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7/2/2014
1
Leadership and HROs
Julianne Morath, RN, MS
High Reliability – A Leadership Imperative for Safe Care
Keynote // March 6, 2014 // 1:00-2:15pm
Attaining High Reliability and Safety for Patients –
Collaborating for Change. Patient Safety Collective of the
Southwest (PSCS). March 6-7, 2014; Albuquerque, NM
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CE Disclosure
In compliance with the ACCME/NMMS Standards for
Commercial Support of CME Julie Morath has been asked
to advise the audience that she has no relevant financial
relationships to disclose or does have relevant financial
relationships to disclose which she will disclose here.
Attaining High Reliability and Safety for Patients –
Collaborating for Change. Patient Safety Collective of the
Southwest (PSCS). March 6-7, 2014; Albuquerque, NM
7/2/2014
2
High Reliability -
A Leadership Imperative
For Safe Care
A Patient Safety Collective of the
Southwest Conference
March 6, 2014
Julianne Morath, RN, MS
Objectives for this session
1. Define Reliability
2. Role of Leaders in building a culture of
reliability and safety
3. Strategies for Risk Surveillance and
Error Management
7/2/2014
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Reliability
• Reliability is defined as “failure-free
operation over time”
• Tough tasks performed without
unintended variation under trying
conditions
• Reliability is designed to “error-proof” a
system so that little room is left for human
error
Measuring Reliability
• Reliability is measured this way:
Reliability = number of actions that
achieve the intended result: total
number of actions taken
• Thus, 10-1 means one defect per 10
attempts, 10-2 is one defect per 100
attempts, and so on.
7/2/2014
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a complex organization with
consistent performance
at high levels of safety
over long periods of time
across all services and settings
What is a High Reliability
Organization?
High Reliability In Action
Teams produce intended outcomes in complex environments
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5
Lessons and Applications from other Industries
United Airlines Flight 232
Discipline, Team,
Resilience/Recovery
Captain Al Haynes Co-pilot Bill Records
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6
Reliability and Resilience are…
• Dynamic, emerging, adaptive.
• They require:
• Dialogue and structured
communications
• Understanding error and learning
from failure
• Rules and breaking rules: heedful
attention
• “Habit of excellence”
Healthcare is, at its heart, people caring for people.
And people are unpredictable, complex, and full of paradox.
Particularly when we interact with each
other and when we are anxious, sick, and confused. Richard Smith
Editor, BMJ
November 2001
Why the Topic of High Reliability in
Healthcare?
7/2/2014
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Part of improving the human
condition,
is improving conditions under
which humans work.
From Applications to Explorations
Pervasive Ambiguity
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8
Think about all that is going on today.
2005 2013
People - relationships - complexity
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9
Monsters Among Us Adapted from Donald Berwick, MD
Health Forum & AHA Leadership Summit July 25 - 27, 2013
“And the wild things roared their terrible roars and gnashed their
terrible teeth and rolled their terrible eyes and showed their
terrible claws.”
Maurice Sendak
Top 10 Patient Safety Issues for
2014
1. Healthcare-associated infections
2. Surgical complications
3. Handoff communications
4. Diagnosis
5. Medical errors
Source: Becker’s Hospital Review
7/2/2014
10
Top 10 Patient Safety Issues for
2014 - continued
6. Failure to implement a culture of safety
7. Lack of interoperability
8. Falls (and other geriatric considerations)
9. Better treatment choices
10. Alarm fatigue
Source: Becker’s Hospital Review
Lens: Leadership with “Radical Clarity”
What you give your time, resource, and commitment to and what you do not.
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Practice and Systems
1. Prevent failure
2. Identify and Mitigate failure
3. Design the process
Artifacts – Stories - Heroes
Leaders
Shape
Culture
Results
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12
The Culture of a High Reliability
Organization is:
• An accountable culture
• A culture of transparency
and learning
• A culture of partnership /
teamwork
• A Just culture
• A culture that supports
situational awareness,
mindfulness, sense making
• A culture of respect
Characteristics of High-Reliability
Organizations
• Process auditing
• Reward systems
• Pursual of quality standards
• Perception of risk
• Command and control Leadership
- Clarity
- Functional hierarchy
- Deference to expertise
- Roles, responsibilities, training
• Sensitivity to operations
• Safety: physical and psychological
Morath J. The Quality Advantage:
A Strategic Guide for Health Care Leaders, American Hospital Association Press,
1999, pp. 62/64
7/2/2014
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• Transparency
• Roles of Responsibilities
• Chain of Command
• Reciprocal Accountability
• Respect for People
• Learning System
• Preconditions
Examples: Leadership Actions
• Meaningful work
• Opportunities to Learn and Develop
• Respect and Engagement
Through the Eyes of the Workforce
7/2/2014
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Can each person in the workforce
answer yes to these 3 questions
each day?
