By Carolyn M. Clancy, MD

Spurred by national attention to the tragedy of preventable medical errors, many hospitals have made improving patient safety and reducing the incidence of medical mistakes a top priority. Some organizations have made impressive progress in pursuing safety-enhancing programs. Others, however, are scrambling to get initiatives under way.

On the whole, hospitals still have a long way to go before they provide patient care that consistently avoids harm and promotes healing. A new report from my agency, the Agency for Healthcare Research and Quality (AHRQ), underscores this reality. The 2007 National Healthcare Quality report, released in March, found that patient safety improved by an annual rate of just 1%.

As a physician, I appreciate the challenges that hospitals face in overhauling standard protocols and maintaining new safety-related interventions. To that end, AHRQ has made a significant investment in research and tools to assess and improve the safety of healthcare services.

However, we recognize that safe healthcare requires more than the use of dozens of safety-related interventions that target specific risks. For patient safety to improve and to be sustained over time, an organization must undergo a culture change that makes high reliability an essential part of all that is done.

Becoming a High Reliability Organization
Principles of high reliability were first applied in industries with significant potential for catastrophic errors, such as nuclear power, aircraft carriers, and commercial aviation. In recent years, lessons from these industries about how to become more reliable are gaining wider appreciation. Innovative healthcare leaders and organizations are learning how an error-free operation can be sustained for extended periods of time.

For example, the Institute for Healthcare Improvement has sponsored a variety of educational efforts that describe reliable processes in healthcare and the types of activities to achieve error-free operation. A 2007 AHRQ-supported publication, Mistake-Proofing the Design of Health Care Processes, describes specific process and design features that some healthcare facilities are using to prevent medical errors.

While re-engineering processes to achieve exceptionally high degrees of reliability is important, other researchers have pointed to the essential role that culture plays in assuring that high reliability is the norm. Research by Karl Weick and Kathleen Sutcliffe identifies five thought processes that are correlated with a high reliability culture:

• Sensitivity to operations. Highly reliable organizations maintain a constant awareness of the state of the systems and processes that affect patient care. This awareness is key to identifying risks and preventing them.
  
  
• Reluctance to simplify. While simple processes may be good, simplistic explanations about why things work or fail (unqualified staff, inadequate training, communication failure, etc.) do not explain the underlying reasons why errors occur.
  
  
• Deference to expertise. Reliable systems defer decisions to those individuals with the knowledge to make them, regardless of organizational hierarchy.
  
  
• Preoccupation with failure. When near-misses occur, they are viewed as evidence of systems that should be improved to reduce potential harm to patients. Rather than regarding near-misses as proof that the system has effective safeguards, they are viewed instead as symptoms of processes that need to be modified.
  
  
• Resilience. Highly reliable organizations are able to anticipate and quickly recover from an error. They are skilled at mitigating any consequences that stem from the original error. Resilience requires that leaders and staff be trained and prepared to respond when system failures do occur.

The concepts of high reliability organizations are intriguing to many healthcare professionals, but concrete examples of translating concepts into practice have been scarce.

A new guide published by AHRQ reflects the experiences and insights of leaders committed to transforming their healthcare systems into high reliability organizations.

In developing the guide, Becoming a High Reliability Organization: Operational Advice for Hospital Leaders, executives met for more than a year to discuss their successes and challenges in how to put concepts into practice. Their stories are designed to support the efforts of other hospitals to become highly reliable, exceptionally safe organizations.

From Concept to Application
Organized to allow executives to quickly locate or share information, the guide describes a range of activities to which high reliability concepts can be applied, such as:

• Responding to external and internal environments to assure patient safety.
  
  
• Implementing improvement initiatives.
  
  
• Measuring progress.
  
  
• Applications to specific improvement initiatives and major infrastructure efforts.

The guide provides a series of specific examples of how the high reliability concepts can be applied to a broad range of organizational challenges. These concepts are very useful in helping hospital leaders create both the culture and the mindset necessary for reliable and safe care.

