From Value to High-Reliability Organization William R Mayfield MD, FACS Chief Surgical Officer WellStar Health System ACS NSQIP Chicago July 2015
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Outline Origins of the High-Reliability Organization (HRO) Characteristics of the HRO Behaviors in a HRO How do we get to a Surgical HRO?
The concept of the High-Reliability Organization (HRO) was shaped by failure, sometimes counted in human lives. HRO arose out studies of the nuclear power industry, aircraft carrier management, and air traffic control in the 1980 s. Ref: Wikipedia: High Reliability Organization July 2015
Examples of Failure Human Factors in Common Chernobyl nuclear power plant meltdown An emergency shutdown experiment went wrong (human factors) 500,000 people exposed Tenerife air disaster 2 747 s collide on runway, killing 583 the primary cause of the accident was the captain of the KLM flight taking off without clearance from Air Traffic Control(ATC). (human factors) Fukushima meltdown The Fukushima Nuclear Accident Independent Investigation Commissionfound out that the nuclear disaster was "manmade" and that its direct causes were all foreseeable. (human factors)
In response. Re-designed themselves to put safety first: from the top to the bottom. As a result: Airline safety has dramatically and measurably improved.
Challenges of HROs They operate in unforgiving social and political environments They employ risky technology and potential for error Consequences from error precludes learning through experimentation To avoid failures, they use complex processes to manage complex technologies and complex work Schulman, P.R. (2004), General attributes of safe organizations. Quality and Safety in Healthcare. 13, Supplement II, ii39-ii34.
Characteristics of an HRO Collective mindfulness for safety Five characteristics Preoccupation with failure Reluctance to simplify interpretations/problems Sensitivity to operations Commitment to resilience Deference to expertise Weike, K.E., Sutcliffe, K.M., & Obstfeld, D. (1999). Organizing for High Reliability: Processes of Collective Mindfulness. In B.M. Staw& L.L. Cummings (Eds.) Research in Organizational Behavior (Vol 21, pp. 81-123). Greenwich, CT: JaI Press, Inc.
Employees of an HRO All workers look for, and report, small problems or unsafe conditions beforethey pose a substantial risk.» Weike and Sutcliffe (2007)» Chassin, MR, Loeb, JM, The Joint Commission, The Milbank Quarterly, Vol 91, No. 3, 2014, (pp 459 490) They rarely, if ever, have significant accidents. They prize identification of errors and close calls in order to analyze the precursors.» Ibid.
How does HRO theory apply to Surgery? Complex environments with complex technology where the stakes are measured in human lives Surgery Programs exist in a very competitive and political environment There is a variety of expertise and skill sets of personnel (power gradient) We have process and outcomes data
The development of a Surgical HRO requires complete commitment from the top to the bottom. So how do you get there?
Four Stages of a Surgery Service Line I. Strategy Thinking externally and competitively II. Quality Thinking internally and critically Utilize clinical outcomes databases, eg NSQIP, STS, TQIP III. Value Integrating cost with outcomes and patient satisfaction Blending outcomes and financial data IV. High-Reliability Organization Culture of Safety, collective mindfulness, proactive planning, zero tolerance for error Utilizing Lean/Six Sigma and Change Management
Leadership Pathway to a Surgical HRO Commitment to the ultimate goal of zero patient harm Complete alignment: Board, senior management, physician leaders, nursing leaders Incorporation of all the principles and practices of a Safety Culture throughout the organization Adoption of and deployment of the most effective process-improvement tools and methods» Chassin, MR, Loeb, JM, The Joint Commission, The Milbank Quarterly, Vol 91, No. 3, 2014, (pp 459 490)
Leadership Pathway to Surgical HRO Beginning Board quality focus is chiefly regulatory CEO/management s quality focus is chiefly regulatory Physicians rarely lead quality improvement activities; physician participation is low Approaching Board commits to an HRO: zero patient harm for all clinical services Management aims for zero patient harm for all clinical processes: some demonstrate zero or near zero Physicians lead clinical QI activities and influence other physicians; participation uniform throughout organization Chassin, MR, Loeb, JM, The Joint Commission, The Milbank Quarterly, Vol 91, No. 3, 2014, table 2, p 474
