Becoming a High Reliability Organization
Whether we travel in an airplane, ride on a roller coaster or live near a nuclear reactor site, we expect the experience will be safe and consistently reliable. If you were told your air travel or roller coaster ride would be safe 90% of the time, how would you feel? Would that be good enough? How would you feel if a nuclear reactor site within miles of your home announced its safety system could be counted on 93% of the time? Would you be impressed?
I'm going to guess that no, you would not be impressed. In fact, if I were told these statistics, I'd opt not to ride an airplane or a roller coaster, and I would not buy a home near the nuclear reactor site. These odds are just not good enough.
Every time a patient enters a hospital, he or she expects the experience to be safe and highly reliable. Patients expect their lab work and diagnostic testing to be performed correctly and assessed in a timely and accurate manner. They assume they will receive the correct care or procedure ordered by their provider. They believe the blood products and medications infusing through their IVs are appropriate for them and their care plan. Care providers hold similar expectations. They expect medications are what their labels say they are, instruments are sterile if indicated, and colleagues are competent.
A high reliability organization (HRO) hospital has consistent performance at high levels of safety over long periods of time. The safety culture of an HRO is dependent on the constant awareness of possible failure. It is this possibility of failure that should keep everyone focused on safety, at all times, so it can be addressed immediately.
Collective mindfulness (Weick and Sutcliffe, 2007) features prominently in the culture of HROs. This is where all of us, as individuals and teams, are acutely aware that even small failures in safety protocols or processes can lead to catastrophic adverse outcomes (Chassin and Loeb, 2011). We ask the question, "How have we harmed or almost harmed a patient since the last time we met?" in order to remain mindful of the fact that hundreds of thousands of patients are unintentionally harmed in American hospitals every year. Mindfulness helps us uncover safety concerns before they actually harm a patient. We intentionally identify safety and quality issues when they can be fixed, rather than missing the opportunity and harming a patient.
Once potential deficiencies in the safety process are identified, our goal is to use powerful tools to eliminate the deficiencies and improve the process. At the Medical Center, these tools are part of our Lean Process Innovation work and are robust in their ability to solve challenging safety and quality problems. Tools alone are not enough; we couple them with a systematic approach that:
- Reliably measures the magnitude of the problem
- Identifies the root cause(s) of the problem
- Finds solutions for the most important causes Ensures the effectiveness of those solutions
- Ensures sustained improvements over time
According to Chassin and Loeb (2011), there are three interdependent and equally critical requirements for achieving high reliability. First, clinical and administrative leadership at all levels must be committed to a long-term process. Second, a safety culture that involves mutual trust, safety-event reporting and improvement of problems is essential. Third, robust process improvement and innovation must exist to take a systematic approach to help us understand safety problems and guide us to create and implement highly effective solutions.
The aviation and nuclear power industries succeed in reliably preventing harm through the approaches I've listed above, but there is one more feature they have that all hospitals need to cultivate: They pursue a zero-defect environment. They set the ultimate goal at zero safety defects.
Is a zero-defect environment possible in a medical center? To date, no hospital anywhere has a zero-defect environment. Some, however, are closing in on certain processes such as hand hygiene, readmissions and surgical site infections (May, 2013) We must be committed to change and we must have aggressive targets. Will we reach a zero-defect environment? It may take years to reach, but how can we be committed to anything less? Why would we be committed to anything less? What if it were for someone you love? Would you accept anything less?
In the coming months, you will hear more about our Lean Process Innovation work and the Plan, Do, Study, Adjust (PDSA) Model (see below). There will be many opportunities for you to get involved as an individual and team. Speak out about your safety concerns. Use the PDSA Model to innovate new, improved and safe processes. Collectively, we must be mindful, committed and unwilling to settle for anything less than moving toward a zero-defect safety culture.
Chassin, M.R. & Loeb, J.M. (2011). The ongoing quality improvement journey: Next stop, high reliability. Health Affairs 30(4), 559-568.
Weick, K.E. & Sutcliffe, K.M. (2007). Managing the unexpected: resilient performance in an age of uncertainty. 2nd ed. San Francisco (CA): Jossey-Bass; 2007.