Sensitivity to Operations. In some hospitals, executive leaders rarely observe direct patient care, and leaders of hospital units meet infrequently to coordinate efforts. In contrast, Sentara Healthcare, a Norfolk, Virginia-based integrated healthcare system, ensures that leaders are continually aware of and sensitive to operations.

During daily check-in meetings, staff and unit leaders review what has transpired in the past 12 hours. They pay close attention to pressing problems, anticipated problems, staffing issues, facility issues, and patient flow. Afterward, hospital leaders visit patient floors to identify issues and concerns and follow up with an action plan. These efforts contribute to Sentara's consistently high national performance in quality and patient safety.

Reluctance to Simplify. Promising solutions can fail if hospital leaders oversimplify the process to define a problem and implement a solution. To prevent that from happening, staff at Exempla Healthcare, a three-hospital system in Denver, Colorado, employed "lean" concepts — originally developed by Toyota — to redesign the process for preparing chemotherapy orders. While the goal of lean manufacturing is to simplify processes by eliminating waste and standardizing work, arriving at this state is by no means simple.

The process required careful analysis preceded by several weeks of preparation. Five days of focused team action were spent on redesigning processes used to obtain, deliver, and administer chemotherapy drugs. This was followed by 3 weeks of follow up and ongoing monitoring to fine-tune the changes. Early results included increased staff satisfaction with the chemotherapy order preparation process and a reduction in the incidence of problems that led to the risk of medication errors.

Deference to Expertise. Leaders at Cincinnati Children's Medical Center recognized that they needed to improve patient flow in the emergency department (ED) admissions process. Accomplishing this goal demanded a more responsive system to triage patients according to their acuity.

In redesigning the admission process, an intake clerk, patient, or family member could supply ED staff with information about the seriousness of a patient's condition before the patient was seen by a nurse. The redesign also enabled triage nurses to summon a physician immediately if they or a family member suspected that a medication other than a fever reducer was needed.

Preoccupation with Failure. Many patient safety initiatives stem from an error that causes patient harm. But leaders from the major hospital systems in Minnesota were unwilling to wait for a tragedy to strike before addressing a potential patient safety problem.

Because hospital systems used different standards for medication dosing, staff who moved from one hospital to another (or who worked part time in at more than one hospital) were at higher risk of making a dosing error. To reduce the chance of a potential medication error, hospital leaders worked collaboratively to create standardized drug concentrations to be used across area hospitals. As a result, dosages recorded in one Minnesota hospital system would be equivalent to those recorded in another.

Commitment to Resilience. Creating systems that anticipate errors and quickly react to them allows an organization to keep patient harm to a minimum.

Christiana Care Health System, a Wilmington, Delaware-based regional health provider, recognized that ICU patients could be placed at risk if staff faced unexpectedly large demands on their time.

To enhance their ability to respond to surges, Christiana staff implemented electronic monitoring and video surveillance systems in ICU rooms. Staff monitoring patients from a remote location can answer patient inquiries, summon unit staff to assist a patient, and continuously monitor the vital signs of the most critically ill patients.

Conclusion
I am excited to see how high reliability concepts are being put into practice in a wide range of healthcare organizational settings. Although we still have a long way to go to make healthcare a consistently safer and more patient-centered enterprise, I believe the information contained in Becoming a High Reliability Organization: Operational Advice for Hospital Leaders will keep us on the right path.

References

Agency for Healthcare Research and Quality. (2008). 2007 National healthcare quality report. Rockville, MD: U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. AHRQ Publication. No. 08-0040.

Grout, J. R. (2007). Mistake-proofing the design of health care processes. Agency for Healthcare Research and Quality, Rockville, MD. AHRQ Publication No. 07-P0020.

Hines, S., Luna, K., Lofthus, J., et al. (2008). Becoming a High reliability organization: Operational advice for hospital leaders. (Prepared by the Lewin Group under Contract No. 290-04-0011.) AHRQ Publication No. 08-0022.

Weick, K. E. & Sutcliffe, K. M. (2001). Managing the unexpected: Assuring high performance in an age of complexity. San Francisco: Jossey-Bass.