Reliability in the hospital

Reliability in hospitals

Status quo of the high reliability organization (HRO) approach

The HRO concept offers a promising way to increase reliability in hospitals by means of the five principles of mindfulness. The central characteristic of HRO is “mindfulness” or “mindful action”.

The five principles are divided into the areas of “anticipation” and “containment/resilience”. Through the interaction of the three principles of anticipation and the two principles of containment or resilience, HROs are permanently able to react to unexpected situations in a timely manner and always remain capable of acting.

1. Establishment of the HRO approach

This article examines the extent to which the HRO approach presented here has now been established in hospitals. Overall, the topic of HRO is receiving increasing attention in the context of patient safety and the associated avoidance of health damage. A wide range of stakeholders are dealing with this. This is particularly evident in the global action plan of the World Health Organization, which calls for “the greatest possible reduction of avoidable harm from our healthcare”

2. The concept of HROs can be found in the action plan under the term “highly reliable systems” and is one of the seven strategic goals for improving patient safety.

In addition to the principles mentioned, an important component of these systems is the “safety culture and leadership”. The action plan argues that this topic is still given too little consideration at the strategic management level. As a result, “safety culture and leadership” should be given more attention as an important prerequisite for implementing an HRO.

3. Building highly reliable systems

The current literature shows that the German Coalition for Patient Safety (APS), which has been setting up various projects and initiatives to improve patient safety in Germany since 2005, is one of the organizations dealing with the topic of “risk and safety culture in healthcare”. The contents have been summarized in a book. The APS also recognizes that safety culture and leadership are fundamental to building highly reliable systems. This is described and explained from the different perspectives of the respective authors in the articles. Among other things, Annette Gebauer describes in her article how to develop a proactive risk culture and what can be learned from high-risk organizations in this regard. The connection between safety culture and leadership is also presented here. She also refers to study results. These show that the HRO approach does indeed have a positive effect on patient safety. The central theme is, on the one hand, to use the principles to drive cultural change and, on the other hand, to accept the challenge of developing a vision as a management team and credibly communicating this to employees through their own attitude and then acting accordingly. Annette Gebauer describes it as “collective fitness training that requires a high degree of discipline”.

Do the details described here match the current situation in hospitals? Is the topic of highly reliable systems present in everyday clinical practice and, if so, how is it implemented?

The consultants at GRB have a comprehensive insight into the hospital landscape and are close to the action with a wide range of projects. In addition to individual clinics and large associations, GRB also supports the development of a risk management system with regard to the transformation of an HRO. In order for such a large-scale project to be successfully implemented, certain procedures have proven effective, which are briefly outlined below on the basis of a few measures.

Establishing a risk management system

First of all, it is essential to get to know the hospital by analyzing the high-risk areas of a hospital. For example, it is important to know how the teams in the respective departments, but also at the various interfaces, work together and how certain communication channels are maintained. What process steps are there and how are they implemented by employees? On this basis, many strengths and weaknesses can already be identified, which provides the starting point for further action. It has proven useful to work with annual goals and to focus on a few key topics. In this way, projects and goals can be realized and successes recorded step by step.

Examples of key topics include the introduction of clinical risk management tools such as CIRS, M&M conferences and regular audits. But individual measures regarding the implementation of, for example, counting controls or marking the surgical area can also be key topics. Regardless of the size of the clinic, it is important to create a common understanding of these topics. In the case of clinic networks, it is important to use the instruments uniformly and to include all facilities. This allows the results to be linked, creating a high degree of transparency, and specific fields of action can be derived.

Further topics include the implementation of so-called “Red Rules”. These should be limited to three to five essential rules in order to emphasize the urgency of compliance throughout the clinic. In addition, there must be no deviations, so the rules must be formulated briefly and precisely.

In principle, training and simulation training in the team are also important starting points for implementing the HRO concept. Every emergency situation, crisis or adverse event should be taken as an opportunity to look at what happened from different perspectives and, in particular, to examine the way people worked together and how they worked, and to reconstruct the events. This is a relatively simple way to strengthen and practise resilience in the team. It also offers the opportunity to make use of the experiences gained in a timely manner.

