Using High Reliability Strategies to Achieve Regulatory AccountabilityNancy McLean, MHSA, BSN, LNHA
Glossary • AHRQ - Agency for Healthcare Research and Quality • AMI - Acute Myocardial Infarction • HF - Heart Failure • HRO - High Reliability Organization • HRT - High Reliability Theory • PI - Performance Improvement • RPI - Robust Process Improvement
References • Crisis Management Volume III. Arjen Boin. Sage, Los Angeles, 2008 Chapter 44, Organizing for High Reliability: Processes of Collective Mindfulness. Karl E. Weick, Kathleen M. Sutcliffe and David Obstfeld • Managing the Unexpected: Resilient Performance in an Age of Uncertainty. Jossey Bass. 2007. Karl E. Weick, Kathleen M. Sutcliffe • http://www.jointcommission.org/highreliability.aspx • Quality Safe Health Care. 2005 Aug;14(4):303-9. Promoting health care safety through training high reliability teams. Wilson KA, Burke CS, Priest HA, Salas E. http://psnet.ahrq.gov/resource.aspx?resourceID=2470 • Making Sense of the Organization Volume 2: The Impermanent Organization. John Wiley and Sons, Ltd. 2009. United Kingdom. Karl Weick. • Adverse Events in Hospitals: National Incidents Among Medicare Beneficiaries. Daniel R. Levinson, Inspector General. November 2010. OEI-06-09-00090
Session Objectives • At the end of this session, the participant will be able to: • Enable the organization to shift the focus from “acceptance of 90% compliance” to “what prevented us from achieving 100%” • Expand their PI activities to incorporate the analysis of near misses and failures
HRO Background • In 1987, University of California - Berkley researchers Todd LaPorte, Gene Rochlin, and Karlene Roberts examined aircraft carrier failures. • In 1998, University of Michigan researchers Karl Weick, Kathleen Sutcliffe, and David Obstfeld re-conceptualized the literature and research, heightening the focus on HR Theory (followed by 2 books in 2001 and 2007). • AHRQ 2008 • The Lewin Group • Delmarva Foundation for Medical Care, Inc. • April 2011 Dr. Chassin and Jerod Loeb, PhD article in Health Affairs • 2013 TJC website contains info on HROs
HRO Principles • High Reliability Teams emphasize the following in the organization; • A strategic prioritization of safety • Careful attention to design and procedures • A limited degree of trial-and-error learning • Redundancy • Decentralized decision-making • Continuous training often through simulation • Strong cultures that create a broad vigilance for and responsiveness to potential accidents (LaPorte & Consolini, 1991; LaPorte, 1994).
HRO Background • High Reliability original focus • Airlines • Aircraft carriers • Nuclear Power Plants • Leap to healthcare • Complexity • Narrow the focus • AMI • HF • Stroke • Wrong site surgery
HRO Principles • “Mindfulness” = the key Concept of HROs • Mindfulness is a new word for “Undivided Attention” • Train staff to focus on the situation • Anticipate distractions • When mind wanders - bring it back quickly
HRO Principles • Key Concepts - 5 Principles of Mindfulness • Sensitivity to Operations • Reluctance to Simplify/Resist oversimplification • Preoccupation with Failure • Deference to Expertise • Resilience
HRO Principles • Sensitivity to Operations • Leaders and staff have a constant awareness of patient care processes and systems. • Focus on the situation, not the organization as a whole. • Eliminate fear of reprisals from expressing concerns. • Establish priorities.
HRO Principles • Reluctance to Simplify/Resist Oversimplification • Do not oversimplify the reasons for a failure. • Track small failures. • Position the organization to see as much as possible. • Enlarge your view. • Encourage skeptics and critics. • Negotiate to reconcile differences.
HRO Principles • Preoccupation with Failure • Use near misses to improve on process. Do not assume the process worked since the miss was caught. • Encourage reporting of errors. • Recognize that success can lead to complacency.
HRO Principles • Deference to Expertise • Leaders welcome, accept and bow to staff input, suggestions, concerns. • Accept and embrace shifting locations of expertise. • Decisions are made by those involved. • The authority is given to those with the most expertise not the highest title. • Experience does not equal expertise.
