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

3. 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%

4. 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

5. 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)

6. 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.

7. 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).

8. 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.

9. 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

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

11. Organizational factors associated with high performance (Keroack et al, 2011)
79 academic medical centers,
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

12. 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

13. 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

14. 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

15. 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).

16. 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).

17. 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)

18. 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.

19. 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.

21. 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.

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

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

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

25. 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.

26. 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.

27. 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.

28. 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.

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