“This department has worked [X] days without accident or injury.” Such signs are common in industrial sites but less so in healthcare, although it doesn’t mean teams and 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 plant failures or RaDonda Vaught’s fatal drug error that gripped nurses across the country). In the healthcare industry, mistakes result in approximately 250,000 deaths annually, despite an increased emphasis on patient outcomes.
High reliability organizations (HROs) 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 hospitals and health systems, that requires establishing a culture of safety focused on operational improvement.
Why is it important to be a high reliability organization in healthcare?
HRO principles are essential to improving patient safety and health 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 to increase safety. 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 consumers ask questions about health care quality when choosing a provider, and hospitals use quality data to compete in the marketplace.
Demands for better patient care quality
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 a culture of safety and 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 improvements are difficult to navigate, but safety software can ease much of the heavy lift.
Adverse health events have significant financial ramifications, with medical errors costing about $20 billion per year. Value-based care (VBC) and payment models strive to improve clinical outcomes while reducing costs. With reimbursement now closely tied to clinical outcomes, demonstrating measurable improvements in care quality and outcomes is critical and still a journey for many healthcare organizations. To succeed, hospitals and health systems must focus on improvements that enhance patient care and the bottom line. That means using technology to standardize and improve policies and workflows, learning from mistakes, and prioritizing a culture of safety over other performance pressures.
What are the 5 characteristics of a high reliability 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 identify how those conditions may support or threaten safety.
HROs work quickly to assess problems and eliminate potential errors. By focusing on operations, you can reduce the number of errors and identify and fix mistakes before their consequences snowball. 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—all things that add to the stress and cognitive load of clinical staff. Focusing on clinical processes leads to observations that guide decision making and operational improvements that can have impact on patients.
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, 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, 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. What separates high performers is that in addition to examining mistakes that caused patient harm, they also focus on near misses, identifying and correcting situations that could cause harm in the future. Staff should 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 current system works “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. Front line 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 event.
5 challenges health systems face when trying to implement HRO principles
Healthcare organizations have several characteristics that make it difficult—and essential—to achieve high reliability.
Hospitals are complex environments involving many teams and team members that must coordinate efforts to promote patient wellbeing. 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 systems 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 of safety 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 care and maintain a culture of safety. As a result, appropriate workforce management (staffing) is a critical consideration.
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 team members are potentially not as synchronized with each other 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 HRO principles (e.g., airlines and chemical and nuclear power plants) deal with machines and systems 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 become a high reliability organization
The Joint Commission and Institute for Healthcare Improvement recommends several strategies for the healthcare industry to achieve high reliability:
Develop leaders: Hospital executives, management, and lead physicians must commit to the goal of zero patient harm and facilitate and mentor teamwork, continuous improvement, and psychological wellness. Hospitals must prioritize keeping patients safe when selecting and developing a pipeline of leaders and creating succession plans.
Establish and support a culture of safety: To promote a culture of safety and HRO principles, The Joint Commission encourages trust-building and accountability, identification of unsafe conditions, and regular assessment of 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: 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. 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 hospitals 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 collaboration between teams and team members.
Technological solutions promote HRO Principles
To prevent adverse events and incidents and promote health care compliance, the health systems 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
Use unbiased clinical evidence to make objective purchasing decisions. Using the right diagnostic equipment, medical devices, and medical-surgical supplies impacts clinical outcomes. 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 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: