Building Cultures of High Reliability: Lessons from the High Reliability Organization Paradigm.

Safety models from disciplines outside of health care have begun to diffuse into the health care safety arena. This article explores high reliability organizing (HRO) theory, which privileges culture as means to adaptively learn and reliably perform. A brief history of the HRO paradigm and factors that contribute to cultures of high reliability is provided, followed by review of existing research to discern which HRO ideas have diffused into research on anesthesiology and perioperative care. High reliability research is growing and concepts seem useful; but there is a long way to go before the benefits of HRO are fully realized.

Informatics Tools in Deprescribing and Medication Optimization in Older Adults: Development and Dissemination of VIONE Methodology in a High Reliability Organization.

PURPOSE: Polypharmacy is common in older adults, with almost 20% of older adults taking ≥10 medications. They are at great risk for adverse events related to potentially inappropriate medications (PIMs). Although evidence-based methods for deprescribing have been successful at reducing polypharmacy and improving quality of medication use, there are several challenges to implementing these methods on a large scale. VIONE, a medication deprescribing methodology, was developed to reduce polypharmacy and PIMs across the Veterans Health Administration (VHA). (VIONE stands for Vital, Important, Optional, Not indicated, and Every medication has an indication.) This study describes the tools created for implementation of VIONE and the dashboards used to track VIONE implementation and subsequent deprescribing across the VHA; their use and sustainment are examined in a health system-wide adoption of this deprescribing practice in a high reliability organization (HRO). METHODS: VIONE was disseminated by the VHA via the Diffusion of Excellence Initiative. Dissemination included an implementation toolkit and four dashboards that collect and display data from the electronic medical record to monitor utilization of VIONE, track medication discontinuations, and prospectively identify veterans who may be candidates for deprescribing. FINDINGS: Between 2016 and the present, VIONE has been adopted at >130 medical centers and influenced almost 700,000 unique patients. In addition, a total of >1.6 million medication orders have been discontinued by >15,000 providers. IMPLICATIONS: The VIONE methodology and informatics tools were widely disseminated and successfully adopted and sustained nationally in a high reliability organization, leading to a reduction in PIM use by older adults and improved quality and patient safety. Future efforts should continue to consider ways to leverage electronic medical record data and other relevant informatics tools to provide customized clinical decision support to further medication optimization and deprescribing efforts.

How the Five Principles of High Reliability Organizations Align with the Five Truths of Special Operations.

Special Operations medicine must provide highly reliable healthcare under intense and sometimes dangerous circumstances. In turn, it is important to understand the principles inherent to building a High Reliability Organization (HRO). These principles include (1) sensitivity to operations; (2) preoccupation with failure; (3) reluctance to simplify; (4) resilience; and (5) deference to expertise. Understanding them is crucial to turning good ideas into sound practical benefit in operational medicine. A prime teaching opportunity involves an interesting coincidence that occurred during the emergence of HROs. Specifically, United States Special Operations Command (USSOCOM) adopted five Special Operations Forces (SOF) Truths that contribute to success in Special Operations, including (1) humans are more important than hardware; (2) quality is better than quantity; (3) SOF cannot be mass produced; (4) competent SOF cannot be created after emergencies occur; and (5) most Special Operations require non-SOF support. These five Truths have more in common with the five HRO principles than merely quantity. They describe the same underlying ideas with a key focus on human performance in high-risk activities. As such, when presented alongside the five HRO principles, there is an opportunity to improve the overall health and performance of SOF personnel by integrating these principles across the range of Special Operations medicine from point of injury care to garrison human performance initiatives. The following discussion describes in greater detail the five HRO principles, the five SOF Truths, and how these similar ideas emerged as more than just a useful coincidence in illustrating the key concepts to produce high performance.

Adopting high reliability organization principles to lead a large scale clinical transformation.

Building high reliable healthcare systems to reduce avoidable patient harm is a global priority. However, there is variability in the application and understanding of the previously identified High Reliability Organization (HRO) principles to make improvements. We describe specific organizational activities exemplifying the five HRO principles during the planning and go-live periods of the new Electronic Health Record (EHR) system at a multi-site academic health sciences centre in Ontario, Canada. Further, we describe a case example where all five HRO principles were exemplified during EHR implementation. Overall, 23 activities exemplifying organizational anticipation and resiliency were identified. Of the 23 activities, 12 occurred during the preparing for go-live and 11 activities occurred during the go-live periods. This article demonstrates how HRO principles can be used in healthcare to detect and adapt to patient safety threats, in order to prevent avoidable patient harm during large scale change.

Quality and Safety in Healthcare, Part LXXXV: Introduction to Teamwork in High Reliability Organizations.

ABSTRACT: A high-reliability organization must have high-performing teams. Core teams in healthcare should include the patient and, where possible, the patient's family. Everyone on the team should understand what is expected of them in terms of expertise, leadership, communication, mutual support, and awareness of the situation. One test of the excellence of a clinical team is having high-quality handoffs of patients.

Measuring psychological safety and local learning to enable high reliability organisational change.

The ability to measure the extent to which an organisation is highly reliable, or the extent to which reliability may change over time, has not kept up with the development of theory. The paper examines aspects of workplace culture, employee motivation and leadership behaviours that support continuous learning and improvement in an effort to measure the transition to high reliability.To evaluate the effectiveness of its high reliability initiative, one children's hospital sought to build measures that would provide an assessment of progressive movement towards a 'culture of safety', and track the success over time. This paper reports on the development of two scales (trust in team members and trust in leadership) that are intended to measure two cultural conditions fostered by the five high reliability principles and a composite measure on local learning activities. The two scales are strongly associated with local learning activities in employees' work areas and with employees' willingness to participate in extra role activities. We suggest that they are foundational to creating a psychologically safe environment and thus to becoming a high reliability organisation.

Toward Zero Harm: Mackenzie Health's Journey Toward Becoming a High Reliability Organization and Eliminating Avoidable Harm.

OBJECTIVES: In response to an organizational survey revealing low safety culture scores, we implemented a "zero harm" approach to eliminate preventable harm across a wide variety of clinical areas. We aimed to achieve this objective within 3 years. METHODS: We developed a 5-part strategy for cultural and process redesign that included (1) engaging leadership; (2) developing an organization-specific patient safety framework; (3) monitoring specific quality aims based on high-risk, high-volume, high-cost, and problem-prone areas; (4) standardizing a 3-part review process that includes a root cause analysis for moderate and critical patient safety incidents; and (5) communicating progress to staff in real time via unit-specific electronic dashboards. RESULTS: In less than 1 year, we increased patient safety incident reporting by 37% while simultaneously decreasing falls with injury by 39%, pressure injury rates by 37%, and central line-associated blood stream infections by 34%. We also improved medication reconciliation rate by 3.3% and decreased our irretrievable specimen rate to 0. Finally, we noted increased awareness around patient safety within clinical teams, with open discussions about patient safety becoming a routine part of patient care. CONCLUSIONS: This study describes an initiative that sought to introduce system-wide changes to practice and patient safety culture in a rapid time frame. Results suggest that our 5-step approach to transformation may confer substantial gains in patient safety for peer institutions. Next steps include continuing to expand and monitor quality aims as we progress through our journey to eliminating preventable patient harm in our healthcare system.

Quality and Safety in Healthcare, Part LXXXIV: Using Patient Safety Culture Surveys to Improve High Reliability Organizations.

ABSTRACT: An important approach to improve the reliability of healthcare organizations is the use of patient safety culture surveys to identify areas that need improvement. Commonly found areas that need development include having more superior leadership regarding safety, improving communications such as with the Ticket to Ride Program and WalkRounds, enhancing teamwork, and using certain collections of "reliability-enhancing work practices."

Quality and Safety in Healthcare, Part LXXXIII: The Culture of Safety in High Reliability Organizations.

