Struggling to invent high-reliability organizations in health care settings: Insights from the field.

The Mission of the Agency for Healthcare Research and Quality (AHRQ) has been to support and conduct health services research and to disseminate those research findings. Recently the Agency has changed its mission to: "Improving the quality, safety, efficiency and effectiveness of health care for all Americans." For agency personnel working with the topic of patient safety, that change has created a need to develop greater awareness of the current patient safety initiatives underway at leading health care systems in order to determine where AHRQ might best play a role in helping these systems more rapidly adopt new practices to improve patient safety. In order to make that determination, AHRQ conducted a customer needs assessment of leaders in selected health care systems, asking them questions about their current implementation initiatives and their perceived needs for continued implementation of patient safety initiatives. Although not designed or conducted as a research study, the hour-long interviews produced rich insights into the implementation efforts of patient safety initiatives. The senior leaders interviewed in each of the health care systems, described implementing patient safety initiatives on multiple fronts-in some systems as many as 15 initiatives were underway. As the number of initiatives attests, there was no lack of knowledge about what patient safety practices should be implemented (CPOE, rapid response teams, reduction in surgical site infections) rather the major struggle these health care systems faced was the "how to" of implementation. Most initiatives were only newly begun, so these leaders were not yet confident about what they had learned from these efforts or whether they could be sustained over time. These health care systems drew many of the ideas for initiatives from outside of health care, for example, the nuclear power industry or aviation. The executives expressed concern about a number of issues including: how patient safety initiatives should be sequenced, the lack of benchmarking data to measure their systems against and the pressing need for IT standardization. The insights from this customer needs assessment revealed a wealth of implementation knowledge in the field and has led AHRQ to create an opportunity for leading edge health care systems to learn from each other via learning networks.

Sensemaking of patient safety risks and hazards.

In order for organizations to become learning organizations, they must make sense of their environment and learn from safety events. Sensemaking, as described by Weick (1995), literally means making sense of events. The ultimate goal of sensemaking is to build the understanding that can inform and direct actions to eliminate risk and hazards that are a threat to patient safety. True sensemaking in patient safety must use both retrospective and prospective approach to learning. Sensemaking is as an essential part of the design process leading to risk informed design. Sensemaking serves as a conceptual framework to bring together well established approaches to assessment of risk and hazards: (1) at the single event level using root cause analysis (RCA), (2) at the processes level using failure modes effects analysis (FMEA) and (3) at the system level using probabilistic risk assessment (PRA). The results of these separate or combined approaches are most effective when end users in conversation-based meetings add their expertise and knowledge to the data produced by the RCA, FMEA, and/or PRA in order to make sense of the risks and hazards. Without ownership engendered by such conversations, the possibility of effective action to eliminate or minimize them is greatly reduced.