High Reliability Organizations Research Articles

Influencing a Culture of Quality and Safety Through Huddles.

Literature shows that interdisciplinary huddles help promote clear communication and proactive reporting of potential errors. High reliability organization (HRO) and just culture models were implemented, yet fragmented team communication about patient safety remained. Huddles were implemented to identify and address patient safety issues. A pre/postintervention design was used. Near-miss and actual event safety metrics, patient satisfaction, and employee satisfaction/work group perceptions were measured at 3 time points over 1 year. Daily interdisciplinary huddles were implemented to improve communication, reduce errors, and improve patient and employee satisfaction. Near-miss reporting increased across time points. Patient satisfaction with how the staff worked together to provide care significantly increased over time. Employee satisfaction and perception of work group communication, collaboration, and psychological safety scores improved, however, were not statistically significant. Implementing huddles demonstrated improved outcomes in patient safety, patient satisfaction, and employee satisfaction/work group perceptions.

366 Using a Serious Incident and Methods from High Reliability Organisations to Make Communications Safer Between A&E and Surgery

Abstract Aim Healthcare is a high-risk environment and for patients’ safety, requires high reliability. Poor communication is one of the leading causes of healthcare error worldwide and was one of the reasons that led to an adverse event in A&E. High Reliability Organisations (HROs) have set in place effective standards of safety where the probability of serious errors is very low. What translatable features can make the job of a Junior Surgical Doctor receiving patients from A&E safer? Method The root cause analysis of the serious incidence was discussed in a Surgical Morbidly and Mortality meeting. Focus groups and observational studies were carried out over a period of 6 months. The results formed the basis of a Task Analysis. A literature review of the evidence of safe communication method was performed and its translatability to healthcare. Results A “work as done” against “work as imagined” task analysis of the handover process showed multiple areas of potential “work system” error with references to the SEIPS 101 model. Combining the literature review and task analysis, standardisation (using SBAR), a handover checklist, read-back, dual-modality communication and a handover zone may prove to increase redundancy and slack in the system – making it safer. Conclusions There are HRO evidenced methods in making communication safer in healthcare. The aviation industries “sterile cockpit” and “crew management resource” methods are proven and effective. Their use of the above techniques can be implemented in healthcare communication. A designated “Handover Zone” could address potential errors. A QI project is required hereafter.

More Than a Catching Name? Entrepreneurial Ecosystem, Risk Anticipation and SMEs’ Resilience

This study investigates whether the commitment to risk anticipation influences small and medium enterprises’ (SMEs) resilience. Moreover, the research adds the entrepreneurial ecosystem (EE) mobilization to the analysis. Specifically, we study how the EE mobilization of SMEs coping with adversities relates with both risk anticipation and resilience. In doing so, we are aimed at contributing to resilience and EE literature, which overlooked the study of the relationship between the EE and resilience at the firm level. The exploitation of the EE resources may be useful for SMEs that cope with crises, as they rarely anticipate risks implementing the best (and costly) practice. Testing the impact of the EE mobilization on firms’ resilience may help us in clarifying – at least partially – the cause-effect network of the EE. This leads us to engage in the debate whether the EE is just a catching name or a valuable and usable construct. Drawing on the resilient response model, we develop a framework that includes risk anticipation and EE mobilization. To test our hypotheses, we estimate OLS regression and probit models using a dataset of 761 questionnaires. These were collected from London, Milan and Frankfurt SMEs’ entrepreneurs that experienced a crisis in the year before the research. We find that the commitment to risk anticipation enhances the EE mobilization level, that, in turn, increases SMEs’ probability of showing a resilient response. Surprisingly, no direct effect is found between commitment to risk anticipation and resilience. Results are commented drawing on High Reliability Organization theory: in particular, we argue that the mobilization of the EE increases the effectiveness and the efficiency of the activation and detection phases that characterize the critical period following the disruption. We posit that a crucial role is played by the increased variety of perspectives obtained via the EE mobilization, that supports a deeper understanding of the threat and a richer generation of solutions. Beside the scholarly debate about the value of the EE – to which we contribute demonstrating an empirical application of the construct –, from the results we derive managerial and policy implications concerning SMEs’ entrepreneurs’ strategies and EE planners’ initiatives.

Fuhrman and Zimmerman’s Pediatric Critical Care, 6th Edition

Fuhrman and Zimmerman’s Pediatric Critical Care, 6th Edition

High-Reliability Organizing (HRO) is Contextual

HRO emerged from engagement with a flux of contingencies to make them more orderly. We cannot treat these environments as isolated systems with demarcated boundaries. Instead, the environment comprises of open, contextual systems always in flux. These sequential events are better viewed as ‘state vectors’ acting like arrows in time, rather than discrete, sequential events. Rational (‘top down’) and heuristic (‘bottom up’) cognitive approaches have limits when engaging these dynamic, open systems. We propose that context-focused engagement reduces the error of “engaged abstraction” and that quantum cognition contains elements used by HRO operators.