ABSTRACT: A safety culture encourages the reporting of mistakes so that all can learn from them and remedy underlying system problems. However, errors will only be reported in a culture in which most types of common human errors are not punished because all humans make errors, and usually there are underlying system problems contributing to this. All healthcare errors must be viewed partly as opportunities to improve. A safety culture includes good leadership, communication, learning, collaboration, mindfulness, medicine that is based on evidence and best practice, and care that is centered on the patient.

Quality and Safety in Health Care, Part LXXXII: Introduction to High Reliability Organizations.

ABSTRACT: Reports from the Institute of Medicine regarding the number of errors in medicine leading to fatalities prompted a major review of medical practices and a move to make medical systems high reliability organizations. Many of the concepts used today to improve performance in health care are borrowed from what has been learned from successes and accidents in other industries, especially in the aviation, space, and nuclear power programs. An emphasis on excellent leadership and communication, the knowledge that there needs to be an emphasis on system failures rather than human failures, and having a safety culture that encourages everyone to be mindful of potential errors and report errors are critical to achieve high reliability.

[Relevance of the theory of High Reliability Organizations in Assisted Reproductive Technology]. / Intérêt de la théorie des organisations à haute fiabilité en Assistance Médicale à la Procréation (AMP).

OBJECTIVES: The objective of this study was to assess the value of applying operating principles for High Reliability Organizations (HROs) to Assisted Reproductive Technology (ART) centres in order to optimise their operation and results. METHODS: Two exploratory qualitative case studies, in the form of ethnographic observations, were conducted in two public hospitals (Antoine-Béclère Hospital, Clamart and Nantes University Hospital). The studies analysed the structural and functional characteristics of these centres compared to HROs. Specific interviews, based on the HRO model from Roberts and Rousseau (1989), were also carried out. RESULTS: The in vitro fertilisation (IVF) procedure is comprised of a sequence of steps for which success depends on the cooperation of a range of medical staff across various specialties. Patients themselves must also play an active part in the protocol. From the different points analysed, the comparison between the characteristics of IVF activity at the ART units and those of HROs reveals structural and functional similarities, however there are also cultural differences. CONCLUSION: The study concluded that ART centres are complex healthcare organisations that face similar challenges to HROs and that they could improve their operational performance by adopting an HRO culture. To confirm the interest of this strategy, it would be useful to clarify these preliminary results by extending the exploratory study to include several public and private ART centres, and to explore the patient/couple dimension before initiating an interventional study.

La revista de la Academia Nacional de Medicina de Colombia y su recorrido en 150 años / The magazine of the National Academy of Medicine of Colombia and its journey in 150 years

FRAGMENTO. La aparición en Europa de revistas científicas sobre temas médicos fue la consecuencia del descubrimiento de la imprenta por Gutenberg. Los tipógrafos de la época comenzaron editando libros (recordamos en particular la Biblia de 42 líneas en el siglo XV), que tenían como antecesores los libros clásicos reproducidos por los monjes copistas. Los ejemplares impresos antes del siglo XVI se han llamado incunables. Los grandes pensadores de aquellas épocas eran a la vez astrónomos, filósofos, frailes, botánicos, médicos, políticos y naturalistas. En el siglo XIX en Colombia, después de Caldas y Mutis, hubo algunos médicos que ejercieron después de que se corrigió aquel decreto de Santander que permitía el ejercicio de la medicina sin necesidad de título.

Race Differences in Reported "Near Miss" Patient Safety Events in Health Care System High Reliability Organizations.

