Forum Focus – Creating exceptional physician-nurse partnerships: Using collaborative partnerships to raise the standard of care and improve the overall patient experience

By Alan J. Conrad, MD, MMM, CPE, FACHE, Medical Director of Palomar Health ( and Tracy Duberman, PhD, FACHE, CEO & Founder of The Leadership Development Group (


To lead today, health care organizations require a fundamentally different approach to care giving, one that is patient-centric with a strong focus on the patient experience, quality and safety, clinical integration, care coordination and waste reduction. In order to be best positioned for the future of value-based care, health care organizations must develop their clinical (physician and nurse) leaders as partners in team-based care delivery. Leaders in health care must work under an interdependent, rather than an independent, leadership model.

To that end, physician and nurse leaders must work collaboratively with open communication and trust in order to achieve common goals. Successful partnerships work together to set goals, create operating and capital budget, implement initiatives, and oversee operating and clinical performance. The focus of the partnership is shared responsibility, and equal accountability. In our recent webinar, we shared a case study of a health care system that has successfully developed its clinical leaders toward effective partnership.

Palomar Health’s Approach

Palomar Health, a 3-hospital system based in San Diego, California, recognized the need to develop physician leaders as partners to meet system, operational and clinical performance goals. Prior to intervention, Palomar lacked formal physician leadership (CMO) on their senior management executive team, and lagged on HCAHPS scores. Palomar sought a partnership with The Leadership Development Group (TLD Group), a recognized leader in physician leadership development, to design and deliver their Academy for Applied Physician Leadership (AAPL) based on TLD Group’s Applied Physician Leadership Academy (APLA©), a multi-faceted physician leadership development program entirely customized to deliver high value and high impact to health care and life sciences clients. The customized physician leadership development model addresses the need for collaborative partnerships between physicians and nurses for enhanced patient satisfaction, engagement and outcomes. The program utilizes multiple learning strategies including 1:1 assessment and coaching, learning and application modules, and action learning projects.

A key component of Palomar Health’s AAPL was, a Partnership Activation Process, an action learning-based experiential learning platform to enable clinical partners to enhance their collaborative leadership skills while tackling issues on their unit. The process enabled partnerships to identify solutions to problems that provide immediate, measurable impact and organizational results. Participants were broken into Partnership Activation groups consisting of physicians and nurses from both inpatient hospital units and outpatient clinics. Groups were facilitated by an Action Learning Coach and were asked to pick a project that would impact their units in a positive way. Groups met on a monthly basis over a 4-month period to work on their projects.

Participants were led through a project planning approach where they identified the problem to be solved, considered potential obstacles or challenges to implementing a solution, formulated a vision of success and desired state to be achieved, and determined the best solutions and actions to achieve success. Projects included: enhancing the physician/nurse rounding process, expansion of acute rehabilitation services, improving the mother-baby discharge process, and several others. The Partnership Activation Process also included a peer coaching/action learning Model, which led participants through reflective listening, active questioning, challenging assumptions, and giving/receiving feedback while taking their projects from concept through to solution and implementation.


Palomar Health’s AAPL program led to significant results that surpassed the desired goals. Press Ganey scores increased considerably. Overall physician ratings increased from the 30th to the 66th percentile, overall nursing ratings jumped from the 33rd to the 82nd percentile, and overall system ratings from 14th to 76th percentile. There was also an increase in HCAHPS scores for the question item entitled “My physician listens carefully to me” suggesting that patients recognized an improvement in physicians’ listening communication skills.

Participants of the AAPL program also developed learning competencies including an understanding of how their emotional intelligence impacts others, knowledge of their role as a clinical leader, identification of a clear purpose for their partnership relationship, and the ability to drive patient satisfaction and physician engagement.


Palomar Health’s customized Academy for Applied Physician Leadership was designed for physician leaders, nurse leaders, and administrators to drive alignment on the system’s goals, build leadership competencies, and facilitate a team-based approach to care giving. The Partnership Activation Process helped to strengthen trust, build relationships, and enhance communication between the physician and their nursing partner to establish collaborative partnerships which raise the standard of care and improve the overall patient experience.

To view the webinar, please visit


Forum Focus – Developing a workforce for health

By Dan Paloski, Communications Specialist, AHA’s Physician Leadership Forum

In 2011, the American Hospital Association (AHA) and a roundtable of clinical and health system experts crafted a model for a redesigned primary care system, one that encompasses the birth to end-of-life continuum and defines primary care workforce roles. Two years later, the AHA convened another roundtable, this time to discuss reconfiguring the bedside care team in order to meet the demands of health care reform. Below are some key findings from the reports.