1. Am I treated with dignity and respect by everyone in each encounter?
2. Do I have what I need so I can make a contribution that gives meaning to my life?
3. Am I recognized and thanked for what I do?
Learning System for Reliability
and Resilience
• Trust and Psychological Safety
• Transparency of errors
• Ask and tell
• Blameless reporting
• Debriefs, simulations and rehearsals
• Stories
• Complex conversations
• Learning from failure
7/2/2014
15
How Different Organizational
Cultures Handle Safety Information
Pathological
Culture
Bureaucratic
Culture
Generative
Culture
Don’t want to
know
May not find
out
Actively
seek it
Messengers
(Whistle blowers)
are “shot”
Messengers
are listened to
if they arrive
Messengers
are trained
and rewarded
Failure is
punished or
concealed
Failure leads
to local repairs
Failures
lead to far-
reaching reforms
New ideas
are actively
discouraged
New ideas
often present
problems
New ideas
are welcomed
Safety culture is generative, constantly “uneasy”, seeking, learning, changing.
Interprofessional Collaborative Learning
7/2/2014
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Experiential Learning
• “Nothing about me
without me”
• “If it looks wrong,
it is wrong”
• Disclosure and
truth-telling
Engage Patients and Families as
Partners in Care
7/2/2014
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• Core Measure Bundle Compliance
• Readmissions
• Pressure Ulcer and Falls Protocols
• Adherence to Bundles to Prevent
Infections (CLABSI)
• Monitors, Measures, and Feedback
Examples: Reliable Care Process
34
7/2/2014
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Before and After 5-S Lean Methods
Before After
Pathology Office
Readmission
286,755/year 786/day 33/hour
7/2/2014
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• Universal Protocol/Time Out (UP-TO)
• Blood Management
• Structured Communications
• Handovers
• Rapid Response Team
Examples: Reliable System Design
Communication at Transitions
and Transfers of Care
7/2/2014
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Leaders Role
Assessment and Management
of
Operating Point
Going Solid:
The Nuclear Reactor
• Boiler
• Gas to liquid ratio
• Conditions of all liquid
• Anticipation, control, recovery
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Dynamic Safety Model
We work inside an envelope defined by 3 boundaries
Cook, R and Rasmussen, J. “Going Solid”: A model of system dynamics and
consequences for Patient Safety. Quality & Safety in Health Care, 14, 130-134,
doi : 10.1136 / qshc. 2003. 009530
Dynamic Safety Model
Low
High
B
enefit
Low Production / Performance High
Operations Boundary
Quality of Work Life
Gradient Towards
Engagement, Joy & Meaning, Respect
7/2/2014
22
Dynamic Safety Model
Low
High
B
enefit
Low Production / Performance High
Operations Boundary
Quality of Work Life
Management Pressure
Towards Production, Efficiency, and Cost
Dynamic Safety Model
Low
High
B
enefit
Low Production / Performance High
Operations Boundary
Quality of Work Life
Technology Safety Regulations,
Certification,
Standards,
Evidence-based medicine
Psychological Safety*
Morath, J & Leary, M. (2004) Creating safe spaces in organizations to talk about safety, Nursing Economics, 22(2), 344-352
7/2/2014
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Questions for Leaders
How do you define your safety
boundary?
- as a work unit?
and
- as an individual?
Balance Seeking Operations
Dynamic Safety Model
Gradient Towards
Best Effort
Margin of Safety
Production Pressure
Towards Efficiency
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Dynamic Safety Model
Financial Boundary
(Market Demand)
Operations Boundary
Quality of Work Life
100% Expected Safe
Space
Safety Boundary
Probability of
Accident High B
T
C
U
Amalberti R, Vincent C, Auroy Y, de Saint Maurice G. (2006) Violations and migrations in health
care; a framework for understanding and management, Quality and Safety in Healthcare, 15, i66-
i71, doi: 10. 1136 / qshc. 2005.015982
Considerations for Leaders of
Border-Line Tolerated Conditions
of Use (BTCU)
• Migrate by drift or by design.
