Engaged care providers, a commitment to ongoing improvement and an uncompromising dedication to patient safety are a few of the qualities of an ideal health care organization. Although the health care industry is complex and full of potential hazards, a culture of high-reliability – operating for extended periods without serious accidents or catastrophic failures – is a goal for many health care systems. With support from leadership, health care providers on the front lines are taking steps toward zero-harm.
Craig Deao is a managing director, national speaker and author at Studer Group, a health care coaching and execution company. In this Q&A, he discusses the principles of high reliability and why they are critical to enhancing the health care experience for patients and providers.
The importance of high reliability in health care
What are the characteristics of a high reliability organization, and why do you believe that high reliability is an important concept for health care organizations to focus on?
Craig Deao: A general definition of a high reliability organization is one that operates in a complex environment where you would expect failure to happen a lot – and if it does, it would be catastrophic – but it doesn’t. Some classic examples are nuclear power plants, long-haul trucking operations, chemical manufacturing, aircraft carriers and commercial aviation. Even though one might expect that a metal tube suspended in the air defying gravity would crash all the time, but it almost never happens. The root reason why it doesn’t crash is that safety is the highest priority in these challenging environments. No matter the industry, high reliability organizations exhibit these five traits: preoccupation with failure, reluctance to simplify, sensitivity to operations, deference to expertise and commitment to resilience.
High reliability is important to look at in health care because the industry is facing quality challenges. Health care organizations do not deliver safe, reliable evidence-based care as often as they should. For more than 20 years, tactical approaches have been used to fix specific quality problems, yielding glacially slow improvement. These tactical approaches have resulted in strong evidence-based practices to prevent harm from occurring across a range of challenges. Yet, when we look at the root causes that keep organizations from adopting these well-known solutions, we almost always find gaps in the underlying culture of the organization. Simply put, if the organization exhibited the traits of high reliability, the tactical solutions would work.
What are the benefits of high reliability for both consumers of care and clinicians?
On the patient side, the top benefit is that they aren’t going to get harmed. A more distant impact is that patients who have trust in their health care system can fully engage as a member of their own care team. We know that 40 percent of deaths in the U.S. and 70 percent of costs are attributed to a handful of chronic diseases that are largely modifiable based on practices such as exercising, eating the right foods and not smoking. While supporting our patients to own their own health has always been the right thing to do, providers will increasingly also bear financial risk for patient outcomes, providing a business model that supports these essential activities.
We also know that two-thirds of physicians suffer from clinical burnout. If they don’t feel like they are operating in an environment that allows them to provide safe and effective care, they can’t fully engage in the profession. Nobody wants to go to work every day thinking they might be part of an untoward event. Leadership must provide the systems of support around people that allow them to be at their best.
The road to high reliability in health care
What are some of the barriers that health care organizations face when trying to achieve high reliability?
The biggest barrier that I see is that many health care organizations still don’t believe that zero-harm is an achievable goal. An organization’s executives must commit to treating harm incidents with the same seriousness that the aviation industry treats a plane crash. Failures and catastrophic events must be learned from so that they never happen again. When harm occurs, everything should stop, and a deep dive should be done to discover the root cause.
Too often, health care organizations accept harm and say, “Oh well, things happen, medicine is messy,” but that is not true in many circumstances. Of course, there are always going to be some bad outcomes. Death is a reality in health care, but too often there is unwarranted deviation from best practices. Leadership should create an expectation that zero-harm is the target.
Health care may never get to zero across the board, but improvement starts with the mindset that zero is not only possible, but it is achievable. There are many organizations that have gone months, if not years, without serious harm events.
How can health care organizations shift their thinking to achieve high reliability?
Leaders must recognize that their organizations have the potential for excellence. There isn’t anything that is holding you back. If you believe everything is possible, then there are a lot of possibilities. If you believe there is a ceiling on what you can achieve, you will limit yourself.
Evaluating care quality
What are the differences between patient-reported quality and technical quality? Why is there a gap?
When you try to define the quality of any product or service, it is easy to look at the technical dimensions. For example, if you are manufacturing a car, you might rate it on fuel efficiency, speed and reliability. It is the same in medicine. Health care providers often measure quality based on if a patient lives or dies or their quality of life. Those are blunt measures. It is more meaningful to look at process measures that are tightly linked to those outcomes. The problem is that patients assume that the technical quality exists. It is invisible to them. For patients, quality is linked to whether their providers listen to them and treat them with dignity and respect.
Although there is a gap between how patients and clinicians define quality, the methods for aligning those measures have become more sophisticated. The Consumer Assessment of Healthcare Providers and Systems survey does not directly ask patients how satisfied they are with their care. Instead, it asks how frequently they experience evidence-based practices that correlate with quality.
Setting a standard for high reliability
How does clinician engagement relate to high reliability? How can organizations make people more engaged?
You can create an environment around someone that supports their ability to engage. Health care leadership needs to understand their obligation to set the tone and empower people to bring their best. People who have been in health care for 20 years are likely burnt out. Organizations must put the joy back into the work of their professionals by providing good communication, clear expectations and an environment where leaders “walk the talk.” It is important to not just tell people what to do but also show them what to do. Set a standard and model it for the behavior to become normalized. If it is going to sustain, it must be demonstrated from the top down.
One thread that is consistent across just about every quality improvement philosophy I’ve seen is the importance of having those at the frontline drive the improvement. Too often I see leaders tell people what to do. In contrast, building the capacity for people to solve the challenges themselves has two immediate benefits over a command-and-control approach. First, because no one fights their own ideas, the odds of a successful and enduring implementation increase. Second, ideas are more likely to be effective when they are designed by those with the greatest understanding of the issue.
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