May, E.L. (2013). The power of zero: Steps toward high reliability healthcare. Healthcare Executive, p.16-24
The Plan, Do, Study, Adjust (PDSA) Model
quality_and_service_improvement_tools/plan_do_study_act.html, last accessed on July 26th, 2013)
What is it and how can it help me?
You can use plan, do, study, adjust (PDSA) cycles to test an idea and temporarily trial a change and assess its impact.
The four stages of the PDSA cycle:
Plan – the change to be tested or implemented
Do – carry out the test or change
Study – examine data before and after the change and reflect on what was learned
Adjust – plan the next change cycle or full implementation
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When does it work best?
You may not get the results you expect when making changes to your processes, so it is safer, and more effective to test out improvements on a small scale before implementing them across the board.
Using PDSA cycles enables you to test out changes before wholesale implementation and gives stakeholders the opportunity to see if the proposed change will work.
Using the PDSA cycle involves testing new change ideas on a small scale.
- Trying out a new way to make appointments for one provider or one clinic
- Trying out a new patient information sheet with a selected group of patients before introducing the change to all clinics or patient groups
- By building on the learning from these test cycles in a structured way, you can put a new idea in place with greater chances of success
As with any change, ownership is key to implementing the improvement successfully. If you involve a range of colleagues in trying something out on a small scale before it is fully operational, you will reduce the barriers to change.
Why test change before implementing it?
- It involves less time, investment and risk
- The process is a powerful tool for learning; from both ideas that work and those that don't
- It is safer and less disruptive for patients and staff
- Because people have been involved in testing and developing the ideas, there is often less resistance
How to test:
- Plan multiple cycles to test ideas. You can adapt these from the service improvement guide so there is already evidence that the change works
- Test on a really small scale. For example, start with one patient or one clinician at one afternoon clinic and increase the numbers as you refine the ideas
- Test the proposed change with people who believe in the improvement. Don't try to convert people into accepting the change at this stage
- Only implement the idea when you're confident you have considered and tested all the possible ways of achieving the change
How to use it
PDSA cycles form part of the improvement guide, which provides a framework for developing, testing and implementing changes leading to improvement. The model is
based in scientific method and moderates the impulse to take immediate action with the wisdom of careful study. The framework includes three key questions and a process for testing change ideas.
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The three questions:
- What are we trying to accomplish? What are our specific aims?
- How will we know if the change is an improvement?
- What changes can we make that will result in improvement?
What we trying to accomplish?
Teams need to set clear and focused goals. These goals require clinical leadership; they should focus on problems that cause concern, as well as patients and staff.
The aims statement should:
- Be consistent with any national goals and relevant to the length of the project
- Be bold in its aspirations
- Have clear, measurable targets
An example of an aims statement from cancer services: Aims: To improve access, speed of diagnosis, speed of starting treatment and patient care of people who are suspected of having bowel cancer.
This will be achieved by:
- Introducing booked admissions and appointments. Target: more than 95 per cent of patients
- Reducing the time from GP referral to first definitive treatment to less than 15 weeks
- Ensuring that over 80 per cent of patients are discussed by the multidisciplinary team
Concentrate efforts and measurements on key stages of care: GP referral, first out-patient appointment, first diagnostic test and first definitive treatment.
How do we know if the change is an improvement?
You will need to measure outcomes, such as reduction in the time a patient has to wait in order to answer this question. If we make a change, this should affect the measures and demonstrate over time whether the change has led to sustainable improvement. The measures in this model are tools for learning and demonstrating improvement, not for judgment.
Each project team should collect data to demonstrate whether changes result in improvement.
You should report improvement progress monthly on time series graphs known as run charts.
What changes can we make that will result in improvement?
There are many potential changes your team could make and it is possible that there may be several PDSA cycles running sequentially (figure 3), or even simultaneously (figure 4). Sequential cycles are common when the study reveals results which suggest a different approach is needed.
Figure 3 PDSA Cycles Running Sequentially
Figure 4 PDSA Cycles Running Simultaneously
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Simultaneous cycles may occur when the changes are more complex, possibly involving several departments. It is important that you identify any interactions between simultaneous cycles, as a change in method in one cycle may alter the impact of another somewhere else.
Having identified the changes with the greatest benefits, the next stage is to fully implement the change. This will require a stakeholder analysis, a project management plan and an ongoing analysis of the outcomes.
This page was last updated: November 8, 2013