What Will it Take to Make Health Care “Highly Reliable?”
May 1, 2011
Posted by chcablogadmin in : Leadership, Quality
by Burl Stamp, FACHE
Stamp & Chase
Burl Stamp
Among the management tools, techniques and approaches that health care organizations have co-opted from other industries during the past two decades, high reliability organization, or HRO, theory is unique. This research, which was spearheaded by Karl Weick from the University of Michigan along with contemporaries at other major research universities in the 1970s, helped identify organizational characteristics that contribute to avoidance, or at least containment, of catastrophes in environments where accidents can be expected due to high risk factors and complexity.
Because high risk and complexity so aptly describe hospitals, it is not surprising that leaders in some of the most progressive, forward-thinking health care organizations across the country – including a number of children’s hospitals — have advocated the adoption of HRO principles to increase safety and improve quality. Just this month, the Joint Commission added a new topic tab on its website titled “High Reliability – Consistent Excellence.”
But despite its applicability, the HRO theoretical framework has been more difficult to propagate in many health care organizations than other management approaches such as Lean, Six Sigma or other process improvement methodologies.
Why is introducing HRO thinking such a challenge? First, high reliability is all about culture and how employees think about their roles and responsibilities in an organization, not simply about what they do. In their comprehensive guide Becoming a High Reliability Organization: Operational Advice for Hospital Leaders developed for the Agency for Healthcare Research and Quality, authors from The Lewin Group and the Delmarva Foundation for Medical Care insightfully describe the relationship between HRO concepts and other process improvement methods.
High reliability concepts help focus attention on the mindset and culture that is essential for any of these (process improvement) approaches to work. Although high reliability concepts are very useful, you should not view them as conflicting with strategies or vocabularies that you may be using to promote quality and safety.
Second, high reliability principles frankly are tough to get your arms around. Because the research attempts to understand the subtle cultural characteristics and relationships that have evolved in organizations over time, the explanations are nuanced and often intellectually complicated. If middle managers and frontline staff cannot relate HRO principles in a straight-forward, meaningful way to their everyday tasks and responsibilities, the chances of changing behaviors are slim.
Specific tactics that address the five key organizational characteristics of HROs are important, but before tackling the minutiae, broad, foundational strategies for building a culture that delivers safe, reliable care consistently make sense as a better place to start.
Communicate in word and action that patient safety is Job #1
Given the number of often conflicting tasks, decisions and responsibilities facing every health care manager, leaders can unintentionally send mixed messages to staff regarding how important patient safety really is. Quantifying and trending safety measures and then adding them to a balanced scorecard is a start, but it falls far short of what’s needed to make patient safety an organization’s top priority. By its very design, a balanced scorecard communicates that all issues have equal importance. Perhaps what we need is an unbalanced scorecard that sets patient safety measures apart in a category above other operational and financial goals.
Managers must consistently reinforce patient safety as the top priority by creating more opportunities to critically review and discuss safety risks during staff meetings, huddles and individual interactions with frontline staff every day.
Prospectively and objectively assess how your current culture supports high reliability
Using the five HRO principles as a framework, managers must ask themselves some of the tough questions about their workgroup that will identify where they have cultural strengths and weaknesses that either contribute to or detract from achieving high reliability and a higher level of patient safety. For example:
- Is teamwork strong within your workgroup and among the other departments you depend on to provide safe care? When unexpected challenges arise, does teamwork help you quickly adapt and resiliently recover?
- Does hierarchy in your area support or discourage deference to expertise, regardless of where it exists in your organizational structure?
- Do staff in your area routinely and proactively look for processes or procedures that are high risk and could lead to failure?
Identifying opportunities is the first step in crafting strategies to change beliefs, practices and behaviors that will lead to a culture that embraces safe practices.
Don’t try to make everyone an expert in HRO theory
The research methodology and conclusions that provide the underpinnings of high reliability theory are complex. Understanding the insights revealed by years of HRO research should be the means not the end in efforts to improve patient safety. In other words, staff do not necessarily need to become conversant in the specific theories underlying HRO principles to effectively implement practices that align with these theories. Of course, this clearly places the responsibility for identifying organizational beliefs, norms and practices on leaders who are committed to building a culture that places safety for the children in our care above all else.
Burl Stamp, FACHE, founded Stamp & Chase in 2003, a St. Louis-based consulting practice that partners with health care organizations nationwide to improve operating results and performance by improving communication. A 20+ year health care veteran, Burl has experience in community hospitals, academic centers and children’s hospitals. He developed the first strategic planning and marketing department at St. Louis Children’s Hospital and went on to lead pediatric service line development for the BJC HealthCare. As former president and CEO of Phoenix Children’s Hospital, he spearheaded development and construction of the first comprehensive, freestanding health care campus in Arizona dedicated to pediatrics. Burl is the author of the book The Healing Art of Communication, a health care professional’s guide to improving communication, and is a frequent speaker on communication, the patient experience, leadership and marketing strategy in health care organizations. Read more of Burl’s advice for health care leaders, or contact him at burl@stampandchase.com.
add a commentRiley Hospital for Children at Indiana University Health Attacks Obesity from the Inside Out
May 1, 2011
Posted by chcablogadmin in : Community Benefit, Innovation
Accountability in Action in Indianapolis
Riley Hospital for Children at Indiana University Health is putting “accountability” into action as it evolves toward an accountable care model. One example of its commitment to population health is a systematic overhaul of the nutrition delivered from all food offerings throughout the organization. It is embarking on several innovative programs that may position Riley at IU Health as a thought leader among children’s hospitals in nutrition and obesity prevention. First Round asked president and CEO Dan Fink to share with his CEO colleagues.
Dan Fink
It is time to begin thinking about the health of populations and our communities—we are not acute care managers anymore. We are responsible for the nutritional messages we send as an organization.–Dan Fink, president and CEO, Riley Hospital for Children at Indiana University Health
There were two forces at play when we stimulated the idea of retooling food services at Riley at IU Health. One was prevalent medical literature about, and our own experience with, the growing obesity rate among children even young children and as a result, the exploding growth in diabetes.
Several years ago, we first responded by developing POWER—Pediatric OverWeight Education and Research—a program aimed at improving the health of children and decreasing the risks of obesity through multi-level and multi-disciplined clinical programs. Led by pediatric gastroenterologist Sandeep Gupta, M.D., POWER follows national guidelines and positioning to take a proactive role in the prevention and treatment of youth obesity. The morbidly obese children in the program receive evaluations, treatment and education from a team of providers—a dietitian, exercise physiologist, behavorialist and pediatrician. Ultimately, patients have seen an increase in their quality of life, improved BMI and improved fitness level.
We knew with the intensity of the services this program wouldn’t generate income for the hospital, but Indiana University Health (formerly Clarian Health) felt strongly about proactively dealing with one of the biggest issues facing the health of children today and funded it without hesitation.
Questioning Organizational Responsibility
Another factor in our decision to retool food services at the hospital was a re-evaluation of our relationship with McDonald’s, who provides commercial food service in our current lobby. Located at the nexus of our campus, McDonald’s serves not only patients and their families but hospital staff, faculty, volunteers, medical, nursing and dental students, as well as employees of the health system.
We began to question our entire food operation and inventoried the food under our control—how it entered our facility and made its way to our staff, volunteers, patients and families. We wanted to understand the message we were sending so I put together a small group to discuss the issues.
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