In “Workforce Roles in a Redesigned Primary Care Model,” the roundtable’s most important recommendation was the creation of a hub-and-spoke model where patients, their families and the healthy community are at the center of everything. Radiating out are the different health care professionals, charged with delivering care in a team-based setting and to the full scope of their practice. Communication is essential for this model to work, not only among those charged with providing care to the patient, but also with patients and families. Clinicians need to engage patients actively in discussions and decisions regarding their own care and develop strategies to help them effectively manage that care.

One of the greatest challenges highlighted by the roundtable was re-educating the workforce to work in a team-based model of care. In order for teams to function at their highest ability, a fundamental shift in how people are trained needs to take place. Medical schools, colleges, and centers of professional education need to redesign curricula to meet today’s current clinical needs. At the time of the report, roundtable members were concerned with the slow progress on the part of schools and universities in preparing their students for team-based care. In the three years since, some progress has been made. For example, two schools, Brown University and the University of Michigan, have incorporated inter-professional education into their curricula. Both universities are piloting workshops and programs that bring together students from different clinical disciplines and have them work together to solve different issues.[1]

The report also emphasizes the need for a stronger partnership between the community and hospitals. Essentially, hospitals need to evolve into “health systems,” with hospitals as the drivers of community-based population health management. This issue is particularly important for rural areas where primary care access can be limited. Innovative ways to deliver care, including utilizing information technology, telehealth, after-hours access, and non-traditional settings will be vital. The focus should be on wellness that spans the full continuum, and not just on treating illnesses and chronic conditions. In a recent article for USA Today, Rich Umbdenstock, president and CEO of the American Hospital Association, said, “Hospitals are undergoing a major shift, building collaborative teams that are improving the coordination of health care. They’re partnering with other health care providers and experimenting with new ways to provide care where people live and work — not just at the local hospital.”[2] Ultimately, this evolution of hospitals into “health systems” will not be successful without the establishment of a true and balanced partnership with the community.

In “Reconfiguring the Bedside Care Team of the Future,” the authors call for a paradigm shift in how the traditional bedside care team is defined. The report touches on a few of the same themes as the “Workforce Roles” report, namely making sure patients and their families are seen as essential members of the care team, as well as the use of information technology in facilitating and complementing the clinical judgment of the care team. The report identifies four other principles to guide this change in the bedside care team. First, bedside care team members must be fully engaged, working at the full scope of their practice. Second, the care team should be localized to a unit and should be limited to only those patients/families located within that unit. Team members must also be vigilant in coordinating communication with the patient/family. Third, the team should be balanced in regard to meeting patient needs. Evidence-based guidelines that improve care should be developed and followed by all team members. Fourth, no matter where they are in the continuum of care, patients needing acute care should be able to safely move through it.

In response to the shifting and evolving health care system, new models of care are needed, specifically concerning primary care and the bedside care team. With more patients coming into the system and a projected clinical workforce shortage, a team-based care approach with clinicians working to the full scope of their practice is critical. Care must revolve around the patient and family and must be available at any access point along the continuum. In 2015, the AHA Workforce Center plans on developing additional resources to assist hospitals with redesigning and reconfiguring their workforce to meet new care model demands. Copies of both white papers discussed above, along with other workforce resources, can be found at the AHA Workforce Center website,


[1] AMA Wire, 4/24/14,

[2] USA Today, 12/8/14,

Forum Focus – AHA unveils toolkit to help hospitals hire veterans

The American Hospital Association (AHA) is excited to share with hospitals and health systems a new hiring resource, “Hospital Careers: An Opportunity to Hire Veterans.” Part of AHA’s continued efforts in support of the federal Joining Forces initiative, the toolkit was developed with input from nearly 20 groups representing hospitals, nurses, physician assistants, community health centers, the federal government, veterans and military members. It’s designed to help hospitals recruit and hire veterans with clinical and leadership skills into nursing, physician assistant and other hospital careers, and includes examples of organizations doing as such, for example the Scottsdale Lincoln Physician Network.

Excerpted from “Hospital Careers: An Opportunity to Hire Veterans,” American Hospital Association, November 2014, pg. 11.