HRO Principles • Resilience • All personnel know how to respond to failures • Sensitivity to operations’ ability to recover from adverse incidents • Workarounds that allow system or process to keep working • TRAIN-TRAIN-TRAIN • Imagine the worst and plan for the best
HRO Principles • Mindfulness results when all 5 Principles are embraced • Shared understanding of what should go right and what could go wrong • “…all else being equal, the more people in an organization who are concerned about the misidentification, misspecification, and misunderstanding of things, the higher the reliability that organizations can hope to achieve.”
HRO Principles • Mindful organizations manage the unexpected • Better equipped to rapidly identify the unexpected • Stop it in its tracks • If the unexpected breaches the stop - they focus on rapid restoration and containment
Pathway to High Reliability Steps along the path: #1.) Where are we now? • How long will it take to become a high reliability organization? • What are our current priorities?
Pathway to High Reliability #2.) Where do we want to be? • Develop a shared vision of quality and safety • Establish Leadership commitment • Who are the leaders • Medical Staff applies vision to by-laws and OPPE/FPPE • Hand-washing • Time out
Pathway to High Reliability #3.) Embrace a culture of safety throughout the organization • Trust • Empowerment • Respectful reminders/criticism • Competencies/evaluations/FPPE/OPPE #4.) Develop a Robust Process Improvement model • Lean Six Sigma • Change Management Theory • Actively search for what we don’t know
HROs in Healthcare • The Debates • Complexity of healthcare vs. simplicity of nuclear power plants and airline industry • Who has a better chance of success? • Large Hospitals and Networks • Small Hospital
HRO Principles • Utilize Change Theory Principles • Reduce the current emphasis on: • success • simplicity • strategy • planning • superiors • Variation
HROs in Healthcare • TJC – RPI – Robust Process Improvement • Transparency takes on a new meaning • Share findings and successes with other organizations • Adapt Best practices when appropriate • CAUTION: Not all things work the same in all organizations • Speak up • TJC Requirements already include the foundation for success
HROs in Healthcare • TJC Groundwork
Survey Application • Assure that everyone knows the characteristics of an HRO • Provide examples to staff about leader’s efforts to become an HRO • Place posters, bulletin boards, etc. to alert staff to HRO requirements
Survey Application • Opening Session • Begin the discussion about your organization’s journey to becoming an HRO • Speak to what the leaders, MS and staff are doing • Demonstrate commitment to becoming an HRO
Survey Application • During tracer activities and sessions: • Demonstrate how the organization uses HRO concepts to achieve and sustain compliance • Provide an example of how HRO concepts were used to improve a situation • Discuss how the medical staff is engaged in efforts to achieve and sustain all the characteristics of HRO
Survey Application • Leadership Session • Surveyors will facilitate the session around HRO characteristics specifically: • Leadership commitment to improvement of quality • and safety • Creating a culture of safety • Robust process improvement • Survey findings that suggest underlying system issues • Leaders should discuss internal systems that do or do not support their efforts to be a HRO
Solutions • Lean Six Sigma format • Train key personnel • Let them spread the philosophy and educate as they go • Focus Organization-wide PI on failures • Ask about shortfalls • What prevented us from achieving 100%?
Solutions • Really, really foster a Culture of Safety • Examine why staff and physicians are afraid to “speak-up” • Train staff on how to “coach” for enhanced care • Practice constructive coachingtechniques • Revise, implement and incorporate the Code of Conduct into the organization’s culture
Solutions • Really, really incorporate Patient-Centered Care • Include education on admission to encourage patients to speak up • Provide a list of what they should expect from caregivers as patientrights - REVIEW THE LIST • Ask them to call STOP when they are concerned about care or don’t understand something • Review and track all incidents where STOP is invoked
Solutions • Leadership -Includethe Medical Staff • This is a top down-bottom up process • Identify MS members interested in Lean-Six Sigma • Provide them the opportunity along with staff • Provide CME on interdisciplinary teams, coaching techniques, the purpose and importance of debriefing sessions • Incorporate Code of Conduct and Team membership into OPPE and FPPE
Solutions • Develop internal High Reliability Teams • Teams are any 2 or more people who are interdependent working toward the same goal in a complex environment with: • 360⁰ communication • Situational awareness • Shared mental model
Solutions • HRT development • Consider easiest first
Save 79,200 Medicare Patients per Year⁶Calculated from information in Reference #6.
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