changing as healthcare consumers, providers, and payers have turned to the use of technology-aided processes to increase safety. They’re demanding better patient care and asking why the healthcare industry isn’t as reliable and transparent about safety as the airline industry.
Now, public reporting of hospital errors by the Centers for Medicare and Medicaid Services (CMS) and many states has increased patients’ awareness of medical errors and care quality. Further, better-informed healthcare consumers ask questions about care quality when choosing a provider, and hospitals use quality data to compete in the marketplace.
Demands for better patient care quality and safety
With increased scrutiny from patients and payers, hospitals must become more reliable to attract patients, provide care that meets their patients’ needs, and comply with payers’ quality requirements. High-reliability organizations foster an environment of mindfulness where physicians, nurses, other caregivers, employees, and management look for and report small problems or unsafe conditions before they become a significant threat to patients—and when they are easier and more economical to correct. Such healthcare safety improvement is difficult to navigate, but safety software can take much of the heavy lift.
Value-based care
Adverse health events have significant financial ramifications, with medical errors costing about $20 billion per year. Value-based care and payment models strive to improve clinical outcomes while reducing costs. With reimbursement now closely tied to clinical outcomes, demonstrating measurable improvements in safety, care quality, and outcomes is critical. To succeed, health systems must focus on process improvements that enhance patient care and the bottom line. That means using technology to standardize and improve policies and processes, learning from mistakes, and prioritizing safety over other performance pressures.
What are the 5 characteristics of a high reliability healthcare organization?
High-reliability organizations foster an environment in which all employees anticipate potential problems, detect them early, and respond quickly enough to prevent catastrophic consequences. Five characteristic ways of thinking support this proactive approach:
1. Sensitivity to operations
People in HROs focus on big picture understanding or “situational awareness” of healthcare operations. They strive to understand the context of their work in relation to what is going on around them in their role, unit, and organization—and how those conditions may support or threaten safety.
HROs work quickly to identify anomalies and problems in their systems and processes to eliminate potential errors. By focusing on operations, you can reduce the number of errors and identify and fix mistakes before their consequences become larger. Sensitivity to operations requires more than the requisite checks of patient identity, vital signs, and medications. It includes situational awareness by staff, supervisors, and management of broader issues that can affect patient care, such as how long a nurse has been on duty, potential environmental distractions (e.g., high noise levels), and the availability of needed supplies. Focusing on clinical processes leads to observations that guide decision making and operational improvements.
2. Acknowledgement that systems are complex
People in high-reliability healthcare organizations understand that their work is complex and dynamic. They realize that their systems can fail in ways that have never happened before and that they cannot identify or control all the ways in which their systems could fail in the future. All staff members are encouraged to recognize the range of things that might go wrong and not assume that failures and potential failures are the result of a single, simple cause.
If a patient has a negative outcome, it could be due to a variety of issues: environmental, staffing, process, or some other cause. For this reason, HROs reject simple diagnoses of problems, instead conducting root cause analyses to identify underlying explanations. To challenge long-standing beliefs about why problems occur, HRO leaders must examine incidents (e.g., adverse events and near misses), benchmarks, and other performance data.
3. Preoccupation with potential failure
People in high-reliability health systems focus on predicting and eliminating catastrophes—not reacting to them. All staff members think about what could go wrong and pay attention to small signs of potential problems. In addition to examining mistakes that caused patient harm, clinicians and hospital staff also need to focus on near misses, identifying and correcting faulty processes and/or situations that could cause harm in the future. Staff view near misses as opportunities to improve current processes by examining strengths, identifying weaknesses, and taking action to improve and correct them. They don’t view near misses as evidence that the processes work “well enough” to keep patients safe.
4. Deference to expertise
High-reliability healthcare organizations rely on experts, not authority figures, for decision-making in crises or emergency situations. The most experienced person or the person highest in the organizational hierarchy does not necessarily have the information needed to respond appropriately to a particular crisis. Physicians, nurses, and other clinical experts—not hospital administrators—are often the best people to assess and correct patient safety issues. Frontline staff are expected and encouraged to share concerns about potential safety threats and problems. When engaged, clinical experts contribute positively to the kind of cultural and operational changes that drive better care.
5. Commitment to resilience
Errors in medicine will occur. People in high-reliability health systems assume that, despite safeguards, systems may fail in unpredictable ways. Therefore, staff practice rapidly assessing and responding to challenging situations and system failures. Leaders train staff to identify potential safety threats quickly so they can respond before patients are harmed or reduce the seriousness of the patient safety event.