HOSPITAL HIRE: From Active Duty to Patient “Coach”

Scottsdale Lincoln Physician Network, part of the John C. Lincoln Accountable Care Organization in Arizona, has begun a program to hire veterans as patient transition coaches in order to lower readmissions.

The health system connected with local veteran organizations and asked that former hospital corpsmen and/or combat medics participate in the program. In September 2012, they started with two veterans and, after the initial success, spent time refining and building out the program, raising $780,000 to date from community groups to fund it. Within months, their readmission rate went from 21 percent to six percent. Currently, there are 14 transition coaches who work from a list of Medicare patients as well as hospitalist/nurse orders for visits. Visits are conducted early in the admission so the transition coach gets to know the patient and helps them get ready for their transition needs. The day after discharge, they visit the patient at home and do a variety of services from health checks to scheduling home health visits, to doing the dishes and moving or rearranging furniture to minimize falls. Furthermore, they do a social work assessment for additional services that might be needed. A transition services record in the electronic health record enables all clinicians to see their notes.

The coaches are highly motivated and have initiated programs with the pharmacy assistants to ensure patients can read their medication bottles (enlarging text as needed). As part of the program, all coaches are enrolled in college degree programs and most are pursuing clinical/health care positions. The program is co-led by a physician leader who reviews cases and provides focused supervision and a retired Air Force colonel administrator who provides an understanding of the specialists’ military background. Click here to view a video of their program:

Forum Focus — It’s not just a numbers game: Implementing a patient blood management program

Patient blood management (PBM) is an evidence-based, multidisciplinary approach to optimizing the care of patients who might need transfusion. According to the AABB, an international, not-for-profit association representing individuals and institutions involved in transfusion medicine and cellular therapies, PBM can reduce complications, save lives, and reduce expenditures.[1] AABB recently issued a list of five recommendations to decrease overuse of blood and improve patient care as part of the American Board of Internal Medicine Foundation’s Choosing Wisely campaign.

Hospitals, as part of their mission to serve as good stewards of limited resources, have begun to develop PBM programs and protocols for efficient and consistent practice across the organization. The American Hospital Association, under the direction of its Committee on Clinical Leadership, developed “Appropriate Use of Medical Resources,” a white paper released in November 2013 that identifies five areas where hospitals, in partnership with their clinical staff and patients, should look to reduce non-beneficial care. To help hospitals and their communities address these recommended areas, the AHA will release toolkits throughout the year targeting each of the five procedures/interventions. The first, appropriate blood management in inpatient services was developed with AABB and released in April.[2]

One of the members of the Committee on Clinical Leadership, Dr. David Perlstein, Chief Medical Officer and Senior Vice President of SBH Health System in the Bronx, New York, shared his hospital’s experience in developing a patient blood management program. Joining him was the PBM physician champion, Dr. Robert Karpinos, Chair of Anesthesiology, and the Medical Director of Perioperative Services. SBH Health System includes a 461-bed community teaching hospital and Level I Trauma Center serving a diverse population in an economically disadvantaged area, with a payer mix largely skewed to Medicaid. With nearly 100,000 emergency room visits and nearly 3,000 staff, SBH Health System has been a cornerstone of their community for over a century, incorporated in April 1866 as America’s first chronic disease hospital and the inspiration for many to follow.

Getting Started

The SBH Health System PBM program grew from a strong patient-centered culture that focuses on putting the patient first and empowering every employee to take an active role in making patient care better. In looking for ways to provide better care and improve the patient experience while remaining good stewards of their limited resources, blood management seemed a worthwhile pursuit. Patient blood management allowed SBH Health to decrease patient risk, improve quality of care and outcomes, respect patient autonomy, and involve patients in the care process. In addition, if done right, the PBM program had the potential to reduce blood use and save resources.

According to Dr. Perlstein, education was the major driver for PBM adoption. Dr. Karpinos agreed that physician buy-in was a matter of education and awareness. The initial development rested largely in the hands of the PBM physician champion, Dr. Karpinos. He began the journey by reaching out to the Society for the Advancement of Blood Management (SABM) to learn more about becoming a certified center of excellence. Dr. Karpinos then met with critical stakeholders and department chairs to make the case for PBM. Using that feedback and enthusiasm to develop a steering committee, Drs. Perlstein and Karpinos brought the concept to the hospital leadership committee. The combination of a patient-centered culture and largely clinically-trained leadership team supporting the effort created a place for the steering committee within the transfusion committee. Deliberate in their choices, Drs. Perlstein and Karpinos brought leaders from Informatics, Care Transitions, Internal Medicine, Outpatient medicine, and other key departments to the steering committee early on to help champion the PBM effort. In addition, support from the nursing community was essential.

