Editor’s note: This month we’re featuring two recent article reviews by J. Thomas Ryan, MD, MSHA, senior physician advisor to the Virginia Hospital & Healthcare Association. Dr. Ryan shares his thoughts on current articles and studies with his colleagues in Virginia and has graciously agreed to host our Forum Focus this month.
All of our hospitals and health systems have sought to improve their quality, patient safety and patient satisfaction metrics in recent years using a variety of performance improvement techniques to “do better” at what we have been doing for years. Many now believe, that to truly transform our performance to one of consistent excellence, we must do things differently, using new performance improvement techniques and adhering to a new set of principles in this quest for excellence. Toward that end, other industries have utilized High Reliability science to make quantum leaps in their performance e.g. aviation, nuclear power. The Joint Commission is now interested in encouraging its monitored hospitals and health systems to become Highly Reliable Organizations. Mark Chassin and Jerod Loeb have written an article in The Milbank Quarterly, Vol. 91, No. 3, 2013 (pp. 459-490) that articulates many of the major characteristics of a high reliability organization. I summarize it so that you can review in three minutes or less.
Hospitals and health systems can develop a framework to achieve and sustain exemplary levels of quality and safety, much like aviation and nuclear power have done in their industries. Weick and Sutcliff give 5 principles that they see in high reliability organizations.
- HROs are preoccupied with failure…never satisfied with anything but zero defects and always alert to the smallest of changes that could lead to a failure.
- People who work in HROs acknowledge that threats to safety present in many ways, and seek early recognition of potential sources of failure before they occur.
- HROs recognize that sensitivity to changes in operations will often yield evidence of pending deviations from expected performance.
- A commitment to resilience characterizes HROs; they may not be error free but they will not be disabled by one. They will recognize failures and move to contain and correct them quickly.
- HROs defer to true expertise…not by hierarchy, but to whom has the greatest expertise in managing a new situation, regardless of their title.
The authors explore three major changes that hospitals and health systems must undertake to make progress toward high reliability.
- Leadership’s commitment to the ultimate goal of zero patient harm. This includes board, senior executives, physician and nurse leaders sharing the vision of eliminating harm to patients regardless of the present levels.
- Incorporation of the principles of a safety culture throughout the organization.
- Widespread adoption of the most effective process improvement tools and methods within the organization. They specifically mention three sets of performance improvement tools including lean, six sigma and change management.
The authors note the importance of physicians to the success of any quality or safety initiative. Physicians must champion initiatives whether in their formal or informal roles. They must be visible and enthusiastic supporters of quality and patient safety. They and the other employees/providers, must embrace three central elements of a safety culture. Those are; trust, report, and improve. For trust to exist, intimidating behavior must be eliminated. Individuals must be comfortable in reporting suspected deficiencies without fear of reprisal. Protocols can be developed and employees can be held accountable for adhering to them.
Robust process improvement (RPI) includes use of the systems of lean, six sigma and change management. All employees and providers should be training in the use of these tools. Their use can facilitate a common language being used throughout the organization, regardless of its size. This article describes four (4) levels of maturity on the road to high reliability and gives the characteristics of each level.
Expect much more discussion in the literature and in practical exercises to move our health care organizations to high reliability organizations. Take advantage of opportunities to learn more about this and to educate your colleagues on these principles.
In Improving The Quality Of Health Care: What’s Taking So Long?; Health Affairs, 32, no. 10 (2013):1761-1765, Mark Chassin notes the mounting frustration with the slow pace of improvement in health care quality. He acknowledges that most metrics of quality have seen some improvement but not at the level that those inside and outside healthcare should expect. He feels that the following three fundamental weaknesses of current US improvement efforts must be addressed to change the pace of advancement.
- Current efforts are focused too narrowly
- Efforts rely too heavily on older improvement methods that are proving ineffective in today’s complex issues
- Insufficient attention has been devoted to changing organizational culture in today’s hospitals…a culture that is incompatible with sustained excellence.
This article clumps problems into three buckets: overuse, underuse, and misuse. He feels that current efforts are mainly applied toward correcting misuse such as surgical errors, HAC and other preventable complications. Chassin feels that until recently, overuse has been neglected and that eliminating the use of health care services where benefits are absent or negligible may improve quality and decrease costs all at the same time. Examples of efforts to address this cause include cautions about prescribing antibiotics for colds, placing tympanostomy tubes in children with brief ear infections, and eliminating early elective delivery before 39 weeks of gestation without any clear medical condition.
Moving forward, the author challenges the concept that “one size fits all”. Each health system has its own culture and challenges. Despite the fact that improvement efforts are helped by common approaches and do produce some improvement, Chassin notes that the improvements are often “less than stellar” and often not sustainable. Chassin proposes that newer techniques, some of which our member systems are already using, are the beacon light for the future. To reach and sustain significant improvement, he recommends, as does the Joint Commission, Robust Process Improvement (RPI) that includes the combination of Lean, Six Sigma and Change Management.
Chassin sees the following differences between our past efforts and RPI.
- Disciplined, systematic approach to rigorous measurement of the magnitude of a particular problem.
- Meticulous determination of all of the causes of the problem
- Focused implementation of interventions targeted to the most important causes
- Careful attention throughout the improvement process to sustaining effective interventions.
Chassin feels that while it is possible to achieve good results with older improvement methods, that RPI produces greater and more sustainable improvement. In current work, the author notes three common themes:
- There are many causes and contributing factors that explain these failures
- Each cause requires a different intervention to deal with it
- Although there may be five or six different causes for the majority of problems, a different group of causes is often found when different hospitals are examined. It is unlikely that the same interventions will improve results across the board.
The article ends by noting that today’s typical hospitals have a long way to go before they achieve the kind of safety culture that exists in high reliability organizations. One of the most important impediments highlighted is intimidating and disrespectful behaviors that suppress the ID and reporting of unsafe conditions. That behavior can come from physicians and non-physicians alike and is often characterized by refusal to answer questions or return phone calls, provision of condescending or demeaning responses to questions and delivery of outright verbal abuse. The final point made is that to create a culture of safety, one must:
- Eradicate such negative behaviors
- Move to celebrate and act upon reports of close calls/near misses
- Establish and enforce clear and transparent disciplinary procedures for blameworthy acts that are applied equitably regardless of who commits them
Chassin concludes by saying that our health care quality challenge is to create what does not exist in the world today….hospitals and health systems in which preventable harm does not occur. The article articulates some effective process improvement strategies and tools that will be necessary to change the culture within our institutions and one that supports high reliability organizational principles.