Becoming a High Reliability Organization: Operational ...

1 Becoming a high Reliability organization : Operational advice for hospital Leaders Prepared for: Agency for Healthcare Research and Quality Department of Health and Human Services 540 Gaither Road Rockville, MD 20850 Contract No. 290-04-0011 Prepared by: The Lewin Group, Falls Church, VA Contract No. 290-04-0009 Appendixes A-D Prepared by: Delmarva Foundation for Medical Care, Inc., Easton, MD AHRQ Publication No. 08-0022 April 2008 This document is in the public domain and may be used and reprinted without permission except those copyrighted materials noted for which further reproduction is prohibited without the specific permission of the copyright holders.

2 Suggested Citation: Hines S, Luna, K, Lofthus J, et al. Becoming a high Reliability organization : Operational advice for hospital Leaders. (Prepared by the Lewin Group under Contract No. 290-04-0011.) AHRQ Publication No. 08-0022. Rockville, MD: Agency for Healthcare Research and Quality. April 2008. The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the Department of Health and Human Services.

3 IiAcknowledgements We thank the authors, Steve Hines, The Lewin Group; Katie Luna, Delmarva Foundation; Jennifer Lofthus, Delmarva Foundation; Michael Marquardt, The Lewin Group; and Dana Stelmokas, The Lewin Group. Additional thanks to Dave Morrell, Delmarva Foundation, for graphic design. iii Contents iii Executive 1 Transforming Hospitals Into high Reliability 3 Introduction and 3 Understanding high Reliability Organizations and Why They 5 Challenges Calling for high 5 high Reliability Organizing 6 Use of high Reliability Concepts in 10 Applying high Reliability Concepts to 11 Changing and Responding to the hospital s 11 External 12 Internal 14 Planning and Implementing Improvement 16 Process 17 People 18 Resource 19 Doing the 19 Measuring 20 Measurement 20 Specific Measurement 21

4 Implementing Specific Improvement 23 Spreading Improvements to Other Units and 24 Between-Unit 24 Spread to 25 Spread Across 25 Using This 26 27 Appendix A: high Reliability organization Learning Network Operational advice from the Sentara Network Site 28 29 Rolling Out 29 Preparing for Successful 30 Planning a Successful 31 Working Out 32 Observations About Sentara s 33 Sensitivity to 34 Preoccupation With 38 Spreading Out 40 Spreading Across 41 Spreading Improvements to 41 Spreading Improvements Across 42 v Appendix B: high Reliability organization Learning Network Operational advice From the Exempla Healthcare Site Visit.

5 43 44 What Is Lean Thinking?.. 44 What Are the Preconditions for Successful Applications of Lean?.. 45 46 Just 47 Alignment of Lean With organization Goals, Performance Reviews, and organization 47 No Overcommitment of Resources and 48 Extensive Communication at the organization and Microsystem 48 Change 48 How Can Lean Be Used?.. 49 Overall 49 Examples of Implementing Lean Concepts and 51 Overall Process Redesign Lessons 56 Rapid Improvement 57 Appendix C: high Reliability organization Learning Network Operational advice From the Cincinnati Children s Site 58 59 Organizational 60 Creating a Shared Vision for 60 Identifying Essential Elements for 61 Summary on Organizational 66 Building a Business Case for Quality and Organizational 66 Engaging the Chief Financial 67 Building the Business 68 Use of Evidence-Based 69 Summary of Business Case 72 Specific Improvements Toward Organizational 72 Emergency 73 Codes Outside the Intensive Care 75 Decreasing Errors Through

6 Computerized Work 76 Surgical Site 77 Safety of 78 Neonatal Intensive Care 79 Transitional Care 80 high Fidelity Simulation 80 Lessons 82 83 Contact 83 Appendix D: high Reliability organization Learning Network Operational advice from the Fairview Health Services and Allina Hospitals & Clinics Network Site 84 85 Value in Community 85 Model for Community 86 vi 86 Specific Improvements Through Community 90 95 Appendix E: Case Studies in high Reliability Applications: Medication Dispensing Machine Redesign and Executive Walkarounds at Sentara 96 97 Explanation of the 97 Medication Dispensing 97 Communication 99 Application and Illustration of high Reliability Concepts.

7 100 Preoccupation With 101 Sensitivity to 102 103 Deference to 103 Reluctance To 104 107 Appendix F: Case Studies in high Reliability Applications: EICU and Sepsis Prevention at Christiana 108 109 Explanation of the 109 Safety Mentor 109 Sepsis 110 112 Application and Illustration of high Reliability Concepts .. 113 Preoccupation With 113 Sensitivity to 114 115 Deference to 115 Reluctance To 116 117 Appendix G: About the high Reliability organization Learning Network: An Explanation .. 118 Index One: Topic 120 Index Two: HRO Concept 123 vii Executive Summary This document is written for hospital leaders at all levels who are interested in providing patients safer and higher quality care.

8 It does not contain the views of researchers or theorists on how you can do better. Instead, it presents the thoughts, successes, and failures of hospital leaders who have used concepts of high Reliability to make patient care better. It is a guidebook for leaders who want to do the same. high Reliability concepts are tools that a growing number of hospitals are using to help achieve their safety, quality, and efficiency goals. These concepts are not an improvement methodology such as Six Sigma or Lean. Instead, they are insights into how to think about and change the vexing quality and safety issues you face.

9 Hospitals do most things right, much of the time. But even very infrequent failures in critical processes can have terrible consequences for a patient. Creating a culture and processes that radically reduce system failures and effectively respond when failures do occur is the goal of high Reliability thinking. At the core of high Reliability organizations (HROs) are five key concepts, which we believe are essential for any improvement initiative to succeed: Sensitivity to operations. Preserving constant awareness by leaders and staff of the stateof the systems and processes that affect patient care.

10 This awareness is key to noting risksand preventing them. Reluctance to simplify. Simple processes are good, but simplistic explanations for whythings work or fail are risky. Avoiding overly simple explanations of failure (unqualifiedstaff, inadequate training, communication failure, etc.) is essential in order to understandthe true reasons patients are placed at risk. Preoccupation with failure. When near-misses occur, these are viewed as evidence ofsystems that should be improved to reduce potential harm to patients. Rather thanviewing near-misses as proof that the system has effective safeguards, they are viewed assymptomatic of areas in need of more attention.