Joanne Disch, PhD, RN, FAAN Clinical Professor University of Minnesota School of Nursing

High reliability organizations

Joanne Disch, PhD, RN, FAAN

Clinical ProfessorUniversity of Minnesota School of Nursing

A world-wide issueAdverse drug events and medication errors in

Australia (IJQHC, 2003)Of coded adverse events leading to death, 27%

involved an adverse drug event Transplant Tourism: Outcomes of United States

Residents Who Undergo Kidney Transplantation Overseas (Transplantation, 2006)6 infections in 4 patients, l rejection

Medication errors in primary care in Riyadh city, Saudi Arabia (EMHJ, 2011)Prescribing errors in 18.7%

IOM Six Aims for Improving Health Care Safety and Quality

AIM DescriptionSafe Avoiding injury and harm to patientsTimely Reducing waitsEffective Care based on evidenceEfficient Avoiding wasteEquitable Quality does not vary because of gender,

ethnicity, socioeconomic factors or geographic status

Patient-centered

Respectful and responsive care based on patient values

High Reliability Organizations (HRO)

Organizations that have cultures of safety, foster a learning environment and evidence-based care, promote positive working environments for nurses, and are committed to improving the safety and quality of care are considered to be high reliability organizations

HRO

High Reliability Organizations (HRO):CharacteristicsCharacteristics of HROs include:

having a safety and quality-centered culture direct involvement of top and middle

leadership safety and quality efforts aligned with the

strategic planan established infrastructure for safety and

continuous improvement and active engagement of staff across the organization

Components of a HROA health care setting is composed of a large set of interacting systems, often referred to as the Macrosystem.

The smaller units are known as Microsystems. admissionsemergency departmentinpatient unitsambulatory units and operating roomdietaryenvironmental services, etc.

Macrosystem

Microsystem

Microsystems- are a small group of people who work together on

a regular basis to provide care to discrete subpopulations of patients. It has clinical and business aims, linked processes, and a shared information environment, and it produces performance outcomes. Microsystems evolve over time and are often embedded in larger organizations. They are complex adaptive systems, and as such they must do the primary work associated with core aims, meet the needs of internal staff, and maintain themselves over time as clinical units.

High-performing front-line clinical units (Nelson et al, 2002)From leaders of 43 clinical units in 20 orgs - Constancy of purposeInvestment in improvementAlignment of role and training for efficiency, staff

satisfactionInterdependence of the care team to meet patient

needsIntegration of information and technologyOngoing measurement of outcomesSupportiveness of the larger organizationConnection to the community to enhance care delivery

and extend influence

The Microsystem ModelCulture

Organizational support

Patient focus

Staff focus

LeadershipInterdependence of care teams

Information & IT

Process improvement

Performance patterns

Organizational factors associated with high performance (Keroack et al, 2011)

79 academic medical centers, 2003-2004Factors assessed: safety, mortality, clinical

effectiveness, equity of careSix institutions studied: 3 top, 3 averageTop levels of performance could result in 150

fewer deaths per year

Key findingsShared sense of purpose

‘Patient care comes first’Leaders are dissatisfied with status quoService excellence part of focus on quality, safety

Accountability system for service, quality, safety (SQS)Prioritizing, developing measures and setting goals are

centralized, while tactics are decentralizedChairs accept responsibility for SQS in departmentsAccountability, innovation and redundancy at the unit

Key findings (cont)Collaboration

The basic relationship among administration, nurses, physicians and other staff

Frequent recognition of employee contributions at all levels

Employees [and physicians] value each other’s critical knowledge when problem solving

Leadership styleCEO is passionate re: service, quality, safety (SQS)Everyday events are connected via stories to SQSGovernance structures minimize conflicts among missions Institution is led as an alliance between executive

leadership team and clinical chairs

Key findings (cont)Focus on results

Relentless effort to improveResults outweigh the approach to performance

improvementFocus on human behavior and work redesignTechnology is accelerator, not substitute for

work redesign

Culture of SafetyWithin a healthcare setting, each discipline can have a different culture, as can each patient care area…so can each individual person

In a culture of safety, the focus is on effective teamwork to accomplish the goal of safe, high-quality patient care.

Elements of a Culture of Safety establishing safety as an organizational priority teamwork patient involvement openness/transparency accountability shared core values and goals non-punitive responses to adverse events and errors adequate education and training

Elements of a Culture of Safety

A safety culture requires strong, committed leadership, and engagement and empowerment of all employees. It entails periodic assessment of the culture and relationship between the organization culture and the quality and safety within the organization

IOM:How to Improve Patient Safety?

The IOM described 9 categories that provide opportunities to improve patient safety:

1. User-centered Design

Approaches include making things visible so the user is able to see actions possible at any time, affordance, constraints and forcing-functions.

2. Avoid Reliance on Memory

Standardizing and simplifying procedures and tasks decreases the demand on memory, planning, and problem-solving.

3. Attend to Work Safety

Work hours, work-loads, staffing ratios, distractions, and counterclockwise shift changes all affect patient safety.

4. Avoid Reliance on Vigilance

Checklists, well-designed alarms, rotating staff and breaks decrease the need for remaining vigilant for long periods.

5. Training Concepts for Teams

Training programs for effective interprofessional communication and collaboration include transitions in care and hand-offs.

6. Involve Patients in Their CarePatients and families should be in the center of the care process.

7. Anticipate the Unexpected

Reorganization and organization-wide changes result in new patterns and processes of care.

8. Design for Recovery

Errors will occur despite the best of planning.

Designing and planning for recovery will allow reversal or make it hard to carry out irreversible critical functions.

9. Improve Access to Accurate, Timely Information

Information for decision making needs to be available at the point of care.

In summary - High reliability organizations have:

A shared sense of purposeFocus on resultsAccountability systems for

service/quality/safetyCollaborationEffective leadership