Creating Highly Reliable Health Care Organizations: Evidence from the Field

1. Creating Highly Reliable Health Care Organizations: Evidence from the Field Timothy J. Vogus Vanderbilt Owen Graduate School of Management November 2, 2011

2. High Reliability... • Conveys the idea that high risk and high effectiveness can coexist. • Refers to the fact that some organizations must perform effectively under very trying conditions. • Reflects the intensive effort that some high-risk organizations sustain over time to achieve their goals, promote safe operations, and prevent the occurrence of adverse outcomes.

3. Where Do We Observe High Reliability? • High Reliability Organizations (HROs) • Organizations that have nearly error-free operations in extremely trying environments • Aircraft carrier flight decks (Weick & Roberts, 1993) • Nuclear power plants (Schulman, 1993) • Air traffic control (Rochlin, 1997) • Medicine aspires to be high reliability (HSR, 2006; IOM, 2000) • The model for JCAHO (Chassin & Loeb, 2011)

4. Basic HRO Characteristics • Operate in unforgiving social and political environments • Have limited opportunities to learn through experimentation • Have potential for adverse consequences • Have potential for surprise and unexpected events

5. Why Use HROs as a Template? • HROs have mastered ways to perform nearly error-free in uncertain, unknowable environments • Aircraft carrier flight decks, nuclear power plants, and air traffic control • HRO operational insights can inform the practices of all organizations • Pressures for “reliability and quality” are building for all organizations (e.g., operational, reputational, legal)

6. How Do HROs Do It? • They don’t just value reliability per se, they disvaluemis-specifying, mis-estimating, and misunderstanding things • They organize so that people are more likely to become aware of discriminatory detail and they work to develop people’s capacities so that they can act on what they see

7. What Behaviors Underlie High Reliability? • Mindful organizing (Weick, et al., 1999) • Preoccupation with failure • Reluctance to simplify interpretations • Commitment to resilience • Sensitivity to operations • Deference to expertise • Mindful organizing allows for the rapid detection and correction of emerging errors

8. Being Mindful Means to Pay Attention in a Different Way • You STOP concentrating on those things that confirm your hunches, are pleasant, feel certain, seem factual, are explicit, and that others agree on! • You START concentrating on things that disconfirm, are unpleasant, feel uncertain, seem possible, are implicit, and are contested!

10. Mindful Organizing Occurs When • People (e.g., nurses) are • Spending time identifying what could go wrong • Discussing alternatives as to how to go about everyday activities • Developing an understanding of who knows what • Talking about mistakes and ways to learn from them • Taking advantage of the unique skills of one’s colleagues (even if the person is of lower status in the organization)

11. Research Questions • Does mindful organizing lead to patient safety? • How do nurses behaviorally enact mindful organizing? • Do other safety-oriented practices enhance the benefits of mindful organizing? • What facilitates the emergence of mindful organizing? • Is mindful organizing responsive to interventions?

12. Data • Sample • 13 hospitals from a large Catholic health system • 125 nursing units, 93 with outcomes data (10 hospitals) • 1,685 RNs (51% response rate) • Method – survey and archival data • Archival dependent variables – medication errors, patient falls • Nurse manager survey – managerial practices, unit characteristics • RN survey – mindful organizing, respectful interaction

13. Does Mindful Organizing Improve Safety? • A one unit increase in mindful organizing leads to 35% fewer medication errors on a nursing unit • 7 fewer errors per year per unit • A one unit increase in mindful organizing leads to 69% fewer patient falls on a nursing unit • 13 fewer falls per year per unit • Mindful organizing also positively related to manager ratings of safety and quality

14. Do Other Safety-Oriented Practices Augment These Effects? • Mindful organizing doesn’t exist in a vacuum • Enhanced by complementary practices • Care pathways • Standardization of care according to best practice - structure interactions, build connections (Feldman and Rafaeli, 2002), and facilitate coordination (Gittell, 2002)

15. Joint Effects – Mindful Organizing and Care Pathways

16. Which Work Practices Enable Mindful Organizing? • HR practices • Selective staffing • Hiring for interpersonal as well as technical skills • Extensive training • Preceptor programs, training in interpersonal skills, ongoing informal training • Developmental performance appraisal • Ongoing, 360-degree, and focused on learning • Employee involvement • Discretion over work practice • Reward suggestions • Job Security

17. How Do HR Practices Help? • Through signaling • Signaling the behaviors expected, supported, and rewarded • Signaling about what? • How work is to be carried out • Developmental performance appraisal and coaching signal the importance of learning and feedback seeking • Hiring for interpersonal skills signals they are valued and an important part of everyday work • They foster a psychological contract • Employees are valued and treated fairly, so they reciprocate and generalize

18. What Enables Mindful Organizing and Patient Safety? Dyadic interactions – trust, honesty, and self-respect Capabilities for detecting and correcting the unexpected HR enhances the quality of interrelating Respectful Interaction Mindful Organizing + + + HR Practices Patient Safety + + + OCB Employee Commitment +

19. Findings – Medication Errors +*** Respectful Interaction Mindful Organizing -* +* Med. Errors HR Practices -* +* +** Commit OCB +**

20. Findings – Patient Falls Respectful Interaction Mindful Organizing +*** -** +* Pat. Falls HR Practices -** +* +** Commit OCB +**