As an initial task, the steering committee looked at blood usage patterns across the hospital and armed with a clear call for reducing unnecessary utilization, launched an educational program with nationally recognized guest speakers sharing the clinical evidence for PBM, the advantages and disadvantages of using blood and blood products, and the potential risks for patients. While in hindsight Dr. Karpinos would have brought the steering committee together sooner to speed the transition, he is pleased with the response across the organization. As they move toward full implementation following the year-long groundwork and education efforts, SBH Health System expects they will need additional resources for data analysis to track results and staff to coordinate the program.

PBM is a comprehensive blood management program, so moving beyond transfusion rates was important to SBH. As part of their comprehensive approach, SBH Health System is making changes to their anemia management protocols; changing standards from two units of blood to one unit, for example. The anemia and transfusion protocol revisions are being reviewed for approval by the medical staff in preparation for full PBM program implementation. By including the directors of medicine and medical informatics on the steering committee, there is broad support to drive the changes.


Dr. Perlstein was most surprised by the rapidity with which the clinicians and staff accepted and were excited about a PBM program. Neither Dr, Perlstein nor Dr. Karpinos expected the multi-disciplinary support across the hospital as well as the buy-in from more senior physicians who would be changing lifelong practice patterns to new protocols. Both credit the clinical evidence and educational campaign for making the PBM case clear and compelling to the full spectrum of clinical staff.

Additionally, although it was not the intent, a PBM program also allows them to provide services to a sizeable population in their community sensitive to the use of blood and blood products. While PBM was undertaken as a quality improvement to the delivery of care, once the program is fully implemented, SBH will be able to address the needs of this population as well.

Lessons Learned

Dr. Perlstein says the biggest lesson he learned is to look for opportunities and not shy away from them because of concerns over culture. Building cultural change takes time, but that shouldn’t preclude efforts like PBM which can help enhance the patient-centered approach. He also cautioned that creating a program like PBM is not a destination, it is a journey and it is important to do your homework before starting out. The key, he says, is to have a plan, approach it slowly and methodically. He also advises gauging the challenges early to address potential pitfalls.

Dr. Karpinos agrees with the slow, methodical approach noting there are many resources available for beginning a PBM program. The Joint Commission has proposed guidelines for transfusion therapy, and their home state of New York has issued transfusion therapy guidelines. He advises those interested in PBM to learn as much as possible from these resources, such as the toolkit available from AHA[3], and build a system that enhances your organization’s strengths and mitigates its weaknesses.

Finally, Dr. Karpinos advises those looking to start a program to “just do it:” get educated, do the research, do the background work, and don’t be afraid of changing the culture. Although it will take time, the results thus far are very rewarding.


[1] Patient Blood Management. AABB. Accessed 6/1/14 at

[2] Appropriate Use of Medical Resources. Physician Leadership Forum. Accessed 6/1/14 at


Forum Focus – A new alternative to clinical practice guidelines

Physicians at Boston Children’s Hospital have created a new alternative to clinical practice guidelines that allow for more flexibility, narrow practice variability, all the while letting clinicians tailor treatments to an individual patient’s needs. Called Standardized Clinical Assessment and Management Plans (SCAMPs), they also aim to optimize resources, improve patient care, reduce costs and keep pace with changing medical knowledge. An article (abstract only) published in the May 2013 issue of Health Affairs provides more details about SCAMPs. A summary of the article follows.

The need for change

Although clinical practice guidelines are intended to reduce variation and improve care, one of their main shortcomings is they do not account for individual and personal preferences among patients. The following of ridged guidelines may also reduce the autonomy of physician practice. Other shortcomings include the limitations clinical studies have in forming the foundation for the guidelines, and medical evidence used to form the basis of the guidelines usually has a short shelf life. Physicians at Boston Children’s Hospital thought there had to be a better way. This is how they came up with SCAMPs.

Creating a SCAMP

Developing and modifying a SCAMP involves eight steps and is led by a multidisciplinary group of clinicians.

