Day 4: The HRO Mindset

High reliability organizations (HROs) operate in complex, hazardous environments without serious accidents. HROs work to detect and address potential problems early, requiring a strong safety culture and persistent mindfulness. Successfully utilized by the airlines and nuclear power, these concepts have gained traction in healthcare where operations are complex and failures often have catastrophic consequences. The HRO mindset has five main concepts: reluctance to simplify, deference to expertise, preoccupation with failure, sensitivity to operations, and commitment to resilience.1 The following questions can help identify gaps in your safety program.

1. RELUCTANCE TO SIMPLIFY

Is your safety program focused on continuous compliance or continuous improvement?

A Joint Commission survey is designed to identify specific issues at a point in time, but doesn’t provide a holistic picture of a hospital’s safety culture or risk across the enterprise. If your strategy is centered around checking boxes of an audit or survey, you’re unlikely to ever achieve your zero harm goals.

Transitioning to a “patient-ready” safety strategy requires a focus on continuous improvement versus continuous compliance. Part of this strategy means making it easier to identify and report events—including near misses and complaints. These instances should be viewed as opportunities for improvement and given high priority with same-day resolution, with learnings for proactive prevention  the ultimate goal.

2. DEFERENCE TO EXPERTISE

Are you promoting compliance or critical thinking?

In many hospitals, front-line staff are reluctant to make decisions for fear of punishment. “This is how it’s always been done” takes precedence over a patient’s unique needs. In this culture, caregivers have little autonomy to make a call and anything outside of standard operating procedure becomes a fire drill escalated to senior leadership. Leadership hands down consequences and reemphasizes approved processes, leading to cynicism and discord among care teams.

An effective safety culture provides autonomy and requires accountability. As Steve Jobs famously said, “It doesn’t make sense to hire smart people and tell them what to do; we hire smart people so they can tell us what to do.”2 Leadership, managers, and front-line staff need to engage in two-way communication, trusting everyone is working in best interest of the patient and enabling critical thinking.

3. PREOCCUPATION WITH FAILURE

Do you celebrate event reporting and seek out new ways to capture events?

In many hospitals, the fewer events reported the better. If you look closely, though, there are events to report, but caregivers are reluctant to report them out of fear of punishment, professional humiliation, or a tedious process. This leads to a culture where covering up events, errors, and close calls becomes the norm.

The strongest safety cultures encourage reporting. The more issues and good catches reported, the greater the opportunity to identify risk and develop long-term safety improvements. Every staff member—from the maintenance person to the nurse manager to the chief physician—all need to take ownership and feel empowered reporting events. They need to understand the reward for their efforts is improved outcomes and an enhanced patient experience.

4. SENSITIVITY TO OPERATIONS

Do you overlook the impact of daily huddles?

Regular 10 to 15-minute stand-up meetings (also known as “huddles”) performed at the beginning of each shift are proven to increase patient safety.3 In fact, daily safety briefings are accepted as a key component of high reliability organizations in many industries, not just healthcare.4

According to The Joint Commission, huddles should cover issues that occurred in the previous 24 hours and potential issues anticipated in the next 24 hours. They should also cover steps already taken to resolve a previously identified issues, and should review resources assigned to correct newly identified issues.

It is important to regularly share the impact of huddles throughout the care team as a way to encourage communication and to build a culture of safety. For one hospital, that impact included reducing the number of patients on catheters by half.5 Hearing the real-life results make it easy to understand the value of those brief daily huddles.

5. COMMITMENT TO RESILIENCE

Are you consistently auditing processes and patient experience?

Rounding allows you to audit processes, engage front-line staff, and listen to patients. Actively seeking out issues and understanding current state to quickly make improvements in real time fosters a resilience mindset, letting you handle problems before they grow and building trust with patients and employees.

We need to build a culture that incorporates a continuous improvement mindset including encouraging event reporting, empowering caregivers to make decisions based on expertise and experience, and embracing existing processes in new ways. It is only when we accomplish this that we will finally improve patient safety and outcomes across the healthcare ecosystem.

  1. https://psnet.ahrq.gov/primers/primer/31/High-Reliability
  2. https://www.inc.com/marcel-schwantes/this-classic-quote-from-steve-jobs-about-hiring-employees-describes-what-great-leadership-looks-like.htm
  3. https://www.ncbi.nlm.nih.gov/pubmed/17254927
  4. https://www.jointcommission.org/assets/1/23/Quick_Safety_Issue_34_2017_Safety_briefings_FINAL.pdf
  5. http://www.ihi.org/communities/blogs/get-your-priorities-straight-tips-for-using-safety-huddles
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