• Result in “stabilized usual level of performance” that
lies outside the expected safe field of use defined in
design.
• To do so safely all aspects of system
production/recovery must be known.
• First seen as benefits, rather than problems. Benefits
are immediate payback, additional risks are felt to be
known, control is supposed, and de facto scarcely
penalized. (“Power through”)
• Driven by performance demands, system
improvements (technology), and individual benefits.
• Implicitly tolerated by proximal hierarchy.
7/2/2014
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Flirting With The Margin
Original Boundary
Acceptable
Operating Point
Repeated shifts,
no error, Margin
redefined
New Acceptable
Operating Point
Normal Conditions
take Operating Point
beyond Margin
Corrective Action
Taken
2
3
4
5
1
New Marginal Boundary
Borderline Tolerated
Conditions of Use (BTCU)
BTCU Management by Design
• Transparent system of production and
recovery
• Anticipation
• Teamwork
• Pullbacks and recovery
7/2/2014
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Dynamic Safety Model
Financial Boundary
(Market Demand)
Operations Boundary
Quality of Work Life
Hospitals
BTCU
Safety Boundary
Probability
of Accident
High
HRO
100% Expected Safe
Space
Question for Leaders
What are conditions under which
your operating unit / function
migrates to BTCU or beyond?
What are your early warning
indicators?
How do you mitigate risk?
7/2/2014
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Going Solid
Here is what the research says:
• Production demands
• Management efficiencies
• Tightly coupled processes
• Technology
• Loss of buffers
• Escalating risk (volume, severity,
complexity)
• Lack of established teamwork
• Perverse reward systems
Question for Leaders
How do you know when you are
approaching boundaries of
exceedency (BTCU)?
7/2/2014
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Early Warning Signals of
Drift Into BTCU
• Denigration in teamwork and
communication
• Interprofessional / Interpersonal jousting
and conflict
• Assumptions verses Clarifications
• Denigration in trust and psychological
safety to speak up
• Clinical “surprises”
• Increase in error-making
Early Warning Signals of
Drift Into BTCU - continued
• Missed “pink flags” and escalation to
emergency responses
• Increased absenteeism / Increased extra
hours or shifts
• Rigidity in work flows and roles
• Increase in work arounds
• Increase in complaints / concerns
7/2/2014
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Common Factors in Safety
Leadership of
High-Reliability Organizations
• Mindful organizing
• Situational Awareness
• Perception of risk
• Process auditing and
feedback
• Aligned reward systems
• Perusal of quality standards
• Command and control
‒ Clarity
‒ Functional hierarchy
‒ Deference to expertise
‒ Roles, responsibilities, training
• Sensitivity to operations
Red Rules
• Actions that pose the highest level of
risk and consequence to safety
• Few in number
• Consequence for non-compliance
• GOAL – Create solid habits in these
actions and reduce the incidence of
human error.
7/2/2014
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Red Rule Examples
• Hospital Wide: Patient Identification
• OR / Procedural: Universal Protocol /
Time Out / Debrief
• Alarm monitoring system
• EVS: Never mix chemicals
• Other candidates?
Executive WalkRounds
• Demonstrate commitment to safety.
• Fuel culture for change.
• Find out what is going on: learn.
• Identify opportunities to improve safety.
• Establish lines of communication about patient safety.
• Allows for the rapid testing of safety improvements.
• Do the obvious things one by one. When processes
need correction, take action.
7/2/2014
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Sharp and Blunt Ends
Errors and
Expertise
Monitored Process
Organizations, Institutions,
Policies, Procedures, Regulations
Practitioner
Knowledge
Focus of
Attention
Goals
Modified from Woods, et al., 1994
Resources and
Constraints
Engage, Align, Model the Way
A string is needed to pull together scattered beads…. Somali proverb
7/2/2014
32
Julianne Morath
Attaining High Reliability and Safety for Patients –
Collaborating for Change. Patient Safety Collective of the
Southwest (PSCS). March 6-7, 2014; Albuquerque, NM
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