Applying High Reliability Concepts to Hospitals

Applying high reliability concepts in hospitals is not easy—or easy to explain. Although practitioners want concrete steps to take, the challenge of becoming a high reliability organization is more complex. In fact, this transformation must occur over a period of time and take into account various factors including general environmental issues; training and oversight of staff; processes for planning, implementing, and measuring new initiatives; and specific work processes occurring on units. A high reliability mindset views each of these levels as important and as a source of opportunities and threats to achieving exceptionally high-quality patient care.

Discussing and enhancing applications of high reliability concepts was the focus of the AHRQ HRO Learning Network. This section is based on a series of site visits and case studies drawn from hospital systems participating in the Network. These documents are included in their entirety as appendixes. This section synthesizes themes from these documents so that you can understand how a high reliability mindset affects the following areas:

• Changing and responding to the external and internal environment.
• Planning and implementing improvement initiatives.
• Approaches to doing work.
• Approaches to measuring progress.
• Specific improvement initiatives.
• Spreading improvements to other units and facilities.

The table of contents and index will allow you to locate topics of interest easily across the appendixes attached to this document.

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Changing and Responding to the Hospital's Environments

Hospitals and their staff operate within an external environment shaped by government regulations, characteristics of their patient populations, the job market for health care professionals, and the extent of competition from other sources of care. Hospital workers also confront an internal environment shaped by leadership priorities, resources available for training and improvement initiatives, and policies regarding responses to medical errors and quality defects. This section summarizes how a high reliability mindset affects responses to these environmental issues. Figure 7 provides an illustrative picture and description.

External Environment

Leaders of hospitals and hospital systems are the people most aware of the environmental factors that affect their facilities and are the ones most capable of attempting to change this environment. In Minnesota, a set of these leaders began to meet informally to discuss issues of mutual concern. Each knew that their facilities had safety and quality concerns, but they recognized that these issues had causes that were more complex than simplified explanations such as inadequate staff training, poor communication, or failure to follow defined policies. This reluctance to simplify was combined with an awareness of operational failures, which hospital leaders sometimes lack. These informal discussions gradually led them to recognize and collaborate on environmental issues that had previously undermined their efforts to become more reliable and safe. Their collaboration allowed them to:

• Address environmental barriers more effectively. Collaborating on community-level barriers to improve safety and reliability through collaboration was more likely to succeed than individual organizations' attempts to address the same barriers. These collaborations made it easier to work with legislative groups and occupational oversight boards to change policies needed for a culture of high reliability. Broad-based support was also critical to efforts to develop an innovative and successful system for reporting near misses and errors.
• Achieve cross-hospital standardization. Sharing a workforce among hospitals, including nurses and specialists, was a great motivation for standardizing forms and processes across all institutions. This strategy reduced variations in work patterns as well as the potential for errors and unnecessary rework. The collaboration also created opportunities to standardize the measuring and reporting of quality issues. This approach made it easier to more accurately set priorities, develop consistent requirements, and evaluate progress.

As leaders of these hospitals reflected on these efforts to collaborate, they identified a number of tangible recommendations for ways to make as much progress as possible. These included:

• Do not compete on patient safety. It is essential to agree at the beginning of any collaboration that the organizations involved will not compete on patient safety initiatives such as preventing wrong site surgery and medication abbreviation errors. Competing on patient safety will both derail collaborative efforts toward improvement and cause misalignments between individual system focuses and established priorities. Even in areas where hospitals do compete, there still may be grounds for collaborating with each other. In Minnesota, even though there is competition related to performance on quality measures, hospitals have worked collaboratively to develop common quality metrics that can be used to measure comparative performance.
• Do not underestimate the value of incremental muddling. Many of the successful collaborations began with informal conversations between relevant leaders about issues of potential interest. While some of these discussions did not progress, others evolved into more focused discussions and formal agreements to work together to achieve important goals. This approach to planning allowed ideas to be explored without major commitments of time or resources, and reduced the likelihood of a major investment in an idea that lacked widespread support.
• Local community collaborations can be more powerful than national collaborations. Geography is an important factor in collaboration because the people involved have a common understanding of the local conditions, such as the market, transportation, and money. National collaborations are sometimes scoped too broadly to apply to local health care systems and practitioners. Collaboration at the local level can be very effective for this reason.
• Expect building community collaborations to take time. One criticism of collaboration is that there are so many possible focuses of work. Rather than attempting to involve all of the organizations and their leaders in all initiatives at the same time, Minnesota has been successful by developing collaborations one at a time and including only the relevant groups for specific initiatives. Trying to do too many things too quickly is always in tension with trying to make sure particular initiatives have enough traction to succeed. Building a coalition over time and bringing in different stakeholders with different needs at the appropriate time makes collaborative work more feasible.

Working together, the organizations in Minnesota have made substantial progress shaping external environmental factors. Three examples reflect the range of what is possible:

• Changing perceptions of medical errors. Working together was necessary to educate legislators, regulators, and members of the media on the importance of a nonpunitive approach to medical errors. It is better to focus on understanding and fixing system failures than singling out individuals for blame. Punitive cultures discourage the open communication needed to respond quickly so that small errors do not become large ones. Working together, leaders of these organizations were more successful in educating those in oversight positions as well as media members regarding best approaches to diagnosing and fixing errors and addressing quality issues.
• Standardizing aspects of care communitywide. Leaders recognized that workforce members often worked in multiple facilities in which "correct" ways of doing work were inconsistent. They also understood that efforts by one facility to insist that physicians comply with policies regarding surgical markings or medication abbreviations would be compromised if the physician could simply practice elsewhere in a place that was more accommodating. By working together, the leaders created communitywide standards for medication concentrations, surgical site markings, and use of only appropriate abbreviations for medications. Creating and implementing these standards together allowed these leaders to reduce threats to reliability in each of their hospitals.
• Standardizing approaches to measuring and reporting results. Hospital leaders also worked together to develop and implement common measures and approaches for reporting on quality. This enabled them and other stakeholders to have more accurate data regarding their facilities' comparative performance and made it easier to meet the reporting requirements of payers and regulators.

More details on how this community collaboration worked to modify the external environment so that their systems could be more reliable are provided in the Fairview and Allina Site Visit Appendix.

Internal Environment

Hospital staff operate within an internal environment shaped by executive leaders, financial constraints, and human resource policies. Creating an internal environment that supports an HRO mindset is essential to achieve the goals of safety and quality. Four key elements in a supportive internal environment are:

• Executive leadership support. Exempla Chief Executive Officer (CEO) Jeff Selberg discussed the importance of supportive executive leadership in achieving high reliability. His observations on what leaders must do reflect many of the HRO principles described above, including:
  • Culture is the foundation for vision and strategy. A culture characterized by fear and self-protection will not lend itself to openness, learning, and improvement.
  • Transparency is the key to change the culture. An unwillingness to face and share the hard facts is an indicator of denial, and denial is not compatible with a safe environment.
  • Safety must be the overarching strategy. Safety should be the root cause of achieving efficiency and effectiveness. If the inverse of this relationship exists, the likelihood of having unsafe, yet highly efficient processes increases. Only if safety is the starting point can the correlation among safety, efficiency, and effectiveness remain positive.
  • Leaders must take ownership for setting the climate and focusing the work. Generating clarity, setting the example, and demonstrating confidence will help to transform organizational culture. However, without outright acceptance of ultimate accountability for setting organizational direction, a leader's vision will not be legitimized in the eyes of his or her followers.