The impact of work demands and operational tempo on safety Culture, motivation and perceived performance in safety critical systems

High reliability organizations (HROs) achieve high levels of safety performance through safety cultures grounded in trust and through reinforced norms and expectations that strengthen and motivate safety-related behaviors. Safety motivation and culture can be eroded by operational constraints, inadequate training, and job demands, but also mitigated by job resources such as adequate rest and preparation. Recent work has suggested that HROs can further enhance their reliability by marrying advanced analytical methods and diverse data sources and experiences. To that end, this work presents an exploratory partial least squares (PLS) model based on the Job Demands-Resources model that is used to consider the links between composite work demand factors and safety culture, safety motivation, and perceived safety performance in one HRO, the U.S. Navy. The model, based on 30 survey items (n = 3,803), suggests that attention to job resources that can bolster high levels of safety performance is important and consistent with safety practices in HROs. Job demands such as stress were found to be important safety motivators, as was sufficient rest. The results show the additive nature of job demands and resources, suggesting that they can support or diminish safety motivation and intent, consistent with previous studies.

Novel medication safety training module.

Escape rooms are effective educational tools for engaging learners and may serve as a strategy for medication safety training to increase perceived learned safety measures and knowledge retention. Escape rooms are lifelike environments in which participants work together to solve a succession of puzzles to escape a locked room in the allotted time. Novel medication safety training modules such as a pharmacy escape room allow medical errors to be simulated in a team-based, controlled environment focusing on system improvement to establish a culture of safety. This project was conducted to improve medication safety knowledge using a novel pharmacy escape room training module piloted within a large, integrated pharmacy department. Several pilot groups of 2 or more pharmacy employees took part in a virtual medication safety escape room as part of a training module at Advocate Aurora Health between January and March 2021. Participants included pharmacists and pharmacy technicians employed at Aurora St. Luke's Medical Center, Aurora Sinai Medical Center, and Pharmacy Integrated Clinical Services. Assessments were administered before and after completion of the escape room module to evaluate medication safety knowledge and perceived learned safety measures by comparing scores. A total of 101 employees participated in the pharmacy escape room, with an average escape time of 42 minutes. Overall assessment scores before completion of the escape room module ranged from 20% to 86.6%, while those afterwards ranged from 33.3% to 93.3%. Participant feedback was positive, with reports that the novel escape room training module was more engaging and interactive than the alternative online self-paced learning modules. Virtual escape rooms can be used as a novel medication safety training module to increase medication safety knowledge and allow medical errors to be simulated in a controlled environment. Incorporating high-reliability tools and tactics into development of the escape room can promote safe medication practices and reinforce principles of high-reliability organizations.

High-reliability organisation principles implemented in dentistry.

Introduction/objectives Successful dentistry inherently requires high-reliability and situational awareness to provide consistent high-quality care. However, treatment errors still occur in dentistry as they do in medicine. The importance of avoiding error is elevated for dentistry due to the increased frequency of irreversible procedures in each patient interaction compared to non-surgical specialties in medicine. Although a universal protocol for time-out exists, wrong-site procedures are a persistent healthcare issue in dentistry.Data By implementing high-reliability organisations (HROs) principles to dentistry, improved safety and quality can be achieved.Sources There are five essential principles that HROs have been observed to adhere to: preoccupation with failure; situational awareness/sensitivity to operations; a reluctance to simplify; deference to expertise; and commitment to resilience. Deep examination of the potential vulnerabilities in dentistry, using HRO ideology will create effective process improvement strategies. It fosters a culture of accountability using systematic problem-solving as opposed to condemnation.Study selection Implementation of HRO principles will improve the existing universal time-out process, while placing quality and performance at the central focus of strategic success.Conclusions Dentists can adopt these HRO principles into their practices to create effective process improvement strategies.

Implementation of High-Reliability Organizing (HRO): The Inherent Vice Characteristics of Stress, Fear, and Threat

High-Reliability Organizations engage threats and adversity to maintain reliable operations. Human stress, fear, and threat responses drive safe and effective engagement of environmental threats. The executive functions integrate perception from opposite ends of the brain, hastily created plans, and motor activity. During a crisis, the hypothalamic-pituitary-adrenal (HPA) axis enables survival behaviors by releasing cortisol to "disarm" the executive functions. Novelty, uncertainty, and uncontrollability, in the domain of the executive functions, cause stress responses. Fear reactions at the subcortical level maintain a safe distance from the threat. Threat reflexes rapidly initiate protective behaviors. However, these same responses, when unmodulated, can harm the individual. The prevalence of unmodulated stress, fear, and threat makes them appear unpreventable, if not normal. This is the inherent vice of stress, fear, and threat. By describing their function and location in the brain, we can identify these behaviors to begin modulation for effective responses to threats.

Striving for high reliability in healthcare: a qualitative study of the implementation of a hospital safety programme

BackgroundHealthcare leaders look to high-reliability organisations (HROs) for strategies to improve safety, despite questions about how to translate these strategies into practice. Weick and Sutcliffe describe five principles exhibited by...