OBJECTIVES: This study aimed to determine if race differences exist in voluntarily reported near-miss patient safety events in a large integrated, 10-hospital health care system on its journey to become a high reliability organization. METHODS: From July 1, 2015, to June 30, 2017, employees in a mid-Atlantic health care system voluntarily reported near-miss events by type using an occurrence reporting system referred to as the Patient Safety Event Management System. Inpatients, outpatients, and observation patients were identified as "Black," "White," or "other" (n = 39,390). Using retrospective analysis and χ2 goodness of fit, comparisons of race proportions were conducted to determine differences at the health system level, by hospital, and by event type. RESULTS: Significant race differences existed: (1) overall across the health care system with higher proportions of events reported for Whites and lower proportions of events reported for Blacks in the Patient Safety Event Management System, (2) by site in 9 of 10 hospitals, and (3) by type. All differences were significant at P < 0.05. CONCLUSIONS: Race differences in near-miss patient safety events exist in voluntary reporting systems by type. Health care organizations, particularly health care high reliability organizations, can use these findings to help to identify areas of further study and investigation. Further study and investigation should include efforts to understand the root cause of the differences found in this study, including the role of reporting bias by race.

High Reliability Organization Principles Improve VA Workplace Burnout: The Truman THRIVE2 Model.

Provider burnout is a significant health care concern. It is unclear whether high reliability organization (HRO) practices can prevent it. The Truman Veterans Affairs Medical Center (VAMC) undertook an initiative implementing HRO principles and assessed for impact on burnout metrics. This became known as the Transformative HRO Initiative Via Employee Engagement (THRIVE2) model. THRIVE2 consisted of Just Culture training, Clinical Team Training, and continuous process improvement through Lean. Truman VAMC was compared with other Veterans Health Affairs (VHA) facilities regarding burnout and employee satisfaction metrics. Truman VAMC saw significant changes in multiple HRO metrics (P < 0.001) as well as improvements in work group psychological safety and employee exhaustion (P < 0.001). High burnout rates decreased by 52% (6.2%-2.95%; P < 0.001). Truman VAMC went from 75th to the No. 1 ranked VHA facility regarding Best Places to Work. These findings have significant national policy implications given the effects of burnout.

A Study Investigating How the Characteristics of High Reliability Organisations Can Be Measured in the Construction Industry in Australia.

Construction activities involve a lot of risk as workers are exposed to a wide range of job hazards, such as working at height, moving vehicles, toxic substances, and confined spaces. The hazards related to a construction project are mostly unpredictable because construction projects move quickly due to project deadlines, and changing work environments. As a result of this, the industry accounts for one of the highest numbers of work-related claims, and the fourth highest incidence rate of serious claims in Australia. This research investigates how key safety management factors can measure the characteristics of high reliability organisations (HROs) in the construction industry in New South Wales Australia. To address the problem, a model is presented that can predict characteristics of HRO in construction (CHC). Using structural equation modeling (SEM), and confirmatory factor analysis (CFA), the model and measurement instruments are tested and validated from data collected from construction workers. The results identified the factors that effectively measure CHC, and the findings can also be used as a safety management strategy and will contribute to the body of knowledge in research.

Race Differences in Reported Harmful Patient Safety Events in Healthcare System High Reliability Organizations.

OBJECTIVES: The aim of the study was to determine whether race differences exist in voluntarily reported harmful patient safety events in a large 10 hospital healthcare system on a high reliability organization journey. METHODS: From July 1, 2015, to June 30, 2017, employees in a healthcare system based in Washington, District of Columbia, and Maryland voluntarily reported harmful patient safety events by type using a Patient Safety Event Management System. Inpatients, outpatients, and observation patients were identified as "black," "white," or "other" (N = 5038). Using retrospective analysis and χ goodness of fit, comparisons of race proportions were conducted to determine differences at the health system level, by hospital, by event type, and by severity. RESULTS: Significant race differences existed: (1) overall with higher proportions of whites and lower proportions of other in a Patient Safety Event Management System; (2) by type across races; (3) in six hospitals across races; and (4) by type and by hospital for blacks and whites. All differences were significant at P < 0.05. CONCLUSIONS: Race differences in harmful events exist in voluntary reporting systems by type and by hospital setting. Healthcare organizations, particularly healthcare high reliability organizations, can use these findings to help identify areas of further study and investigation. Further study and investigation should include efforts to understand the root cause of the differences found in this study, including the role of reporting bias.