Figure 1. The five specific concepts that help create the state of mindfulness that is needed for reliability, which in turn is a prerequisite for safety

Becoming a High Reliability Organization: Operational Advice for Hospi

 

Figure 1. The five specific concepts that help create the state of mindfulness that is needed for reliability, which in turn is a prerequisite for safety.

Text Description

A flowchart with 4 columns. The first column is titled: Specific Considerations. Five concepts are listed in the column: sensitivity to operations; preoccupation with failure; deference to expertise; resilience; and reluctance to simplify. The concepts flow into the second column, titled: General Orientation. There is a sunburst in the center of the column, with the words: State of Mindfulness. This flows into the third column, titled: Impact on Processes. There is a checkmark in the center of the column, with the words, High Reliability. This flows into the fourth column, titled: Ultimate Outcome. In the center are the words, Exceptionally Safe, Consistently High Quality Care.

Return to Document

 

Figure 2. Sensitivity to operations

Figure 2. Sensitivity to operations encompasses more than checks of patient identity, vital signs, and medications. It includes awareness by staff, supervisors, and management of broader issues that can affect patient care, ranging from how long a person has been on duty, to the availability of needed supplies, to potential distractions.

Text Description

A drawing of a man in a hospital bed surrounded by three staff members. The following objects in the room are circled: the face of one doctor, the folder in a doctor's hand, a clipboard, a cabinet, a monitor, pills and glass of water on a table, an infusion bag, a clock face, the identification tag on the patient's wrist.

Caption

Sensitivity to operations encompasses more than checks of patient identity, vital signs, and medications. It includes awareness by staff, supervisors, and management of broader issues that can affect patient care, ranging from how long a person has been on duty, to the availability of needed supplies, to potential distractions.

Return to Document

 

Figure 3. Reluctance to simplify

Figure 3. Oversimplifying explanations for how things work risks developing unworkable solutions and failing to understand all the ways in which a system may fail, placing a patient at risk.

Text Description

A drawing of a humorous production line. A gloved hand is pushing a squirrel holding a nut. There are many levers, pulleys, weights, hammers, and balls. The goal of the production line is not clear.

Caption

Oversimplifying explanations for how things work risks developing unworkable solutions and failing to understand all the ways in which a system may fail, placing a patient at risk.

Return to Document

 

Figure 4. Preoccupation with failure

Figure 4. A preoccupation with failure means that near misses are viewed as invitations to improve rather than as proof that a system has enough checks to prevent a catastrophic failure.

Text Description

A drawing of a car that has run off the road and is on the edge of a cliff. One passenger is thinking, "Wow that was close! Glad we had good brakes!"

The other passenger is thinking, "Wow that was close! We almost died!"

Caption

A preoccupation with failure means that near misses are viewed as invitations to improve rather than as proof that a system has enough checks to prevent a catastrophic failure.

Return to Document

 

Figure 5. Deference to expertise

Figure 5. Deference to expertise. In many situations, different staff members as well as the patient and family may have information essential to providing ideal care. Deference to expertise entails recognizing the knowledge available from each person and deferring to whoever's expertise is most relevant to the choices being made.

Text Description

A drawing of a woman in a hospital bed surrounded by three staff members and a family member. The nurse is thinking, "She's getting weaker."

The doctor is thinking, "Several complications could explain this."

The pharmacist is thinking, "Some meds could be interacting."

The husband is thinking, "She's upset about going to a nursing home."

Caption

In many situations, different staff members as well as the patient and family may have information essential to providing ideal care. Deference to expertise entails recognizing the knowledge available form each person and deferring to whoever's expertise is most relevant to the choices being made.

Return to Document

 

Figure 6. Resilience

Figure 6. Resilience. A good boater never leaves the dock without preparing for many situations that are unlikely, but possible. Oars, pump, lifejacket, and fire extinguisher ensure the boater can quickly respond to unexpected system failures.

Text Description

A drawing of a man in a small motor boat. The man is wearing a life jacket and the boat is equipped with a life buoy, fire extinguisher, oars, and a pump.

Caption

A good boater never leaves the dock without preparing for many situations that are unlikely but possible. Oars, pump, lifejacket, and fire extinguisher ensure that the boater can quickly respond to unexpected system failures.

Return to Document

Current as of April 2008
Internet Citation: Figure 1. The five specific concepts that help create the state of mindfulness that is needed for reliability, which in turn is a prerequisite for safety: Becoming a High Reliability Organization: Operational Advice for Hospi. April 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/hroadvice/hroadvicefig1-6.html