• Alignment with your business case. Hospitals can be highly reliable producers of adequate profit margins at the expense of highly reliable safe and quality care. The only way to ensure that the pursuit of reliability encompasses both is to work to align the business case with the case for quality. This is not easy, but Scott Hamlin, the Chief Financial Officer (CFO) at Cincinnati Children's Hospital, offered his perspective on how this goal can be achieved. He noted that:
  • Getting the CFO on board is critical. To the extent that the CFO influences resource allocation decisions, interacts with the board, and shapes compensation strategies for organizational leaders, organizational transformation is unlikely without the full support of the CFO.
  • Getting the CFO on board is a gradual process. The CFO needs to be tactfully and patiently educated about issues related to quality and safety, as well as how these issues affect the hospital's financial performance. In Mr. Hamlin's case, it took several years for him to evolve from a skeptic about issues related to quality to a champion for quality's role in the hospital's business case. CFOs are trained to be skeptical and focused on financial issues, so it is unrealistic to think that a single presentation, workshop, or set of data will lead to a dramatic change in their outlook. More time and patience will be required.
  • Giving CFOs data and tools that they can use to convince themselves of the business case for quality is essential. Cincinnati Children's helped to train the CFO's staff to perform analyses required to convince the CFO of the business case for quality. Analyses performed by quality staff would have been suspect, but once the financial analysts could evaluate data independently to draw financial conclusions, the results were credible to the CFO. The approach used at Cincinnati Children's involved providing the CFO with the data and tools that he and his staff could use to convince themselves of the business case for quality.

• Linkage of staff behavior with desired outcomes. Sentara is highly reflective about creating and reinforcing these links, since they recognize that their staff will probably do the things they are rewarded for doing. If they want staff to be sensitive to operations and preoccupied with failure, they need to ensure that these behaviors are rewarded. Recommendations based on their experiences include:
  • Don't introduce interventions unless they are fully linked with policies and aligned with incentives for performance. Several systems expect all new initiatives to be linked to dashboards reviewed by executives or the board before the initiative can begin. Sentara and other systems also incentivize improvements in areas where they are looking to improve. For example, employee bonuses linked to improvements on behavior-based expectations (BBEs) for error prevention amounted to the equivalent of 2 weeks' pay. Effective alignment helps new initiatives get running quickly and effectively.
  • Make sure there are clearly identified owners for all actions that are key to a successful implementation. Systems reported substantial improvements in performance when actions were assigned to specific owners. When an action is owned by a team rather than an individual, it is less likely to happen.
  • Make sure that safety and quality issues are carefully linked to operational issues. When quality improvement (QI) staff attempt to develop an intervention without close coordination with operational leadership, the project is unlikely to work. If operational and improvement planners work together to link their goals and processes, the project is more likely to have a successful start.

• A just culture. A just culture is one where people can report mistakes, errors, or waste without reprisal or personal risk. This does not mean that individuals are not held accountable for their actions, but it does mean that people are not held responsible for flawed systems in which dedicated and trained people can still make mistakes. All staff must feel empowered to identify errors, defects, and system failures that could lead to an unsafe environment for patients.
  • Christiana Care actively promotes a just culture in their innovative electronic intensive care unit (EICU). A major key to making the EICU successful was to allay concerns that EICU staff were judging the quality of the work performed by staff providing direct patient care in the ICU. The wall of their EICU is covered with fish—each fish represents a good catch of a problem that protected a patient from potential harm. Rather than covering up near misses or threats to patients, Christiana actively acknowledges that these threats exist and celebrates rather than hides the fact that they are detected and prevented. It is an approach that reinforces a nonpunitive view of errors and one that encourages preoccupation with failure.
  • Cincinnati Children's has worked with units to increase reliability and celebrate successes. When a near-miss event takes place and a staff member accurately records the event, that staff member is acknowledged for reporting the event. Similar approaches are used in many of the other hospitals.
  • Christiana Care and Sentara staff both relayed the importance of stories in fostering a just culture. When stories are told by staff about being validated rather than criticized by leaders for reporting mistakes, these stories become part of a culture in which potential risks can be discussed and reduced rather than concealed and allowed to continue.