Introduction of a culture of error management and safety

In practice, it often turns out that the concept of error or safety culture implies a so-called “no blame culture”. Systemically caused errors should not be assigned to one person, but should be openly presented in order to find suitable solutions for process improvement. A culture characterized by fear of sanctions may conceal serious errors and deprive an organization of the opportunity to eliminate them at an early stage and prevent worse from happening. This fundamental attitude is an important basis for implementing the five principles of mindfulness in the HRO approach and is also fundamentally present in those working clinically. In the past, particular attention was paid to introducing the above-mentioned instruments of clinical risk management to promote this attitude. In the meantime, the application of these instruments has also been prescribed by law in some cases, such as the Critical Incident Reporting System, and they have certainly provided food for thought, leading to many things being scrutinized and appropriate measures for improvement being derived and introduced. They have become indispensable in the healthcare system and serve as a reminder of the existing safety culture in an organization.

Shaping the culture

Nevertheless, it cannot be assumed that the introduction of such tools will automatically lead to a change in the safety culture of a company. The attitude at all levels when dealing with preventable and actual events is equally important to achieving consistency and transformation. In order to shape and change the culture in the company in the long term, managers in particular are called upon to reflect this attitude in their daily activities and to demand it from their employees. Security should thus not be symbolized solely by the use of instruments, but should be given a central role as a corporate goal. The more willing management and leadership are to address the issue of a resilient organization or behavior and to establish it in practice, the better a team can engage with different situations and develop solutions for the future together. This behavior must be practiced and demanded by managers, as illustrated by the examples above.

An example from Texas makes it clear how it is possible to pursue and gradually implement the HRO approach described here in hospitals. The Memorial Hermann Health System is one of the largest non-profit organizations in Texas and received the Eisenberg Patient Safety Award as early as 2012.
 

The vision of “Patient Safety is our core value” has since been firmly anchored in the company's objectives and is pursued through a wide range of decisions and measures at the highest management level. The creation of a “culture of high reliability” is also fundamental to this.

The six dimensions for a “Culture of High Reliability”, as practiced in the company presented, are as follows:

• Establishing a vision in which safety is of central importance;
• Leadership development with the aim of reflecting the values of the safety culture; Selection;
• Development and motivation of leaders
• Trust, respect and inclusion, with the aim of defining organizational behavior;
   
• building a Just Culture in which deviations or errors are not attributed to an individual, but rather the weak point should be found in the complex system;
• managers' responsibility to establish safety awareness among employees.

The HRO approach could be realized because the safety culture in the company forms the foundation. The top management level strives to achieve a “Culture of high Reliability” and to communicate this attitude at all levels. This vision was realized by creating a safety culture that is practiced by all managers and implemented in their daily activities.

Footnotes

1 Managing the Unexpected: Learning from Extreme Events, Weick, K. and Sutcliffe, K.M., 2010.

2 Global Action Plan for Patient Safety 2021-2030, S.VI, 2021.

3 Global Action Plan for Patient Safety 2021-2030, p. 23, 2021.

4 Risk and Safety Culture in Healthcare, Ruth Hecker, APS (ed.), 2022.

5 Systemic organizational consultant and owner of Interventions for Corporate Learning (ICL) in Berlin.

6 Dr. Gebauer, Annette, p. 55, in Risk and Safety Culture in Healthcare, R. Hecker, APS (ed.), 2022.

7 Dr. Gebauer, Annette, p. 55, in Risk and Safety Culture in Healthcare, R. Hecker, APS (ed.), 2022.

8 Establishing a Culture of High Reliability: Memorial Hermann's 11-Year Journey, online, 2019.

Literature

Weick, K. and Sutcliffe, K.M. (2010): Managing the Unexpected, How Organizations Learn from Extreme Situations. Schäffer-Poeschel Verlag Stuttgart, 2010.

Global Action Plan for Patient Safety 2021-2030, Towards the elimination of preventable harm in healthcare 2021, available online at: “https://www.bundesgesundheitsministerium.de/fileadmin/Dateien/3_Downloads/P/Patientensicherheit/WHO_Global_Patient_Safety_Action_Plan_2021-2030_DE.pdf”.

Risk and Safety Culture in Healthcare, Ruth Hecker, APS (HRSG), Medizinisch Wissenschaftliche Verlagsgesellschaft 2022.

Establishing a Culture of High Reliability: Memorial Hermann's 11-Year Journey, November 2019, online at: “https://www.beckershospitalreview.com/pdfs/November12/840AM_KEYNOTE_Stokes.pdf”.