High reliability organizations Joanne Disch, PhD, RN, FAAN Clinical Professor University of Minnesota School of Nursing

A world-wide issue Adverse drug events and medication errors in Australia (IJQHC, 2003) Of coded adverse events leading to death, 27% involved an adverse drug event Transplant Tourism: Outcomes of United States Residents Who Undergo Kidney Transplantation Overseas (Transplantation, 2006) 6 infections in 4 patients, l rejection Medication errors in primary care in Riyadh city, Saudi Arabia (EMHJ, 2011) Prescribing errors in 18.7%

IOM Six Aims for Improving Health Care Safety and Quality Description Safe Avoiding injury and harm to patients Timely Reducing waits Effective Care based on evidence Efficient Avoiding waste Equitable Quality does not vary because of gender, ethnicity, socioeconomic factors or geographic status Patient-centered Respectful and responsive care based on patient values Table 3

High Reliability Organizations (HRO) Organizations that have cultures of safety, foster a learning environment and evidence-based care, promote positive working environments for nurses, and are committed to improving the safety and quality of care are considered to be high reliability organizations HRO (Carrol, 2006)

High Reliability Organizations (HRO):Characteristics Characteristics of HROs include: having a safety and quality-centered culture direct involvement of top and middle leadership safety and quality efforts aligned with the strategic plan an established infrastructure for safety and continuous improvement and active engagement of staff across the organization (Shortell, 2005; Baker, 2006; Bagin, 2001) The safety and quality of care can be improved by holding systems accountable, redesigning systems and processes to mitigate the effects of human factors and using strategic improvements.

Components of a HRO A health care setting is composed of a large set of interacting systems, often referred to as the Macrosystem. The smaller units are known as Microsystems. admissions emergency department inpatient units ambulatory units and operating room dietary environmental services, etc. Macrosystem Microsystem (Shortell, 1985, 2005) At a basic level, systems are a set of interdependent components that interact to achieve a common goal. The interacting Microsystems each have technical, environmental, and social components (Weick, 1999).

Microsystems - are a small group of people who work together on a regular basis to provide care to discrete subpopulations of patients. It has clinical and business aims, linked processes, and a shared information environment, and it produces performance outcomes. Microsystems evolve over time and are often embedded in larger organizations. They are complex adaptive systems, and as such they must do the primary work associated with core aims, meet the needs of internal staff, and maintain themselves over time as clinical units.

High-performing front-line clinical units (Nelson et al, 2002) From leaders of 43 clinical units in 20 orgs - Constancy of purpose Investment in improvement Alignment of role and training for efficiency, staff satisfaction Interdependence of the care team to meet patient needs Integration of information and technology Ongoing measurement of outcomes Supportiveness of the larger organization Connection to the community to enhance care delivery and extend influence

The Microsystem Model Culture Organizational support Patient focus Staff focus Leadership Interdependence of care teams Information & IT Process improvement Performance patterns

Organizational factors associated with high performance (Keroack et al, 2011) 79 academic medical centers, 2003-2004 Factors assessed: safety, mortality, clinical effectiveness, equity of care Six institutions studied: 3 top, 3 average Top levels of performance could result in 150 fewer deaths per year

Key findings Shared sense of purpose ‘Patient care comes first’ Leaders are dissatisfied with status quo Service excellence part of focus on quality, safety Accountability system for service, quality, safety (SQS) Prioritizing, developing measures and setting goals are centralized, while tactics are decentralized Chairs accept responsibility for SQS in departments Accountability, innovation and redundancy at the unit

Key findings (cont) Collaboration Leadership style The basic relationship among administration, nurses, physicians and other staff Frequent recognition of employee contributions at all levels Employees [and physicians] value each other’s critical knowledge when problem solving Leadership style CEO is passionate re: service, quality, safety (SQS) Everyday events are connected via stories to SQS Governance structures minimize conflicts among missions Institution is led as an alliance between executive leadership team and clinical chairs

Key findings (cont) Focus on results Relentless effort to improve Results outweigh the approach to performance improvement Focus on human behavior and work redesign Technology is accelerator, not substitute for work redesign

Culture of Safety Within a healthcare setting, each discipline can have a different culture, as can each patient care area…so can each individual person In a culture of safety, the focus is on effective teamwork to accomplish the goal of safe, high-quality patient care. While differences may benefit the work of the organization, more frequently it results in communication difficulties particularly around patient handoffs (Lamb, 2003; Walsh, 2004).

Elements of a Culture of Safety establishing safety as an organizational priority teamwork patient involvement openness/transparency accountability shared core values and goals non-punitive responses to adverse events and errors adequate education and training A balance needs to be achieved between not blaming individuals for errors and not tolerating egregious behavior. This is currently referred to as a “Just Culture” (Yates, 2005; Mitchell, 2008).

Elements of a Culture of Safety A safety culture requires strong, committed leadership, and engagement and empowerment of all employees. It entails periodic assessment of the culture and relationship between the organization culture and the quality and safety within the organization (Wachter, 2009)

IOM: How to Improve Patient Safety? The IOM described 9 categories that provide opportunities to improve patient safety: IOM (2001) The key question is how to improve patient safety. It is necessary to differentiate between the blunt end latent conditions and sharp end where the event takes place.

1. User-centered Design Approaches include making things visible so the user is able to see actions possible at any time, affordance, constraints and forcing-functions. For example, making something visible would be directions on a piece of machinery on how to return to an earlier step or how to change settings. Affordance indicates how something is to be used such as marking the correct limb before surgery and a sign on a door indicating which way to open it. A constraint makes it hard to do the wrong thing. Forcing function makes it impossible to do the wrong thing, such as put the active electrode of the bovey cautery machine into the grounding plate.

2. Avoid Reliance on Memory Standardizing and simplifying procedures and tasks decreases the demand on memory, planning, and problem-solving. The use of protocols and checklists reduces reliance on memory and serves as a reminder for the steps to be followed. Simplifying processes minimizes problem-solving. Having the usual dose of a medication as the default in an electronic order entry. Purchasing equipment that is easy to use and maintain are examples of simplification of processes.

3. Attend to Work Safety Work hours, work-loads, staffing ratios, distractions, and counterclockwise shift changes all affect patient safety.

4. Avoid Reliance on Vigilance Checklists, well-designed alarms, rotating staff and breaks decrease the need for remaining vigilant for long periods.

5. Training Concepts for Teams Training programs for effective interprofessional communication and collaboration include transitions in care and hand-offs.

6. Involve Patients in Their Care Patients and families should be in the center of the care process. This includes clinicians obtaining accurate information and including patients and families in decisions about treatments and comprehensive discharge planning and education.

7. Anticipate the Unexpected Reorganization and organization-wide changes result in new patterns and processes of care. Introduction of new processes and technologies depends on a chain of involvement of frontline users and the need for pilot testing before widespread implementation.

8. Design for Recovery Errors will occur despite the best of planning. Designing and planning for recovery will allow reversal or make it hard to carry out irreversible critical functions. Simulation training promotes the practice of processes and rescues using models and virtual reality.

9. Improve Access to Accurate, Timely Information Information for decision making needs to be available at the point of care. This includes easy access to drug formularies, evidence-based practice protocols, patient records, laboratory reports, and medication administration records.

In summary - High reliability organizations have: A shared sense of purpose Focus on results Accountability systems for service/quality/safety Collaboration Effective leadership