Leadership Pathway to a Surgical HRO Beginning Quality is not a Strategic Imperative Quality measures are not prominently displayed, not part of reward system Approaching Quality is the highest-priority Strategic Goal frequent and continuous feedback; key quality measures are publicly reported; reward system reflects successes IT provides little or no support to QI IT solutions are integral to sustaining improved quality Chassin, MR, Loeb, JM, The Joint Commission, The Milbank Quarterly, Vol 91, No. 3, 2014, table 2, p 475
Evolution of Behaviors Beginning Trust is not cultivated, intimidating behavior tolerated Approaching High levels of (measured) trust; power gradient eliminated, intimidating behavior eradicated Accountability is blame Unsafe conditions are addressed in root cause analysis of sentinel events; close calls are not recognized Personal accountability for culture of safety Close calls and unsafe conditions routinely reported to prevent patient harm Adapted from: Chassin, MR, Loeb, JM, The Joint Commission, The Milbank Quarterly, Vol 91, No. 3, 2014, table 3, p 478
Evolution of Behaviors Beginning Limited efforts to assess system defenses against quality failures Approaching System defenses are proactively assessed, weakness proactively repaired No measures of safety culture exist Safety culture measures are part of strategic metrics reported to the Board; improvement initiatives underway Adapted from: Chassin, MR, Loeb, JM, The Joint Commission, The Milbank Quarterly, Vol 91, No. 3, 2014, table 2, p 474
Tools of the Trade: Robust Process Improvement Lean Eliminating waste; focus on speed Six Sigma reduce the frequency of defective outcomes; focus on quality Change management Prepares an organization to accept, implement, and sustain the improved processes Techniques to reduce wasted effort without reducing quality Baldridge TQM Total Quality Management Chassin, MR, Loeb, JM, The Joint Commission, The Milbank Quarterly, Vol 91, No. 3, 2014, pp 459-490 Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. AHRQ Publication No. 08-0022 April, 2008
Application of HRO principles to Surgery
Collective mindfulness for safety Apply the five characteristics of the HRO Preoccupation with failure Reluctance to simplify interpretations/problems Sensitivity to operations Commitment to resilience Deference to expertise Weike, K.E., Sutcliffe, K.M., & Obstfeld, D. (1999). Organizing for High Reliability: Processes of Collective Mindfulness. In B.M. Staw& L.L. Cummings (Eds.) Research in Organizational Behavior (Vol 21, pp. 81-123). Greenwich, CT: JaIPress, Inc.
Preoccupation with failure Two patient identifiers at all times Clear cut, legible consents WHO time out procedures Right patient, right procedure, right site Preventable morbidity should be zero CLABIs CAUTIs VAPs Pneumthorax/hemothorax with central lines Wrong site / wrong patient procedure Eliminate blame and encourage identification of errors
Preoccupation with failure Report near misses and errors Use them to adjust protocols Measure and report results in a continuous feedback loop
Sensitivity to Operations Reduce the power gradient and improve communication Eliminate intimidation Listen to front line personnel Anyone can stop the assembly line Create strict protocols using IT Make it hard to do the wrong thing Measure compliance with 200% accountability Timeout procedure Reward compliance Measure and report results in a continuous feedback loop
Sensitivity to Operations Standardize, standardize, standardize Reduces error Makes errors easier to detect Reduces cost and increases Value Serves as a starting point for Performance Improvement If you don t have a starting point, you don t know where to go or how much you have improved Maintain physician autonomy based on patientfactors, not physician preference
Standardization reduces Error Tools Uniform code carts Uniform surgery trays For CPT code Uniform preference cards For CPT code Processes ERAS Pathways for colorectal and other procedures Peri-operative glucose control protocols Time outs Pre op huddles Order sets
Systems Approach to Error Prevention Old Thinking Bad people make errors Removing bad people will reduce errors New thinking People are fallible System factors are the main reason for errors Reliable outcomes can be obtained with the right mix of people and processes
Memorial Hermann Cincinnatti Children s Sentara Thedacare WellStar On the Journey
Summary HROs are complex organizations that have high risk for harm but create systems to proactively identify sources of error HROs create a Safety Culture from the Board level to the bedside Hospitals in the US are behind industry in creating HROs Motivate physicians with continuous feedback of individual outcomes and cost