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Planning and Implementing Improvement Initiatives

Improving quality and safety requires both knowing what to do and how to do it. Many initiatives are excellent ideas but still fail because the approach to implementation is poorly designed. A high reliability mindset must be applied to how your organization plans and implements improvements. If you don't understand the pressures and challenges facing the people key to your implementation, you probably won't succeed. You also will not succeed if you oversimplify your implementation strategy, fail to listen to people with the most expertise about what success requires, or fail to constantly consider what can go wrong and work to avoid those challenges.

Systems in the network offered considerable practical advice about how to apply high reliability concepts to their planning and implementation activities. This advice falls into three general categories:

• Processes.
• People.
• Resources.

Process Applications

Success requires introducing innovations into systems that are prepared to respond to them. Systems in the Network have learned much from their successes and failures in rolling out new initiatives. Preconditions for success that they have identified include:

• If an improvement cannot be integrated into an ongoing initiative or process, do not try it. Until it is integrated it will not be successful. A key to high reliability is simplifying systems and processes so that they can be performed consistently. The more separate initiatives or processes that exist, the less reliable the overall system will be.
• Negotiate in advance where savings from an innovation will go. This will ensure that resources that are freed up can support top priorities and will increase motivation by key people needed to make the innovation successful. Because not all innovations result in cost savings, it is even more important to agree on where savings from those that do are allocated.

Rollouts also work better if they are sequenced or staged in ways that make them more palatable to staff. Key observations related to success include:

• Christiana Care embeds initiatives into the training that they provide to new staff. This creates the expectation that the initiatives are essential and avoids having to retrain staff after they begin work.
• Start by simplifying policies and procedures to make it possible for staff to comply. Shortly after Sentara introduced BBEs, they began to simplify processes so that people could see that changes would not be a net increase to their workload. Gaining buy-in and appreciation for making jobs easier before adding new procedures or processes helps employees to avoid seeing the new things as an extra burden.
• Roll initiatives out incrementally and begin with ones that are nonpunitive. For example, Sentara introduced and educated staff regarding the BBEs first before implementing Red Rules. They did this because they wanted people to believe that they had the training and clarity required to be successful before Sentara introduced Red Rules, which focused on actions that should always be prevented. Without a culture that supports disclosure and questioning, introducing Red Rules could be counterproductive.
• Exempla uses Lean thinking approaches to rolling out initiatives. By drawing together key people and allowing them to spend an extended period of time working together to map out the process and then redesign it, they reduce the likelihood of redesign efforts that are likely to fail. Even then, Exempla has learned that further adjustments should be expected once the process redesign is extended to other units or work shifts.

People Applications

Although the importance of people is obvious, many initiatives in hospitals still fail because key perspectives are overlooked, physicians are not included (or do not want to be included), or improvement staff are different from operational staff. Anticipating the people problems that can prevent your improvements from succeeding is a key dimension of preoccupation with failure. Observations from Network members related to people include:

• To involve physicians, avoid systems or procedures that decrease their efficiency. Physicians do not mind changes in how they practice medicine if those changes make them more efficient (or at least do not decrease their efficiency). Involving them in the planning process is crucial toward preventing the implementation of changes that they will perceive as making them less efficient.
• Provide resources and expertise that allow physicians to help lead improvement efforts. Cincinnati Children's works extensively to provide resources and expertise that will allow its physicians to help lead improvement efforts. Each Clinical System Improvement Integrating team is led by a physician and a nonphysician. In this capacity, physicians work collaboratively to help develop and lead initiatives that improve systems and processes. The net effect of this effort is a growing number of physician leaders who can provide valuable perspectives and ideas required to drive the transformational goals that have been established.
• Include people from multiple shifts and work units. Each site visit involved at least one story of an implementation that was developed by one set of people and resisted by another because they were not involved in planning. Christiana Care found that their EICU initiative benefited greatly from involving staff from the ICU in planning and having them spend time in the EICU to understand how it works. Exempla found that their pharmacy redesign was resisted by night shift staff who were not involved in its planning. Every system reported that initiatives developed in particular units or hospitals were not as well received in others. Including as broad a set of people who will be affected by the initiative is critical.
• Encompass multiple staff types in planning. Sentara's medication dispensing machine system redesign succeeded in part because they included nurses, pharmacists, supervisors, and other staff in the planning process.
• Avoid having quality improvement staff design initiatives without input from operational staff. The role of quality improvement staff at Cincinnati Children's is to serve the teams working on the improvement rather than function as the leads responsible for achieving the change. This consultative role ensures that ownership of the improvement efforts remains with the units and teams that provide patient care. This approach increases staff buy-in as well as the sustainability of improvement efforts.