21. Which Employee Characteristics Enable Mindful Organizing? • Mindful organizing is a function of the skilled efforts of “reliability professionals” (Roe & Schulman, 2008) • Interconnected knowledge base (Roe & Schulman, 2008) • Communication • Motivation and commitment

22. How Employee Characteristics Enable Mindful Organizing • Workgroup professional tenure • Increases the pool of expertise and experience • Up to a point, diminishing returns • Professional tenure variability • Increase amount of communication needed • Decreases workgroup willingness and ability to engage in communication • Workgroup professional commitment • Increases altruism and extra-role behaviors

23. Mindful Organizing and Professional Tenure MINDFUL ORGANIZING PROFESSIONAL TENURE (YEARS)

24. Mindful Organizing, Tenure, and Tenure Variability

25. Mindful Organizing, Tenure, and Commitment

26. Implications • Professional tenure important for hiring • Effectively manage entry and exits • Think about how affects the workgroup composition • Increase professional commitment • Campaigns to foster pride in the profession • Redesign work to foster connection to professional ideals

27. What About VHVI/VUMC?

28. Generating High Reliability • Little is known about how to move from reliable to highly reliable • Longitudinal intervention with VHVI • Heart and Vascular – inpatient units, labs (e.g., Cath Lab), and clinics (~900 employees) • Focus groups, survey data (2 waves) • Interventions and consulting • Resurvey

29. Baseline Data • Qualitative • “Failing to close the loop” • Quantitative • Underdeveloped processes of mindful organizing • Reluctance to simplify interpretations, commitment to resilience • Weak psychological safety • Unsafe to take an interpersonal risk • Poor leader-member exchange

30. Interventions • Change the conversation • Leader rounding • Managers on their units • Top management on all units • Huddles • Post-event cross-profession debriefs; what, why, and lessons to learn • Create mechanisms for change • Safety action teams

31. Emerging Evidence • Increased leader engagement • Regular rounding • Immediate follow up actions • Institutionalization of huddles • Increased reporting of errors and threats to safety • “The list” • Safety action teams a mechanism for frontline change and dissemination of safety and reliability information

32. Conclusions • Mindful organizing improves performance • Reduces medication errors • Reduces patient falls • The benefits of mindful organizing are enhanced when coupled with complementary practices • Use of care pathways • HR practices provide powerful signals that shape mindful organizing and patient safety • Professional tenure, homogeneity of tenure, and professional commitment also enable mindful organizing

33. A well-designed organization is not a stable solution to achieve, but a developmental process to keep active.(Starbuck & Nystrom, 1981, p. 14)

34. That means:You NEVER get High Reliability Organizing behind you!

35. Leadership Matters “Only in the upper levels of the system can we begin to get to grips with the ‘parent’ failures...that create the downstream ‘problem children’. If these [conditions] remain unchanged then efforts to improve things at the workplace and worker level will be largely in vain.” (James Reason, 1997, p. 121)

36. High Reliability and Mindful Organizing Resources • Roberts, K. H. and R. G. Bea (2001). "When Systems Fail." Organizational Dynamics 29(3): 179-191. • Rosenthal, M. M., and K. M. Sutcliffe (2002). Medical Error: What Do We Know? What Do We Do? San Francisco, CA, Jossey-Bass. • Sutcliffe, K. M., E. Lewton, et al. (2004). "Communication Failures: An Insidious Contributor to Medical Mishaps." Academic Medicine 79(2): 186-194. • Vogus, T. J. and K. M. Sutcliffe (2007). "The Safety Organizing Scale: Development and Validation of a Behavioral Measure of Safety Culture in Hospital Nursing Units." Medical Care 45(1): 46-54. • Weick, K. E. (1987). "Organizational Culture as a Source of High-Reliability." California Management Review 29: 112-127. • Weick, K. E. and K. M. Sutcliffe (2001). Managing the Unexpected: Assuring High Performance in an Age of Complexity. San Francisco, Jossey-Bass. • Weick, K. E. and K. M. Sutcliffe (2003). "Hospitals as Cultures of Entrapment: A Reanalysis of the Bristol Royal Infirmary." California Management Review 45(2): 73-84. • Weick, K. E. and K. M. Sutcliffe (2007). Managing the Unexpected: Resilient Performance in and Age of Uncertainty, Second Edition. San Francisco, CA, Jossey-Bass.

37. Why High Reliability? • Safety (IOM 2000, 2001, 2004) • Medical Error • Up to 98,000 deaths annually (Kohn, et al., 2000) • Problem has not improved (Landrigan, et al., 2010) • And may be even larger (Classen et al., 2011)

38. A Cultural Solution • Safety culture • A safety culture is the product of the shared values, attitudes, and patterns of behavior that determine the observable degree of effort with which all organizational members direct their attention and actions towards minimizing patient harm that may result from the process of care delivery

39. Safety Culture • Enabling • Leader actions that • Direct attention to safety • Create contexts safe to speak up and act in ways that improve safety • Enacting • Frontline actions that • Surface latent and manifest threats to safety • Mobilize resources to reduce threats • MINDFUL ORGANIZING Safety Outcomes • Elaborating • Learning practices that • Develop comprehensive representations of safety outcomes • Provide feedback that modifies enabling and enacting