  1. A group formulates a background paper on a particular disorder, examining the medical literature and relevant professional society guidelines in order to establish a foundation for sound clinical practice.
  2. Modeled on the processes/standards used to create practice guidelines, the group reaches a consensus on which patients to include in the SCAMP, what clinical assessments to include and how to structure the treatment methods.
  3. The group identifies what data will be collected to inform knowledge gaps that may exist.
  4. Electronic forms/tools are created to collect the data.
  5. The SCAMP is then piloted at a few sites before being deployed on a larger scale. A data coordinator helps with patient enrollment. Clinicians see and treat patients, in general, according to the appropriate SCAMP protocol, but are free to vary from the protocol for any reason, as long as he or she documents why they diverted from the protocol. The clinician makes sure to collect and record data on the patient, including the reason for diversions.
  6. A data coordinator gathers the information collected by the clinicians, as well as additional relevant information from the patient’s electronic health record. All of this information is stored in a database.
  7. After a period of six to 12 months, or a minimum of 200 patients have been enrolled, a statistician analyzes the data. The report is reviewed by the clinical group, as well as all of the clinicians participating in the SCAMP.
  8. Using data from the report, including the diversions, and new medical literature, the SCAMP is then modified for future use.


From early 2009 until the publishing of the Health Affairs article, more than 12,000 patients were enrolled in 49 SCAMPs in nine states and Washington, D.C. One study found clinician adherence to SCAMP protocols has exceeded 80 percent. Another analysis found that revising the SCAMP criteria for a genetic specialist referral on pediatric patients with a dilated aorta rose from 19.6 percent to 75 percent. Boston Children’s own analysis on six episodes of care where a SCAMP was implemented showed an 11-51 percent decrease in total medical expenses.


SCAMPs have shown to be a viable alternative to clinical practice guidelines. Because of their design, SCAMPs allow for a more flexible approach when it comes to patient care and clinician adherence, as diversions are permitted. They are routinely examined and modified to stay current with the growth of medical knowledge, thus ensuring high quality care is delivered using the appropriate amount of resources.

“SCAMPs have proved to be a very useful tool for many clinical scenarios, where there is insufficient information to inform medical decisions,” said Kathy Jenkins, MD, MPH, Senior Associate in Cardiology, Senior Vice President, Chief Safety and Quality Officer, Boston Children’s Hospital, and Professor of Pediatrics, Harvard Medical School. “SCAMPs allow rapid progress to reduce unnecessary resource utilization, while improving care delivery.”  

For more information on SCAMPs, contact Kathy Jenkins at Kathy.Jenkins@CARDIO.CHBOSTON.ORG.

Forum Focus – AIAMC National Initiative IV: Mastering the Clinical Learning Environment


By Dan Paloski, Communications Specialist, AHA’s Physician Leadership Forum

In 2007, the Alliance of Independent Academic Medical Centers (AIAMC), a national membership organization of major independent academic medical centers and health systems, was searching for opportunities to provide greater resident involvement in hospital safety and quality efforts. As part of their mission to help members integrate medical education and research into the organizational clinical mission, AIAMC felt focusing on resident quality improvement efforts had the potential to improve safety and quality quickly and with the greatest impact. To test this hypothesis, AIAMC created National Initiative I with the goal of improving patient care through graduate medical education (GME). Nineteen member academic teaching centers participated, integrating residents and GME into quality and patient safety initiatives. Participants found that integrating residents into existing efforts greatly increased the strategic value of their academic programs to the organization. The December 2009 issue of Academic Medicine featured five articles regarding the results of National Initiative I.

Two years later, AIAMC launched National Initiative II, this time focusing on residents and their involvement in five specific quality improvement areas: effective communication, hand-offs, infection control, readmissions, and transitions of care. Thirty-five institutions participated with results shared in a variety of publications including the May/June 2012 special supplement issue of the American Journal of Medical Quality, which recapped the June 2011 “Integrating Quality” meeting sponsored by the American Association of Medical Colleges. Thirteen AIAMC members that participated in National Initiative II and their project results were featured at this meeting.

In 2011, National Initiative III involving 35 teams was launched. It built on the strength of the first two phases and addressed the development of medical education faculty and teaching leadership. One of the main outcomes of National Initiative III was the development of a national network for improvement and sharing of best practices across the United States. Participants were also able to show how GME and continuing medical education (CME) play a central role in quality improvement, and how GME and CME can align with hospital leadership to improve quality of care. The proceedings of National Initiative III were published in the spring 2014 issue of The Ochsner Journal.