5 Challenges health systems face when trying to achieve high reliability
Healthcare organizations have several characteristics that make it difficult—and essential—to achieve high reliability.
1. Hypercomplexity
Health systems are complex environments involving many teams that must coordinate efforts to promote safety. Physicians, nurses, pharmacists, technicians who maintain equipment, and support staff who maintain the physical environment must work together to keep hospitalized patients safe. That’s a lot of moving parts, requiring near-flawless communication and coordination.
2. Multiple decision makers
High-reliability healthcare organizations include many decision makers working to make important, interconnected choices on behalf of patients, staff, and the organization. HROs must develop processes that allow these decisionmakers to communicate effectively with each other and weigh the outcomes of their choices.
3. Time pressure
Many patient care emergencies require immediate action. In HROs, the systems and culture allow staff to identify when they lack time to reliably complete all needed tasks and must obtain additional assistance. Hospitals do not always have extra staff with the resources and training needed to deliver quality, safe care. As a result, appropriate workforce management (staffing) is a critical consideration in HROs.
4. High staff turnover
The healthcare industry workforce is experiencing high turnover due to fatigue, burnout, and other issues. The result is teams that are less intact and potentially not as synchronized as staff who have worked together long term. Therefore, frequent staff training is more critical, and standardization of equipment and procedures is essential.
5. Patients have unpredictable behaviors and needs
Most of the industries that emphasize high reliability (e.g., airlines and chemical and nuclear power plants) deal with machines and processes that are mechanical/predictable and whose design and condition are meticulously documented. Caring for patients, whose behavior and needs vary from other patients’ and change over time in unpredictable ways, is uniquely challenging.
Best practices to achieve high reliability
The Joint Commission and Institute for Healthcare Improvement recommend several strategies for the healthcare industry to achieve high reliability:
Develop leaders: Hospital leaders (executives, management, and lead physicians) must commit to the goal of zero patient harm and facilitate and mentor teamwork, continuous improvement, and psychological safety. Hospitals must prioritize safety when selecting and developing a pipeline of leaders and creating succession plans.
Establish and support a safety culture: To promote a safety culture and to increase high reliability, The Joint Commission encourages trust-building and accountability, identification of unsafe conditions, and regular assessment of processes and systems as best practices. To achieve transparency and a blame-free environment, consider establishing a Just Culture, recognizing that individual practitioners should not be held accountable for system failings over which they have no control.
Build and use data systems to measure progress and improve processes: The Joint Commission emphasizes the need to track and display quality measures and involve IT support in developing solutions to quality improvement problems. Use the data to improve your work processes. For example, you should review new medical technologies six to 12 months after implementation to answer these questions:
- Did usage produce the appropriate patient length of stay?
- Was the support staff number appropriate?
- Are the patients in the appropriate status post-procedure?
- What impact has the service/procedure had on patient satisfaction and outcomes?
Improving clinical evidence-based decision-making is one important step health systems can take toward high reliability and improving care quality. This requires engaging clinical staff in decision-making regarding products, technology, and patient care protocols. You’ll also need an appropriate combination of supporting technologies, evidence sources, and team collaboration.
Technological solutions promote high reliability
To prevent adverse events and safety incidents, the healthcare industry must collect and analyze large quantities of data. Compliance, quality, and safety software holds the key to data reporting, tracking, and analysis.
Use incident management software
Event reporting is an effective way to mitigate damage from errors and avoid repeating them. According to a case study by the Occupational Safety and Health Administration (OSHA) and National Safety Council Alliance, “Most loss-producing events (incidents), both serious and catastrophic, were preceded by warnings or near-miss incidents.” By using incident management software to track near misses and events—and analyze them to identify root causes—you can take action to correct the underlying causes and prevent patient harm.
Use workflow software to standardize your new product decision-making processes
Use unbiased clinical evidence to make objective purchasing decisions. Using the right diagnostic equipment, medical devices, and medical-surgical supplies impacts clinical outcomes and safety. One review identified 290,141 reports of serious injury or death due to medical device adverse events. Decision-making teams must consider the clinical evidence and safety data for new products (e.g., capital equipment, medical devices, and med-surg supplies), instead of making purchasing decisions based solely on cost or subjective opinions. Clinical evidence reveals the effectiveness (or lack thereof) of a device or technology, which has a direct impact on patient satisfaction, readmission rates, and measurable improvements in care.
There is no one-size-fits-all approach to quality improvement and the achievement of a high-reliability healthcare organization. symplr is here to help.
Solutions for high-reliability healthcare organizations:
- Incident management
- Value management
- Compliance, quality, and safety solutions
- Workforce management
- Spend management
