High reliability organizations

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

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

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

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.

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

11. 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

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 • 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.

16. Elements of a Culture of Safety • establishingsafety 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

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

18. IOM:How to Improve Patient Safety? The IOM described 9 categories that provide opportunities to improve patient safety:

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.

21. 2. Avoid Reliance on Memory Standardizing and simplifying procedures and tasks decreases the demand on memory, planning, and problem-solving.

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.

26. 7. Anticipate the Unexpected Reorganization and organization-wide changes result in new patterns and processes of care.

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.

28. 9. Improve Access to Accurate, Timely Information Information for decision making needs to be available at the point of care.

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