Resource Applications

Having adequate resources is critical for many initiatives to succeed, and the most important resource is sufficient time for key leaders to focus on the effort. Systems have used a variety of strategies to ensure that sufficient resources are available. These include the following:

• Exempla provides replacement staff for people participating in the Lean Change Process Efforts. It is unreasonable to expect staff to focus on these planning efforts while still attempting to do their normal jobs.
• Cincinnati Children's budgets a substantial amount to support personnel on high-profile initiatives. Particularly for physicians, this support is essential to ensure their participation.
• Resources and labor are always in short supply, so many systems actively monitor the number of priorities to ensure that there are not too many to support. Cincinnati Children's stresses keeping a short priority list. The only way something goes onto this list is if something on the list is completed or removed. This plan ensures the focus new projects require. At the microsystem level, several systems use strategies that require managers to list all the things they are trying to do and then to classify these things based on whether they can or cannot do them. Management then must respond to these lists by setting priorities and making decisions about more resources. This task is very difficult for managers but helps avoid starting new things that personnel feel cannot be done.

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Doing the Work

HRO concepts emphasize a different way of thinking about and performing work at every level. If tasks are too complex it becomes impossible to distinguish doing the work right from doing it wrong. If there are no opportunities to talk about issues with other staff, there is little chance that people will be exposed to other views or information and little opportunity to discuss near misses. If leaders aren't routinely observing and talking with staff providing direct patient care, they will not understand the operations for which they are responsible.

The Sentara site visit and subsequent case study at Sentara focused attention on a range of strategies that they (and other systems) are using to encourage high reliability thinking as people do their work. These strategies include:

Simplifying work process. If you cannot reduce what you want staff to do into a limited set of clearly defined behaviors, your system will not be reliable. As noted above, Sentara has created a set of behavior-based expectations (BBEs) for their staff. These BBEs were associated with a substantial reduction in sentinel and other serious events and substantially reduced insurance claims over a 3-year period.

Daily check-ins. These short, focused meetings of leaders and staff on a unit follow a set agenda and occur at the same time each day. The meetings allow staff to raise questions, give them information that may affect their work, and provide a forum for raising issues, which are delegated and handled outside the meeting.

Executive rounds. Executive rounds enable hospital leaders to retain an awareness of operations that is needed for good decisionmaking. These rounds also create an opportunity for staff to raise issues with leaders and for leaders to model the behaviors they want staff to exhibit, including following up on issues that are raised. They are key to supporting a culture that defers to expertise and encourages staff to speak out about safety and quality concerns. In order for executive rounding to be most effective, however, hospital leadership must follow-up on the concerns voiced by staff members in order to ensure receiving continual feedback.

Safety huddles. Sentara uses these huddles in units every 12 hours, which ensures that the unit is thinking specifically about safety issues at least twice a day as a team. The huddles are very short but allow people to comment on any safety issues they observed or were concerned about. They also allow people to comment on their own condition so that people can receive extra assistance on days when they may need it.

Performance management. Many systems in the HRO Network have very rigorous processes for managing performance and rewarding individual and team accomplishment. These approaches often include behavioral observation of staff by trained supervisors and substantial bonuses linked to fulfilling the BBEs. Performance management is key to ensuring that staff are rewarded for desired behavior and discouraged from other actions.