Last year, AIAMC launched National Initiative IV, which focuses on navigating the Accreditation Council for Graduate Medical Education’s (ACGME) new Clinical Learning Environment (CLE) review program. Created in 2012, CLE provides residency sponsoring institutions feedback on resident and fellow engagement in the following six areas:

  1. Patient safety
  2. Quality improvement
  3. Transitions in care
  4. Supervision
  5. Duty hours oversight, fatigue management, and mitigation
  6. Professionalism[1]

Each CLE site visit provides an opportunity for feedback and evaluation of how the institution addresses each of the six areas and begins and ends with a meeting with the senior leadership of the institution and the residency programs. Feedback is viewed as formative and the aggregate results of the CLE visits will help inform the ACGME’s next accreditation system, which emphasizes resident outcomes and learnings indicating they’re on the right path toward individual practice. The goal of CLE is for sponsoring institutions to use the feedback to continually improve in the six areas. In addition, ACGME hopes to learn how to best engage and involve residents and fellows in hospital efforts regarding patient safety and quality in the clinical environment.[2]

AIAMC’s current effort, National Initiative IV, began last October with 34 teams. Each team consists of a resident, faculty member, quality improvement professional and additional staff as needed. To begin, each of the teams completed a self-assessment survey against the six areas of CLE to determine which area would be their focus. The teams were subdivided by area for monthly teleconferences and discussions to share progress. As with the other initiatives, the groups convene for monthly conference calls, as well as attend four live meetings throughout the 18 months of the initiative. The four in-person meetings allow the six subgroups to collaborate and share best practices across the spectrum.

According to AIAMC, National Initiative IV is providing teams the training and guidance to:

  1. Identify strengths and weaknesses across the six areas
  2. Prioritize areas for improvement
  3. Outline, streamline and implement improvement strategies
  4. Significantly and measurably advance the institutional level of preparedness for addressing the CLE focus areas[3]

The next group meeting will be in Fort Worth, Texas in October 2014 with the final one taking place in March 2015. Led by AIAMC’s steering group, the Committee on the Integration of Academics and Quality, three scholarship teams have been formed to disseminate findings in the form of research, resource materials, and program descriptions at the conclusion of the initiative.

Overall participation has increased over the life of the National Initiatives and yielded results that have echoed throughout the organizations that have participated. “Ochsner Health System’s participation in all four AIAMC National Initiatives (NIs) has yielded far more than just finalized projects and presentations,” said Ronald Amedee, MD, Designated Institutional Official and Chairman, Otolaryngology, Ochsner Health System, and President, AIAMC Board of Directors. “In addition to substantial patient safety improvements, the NIs have provided us with the ability to submit manuscripts, create a robust Resident Quality Council and be recognized by our C-Suite for the value of GME and its integration in quality improvement efforts.”

For National Initiative V, AIAMC plans to involve residents and fellows in addressing health care disparities from the front line. National Initiative V participants will be selected in the summer of 2015 with the first meeting in October 2015.

For more information on the AIAMC and their National Initiatives, contact Kimberly Pierce-Boggs, Executive Director, at or visit



[1] Weiss KB, Wagner R, Bagian JP, et al. Advances in the ACGME Clinical Learning Environment Review (CLER) Program. Journal of Graduate Medical Education. Dec. 2013; 718-21.

[2] Ibid.

[3]Background of the AIAMC National Initiative. The Alliance of Independent Academic Medical Centers. Accessed 7/11/14 at

Ryan’s Review….in three minutes or less!

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.

Review 1

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.

  1. 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.
  2. 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.
  3. HROs recognize that sensitivity to changes in operations will often yield evidence of pending deviations from expected performance.
  4. 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.
  5. 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.

  1. 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.
  2. Incorporation of the principles of a safety culture throughout the organization.
  3. 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.


Review 2

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.

  1. Current efforts are focused too narrowly
  2. Efforts rely too heavily on older improvement methods that are proving ineffective in today’s complex issues
  3. 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.

  1. Disciplined, systematic approach to rigorous measurement of the magnitude of a particular problem.
  2. Meticulous determination of all of the causes of the problem
  3. Focused implementation of interventions targeted to the most important causes
  4. 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:

  1. There are many causes and contributing factors that explain these failures
  2. Each cause requires a different intervention to deal with it
  3. 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:

  1. Eradicate such negative behaviors
  2. Move to celebrate and act upon reports of close calls/near misses
  3. 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.