The divides that health organisations experience on their journey towards high reliability: Moving from theory to practice

Organisations, specifically in the healthcare industry, often find themselves in a state of ‘Reliability Divide’. This is a concept that the authors have developed to explain why most organisations never realise the culture change needed to become highly reliable. In an organisation there is a variable time frame to get to daily work. Because of the time involved, some of the front-line staff who participated in theory, academics and now operations have become mid- or lower senior level leaders. Along the journey they become the vector that infiltrates the organisation to reach Fabric. Multidirectional high reliability organisation (HRO) adoption starts to occur here, which further drives an organisation towards zero harm (nirvana).

Patient, Procedure, People (PPP): recognising and responding to intraoperative critical events.

Intraoperative critical events are rarely experienced by individual surgeons but are commonly experienced at a workforce level. Finding unfamiliar or unexpected pathology, anatomy, haemorrhage or an iatrogenic organ or structure injury cannot be completely eliminated in the complex surgical environment. It is vital that an appropriate, safe response to these infrequent events takes place to prevent possible further harm to patients. This paper introduces 'Patient, Procedure, People', a tool adapted from aviation threat and error management (TEM) training. It allows surgical teams to improve situational awareness (SA), communicate effectively, flatten team hierarchy gradients and improve decision-making before responding to critical events. We review factors contributing to poor decision-making, with resulting errors. These include loss of SA (tunnel vision), acute stress reactions (fight-flight or freeze-hide) and limbic hijacking (surprise and startle events). Events may cause workload to increase beyond cognitive capacity, further exacerbating the situation. After completing initial actions to achieve a temporary 'place of safety', surgical teams may use the tool to effectively manage threat or mitigate error. Aviation is a high-reliability organisation that has pioneered human factors research and training. Airline pilots undergo regular simulated emergencies assessment, including mandatory human factors assessment. Although the complexities of the operating theatre do not currently lend themselves to high-fidelity simulation as in aviation, valuable transferrable lessons can be learnt from aviation's approach to TEM.

Leader Trait Self-control and Follower Trust in High-Reliability Contexts: The Mediating Role of Met Expectations in Firefighting

Drawing from the theory of met expectations, this study aims to create new knowledge on the antecedents of follower trust in leaders in the context of high-reliability organizations. We hypothesize that highly self-controlled leaders instill more trust than leaders with less self-control, as the former tend to meet follower expectations. This work combines data from a field survey ( N = 256) and a multi-wave field study ( N = 106), using samples of professional firefighters to support our hypotheses that met follower expectations mediate the relationship between leader trait self-control and follower trust in the leader. Our research highlights the importance of met expectations in high-reliability contexts and demonstrates the value of leader trait self-control in building trustful relationships.

The Perceived Role of Healthcare Providers and Systems in the Development of Secondary Health Conditions among Adults with Spinal Cord Injury

Individuals with spinal cord injury (SCI), with high healthcare utilization rates and costs, require special attention and tailored care protocols to meet their healthcare needs. This qualitative study collected narrative information from adults with SCI and their family members and/or caregivers to examine the perceived role of healthcare providers and systems in the development and treatment of secondary health conditions (SHCs). After personal information was collected, individuals participated in focus groups which were recorded and transcribed; transcripts were then reviewed, cleaned, and uploaded to NVivo10 software to facilitate the analysis. An initial stage of coding was conducted which identified potential categories and themes; afterwards, the perceived role of healthcare providers in the development and management of secondary health conditions (SHC) was prioritized and transcripts were re-coded. Two overlapping themes emerged: (1) Iatrogenic and nosocomial factors; and (2) Relationships with healthcare providers. Iatrogenic and nosocomial factors had three subthemes: (1) Misdiagnosis; (2) Perceived mistreatment or mistakes made during treatment; and (3) Unintended consequences of medical treatment; while three subthemes were identified for Relationships with healthcare providers: (1) Respect; (2) Knowledge and experience; and (3) Patient Expertise. To improve safety, reduce healthcare costs, and facilitate more favorable perceived outcomes for individuals with SCI, healthcare providers, organizations and systems need to implement principles of high reliability organizations to improve outcomes through the treatment and prevention of SHC.

Implementation of High Reliability Organizing (HRO): The Inherent Vice of Stress, Fear, and Threat

Implementation of High Reliability Organizing (HRO): The Inherent Vice of Stress, Fear, and Threat

Implementing Just Culture to Improve Patient Safety.

The number of deaths in the United States related to medical errors remains unacceptably high. Further complicating this situation is the problem of underreporting due to the fear of the consequences. In fact, the most commonly reported cause of underreporting worldwide is the fear of the negative consequences associated with reporting. As health care organizations along the journey to high-reliability strive to improve patient safety, a concerted effort needs to be focused on changing how medical errors are addressed. A paradigm shift is needed from immediately assigning blame and punishing individuals to one that is trusting and just. Staff must trust that when errors occur, organizations will respond in a manner that is fair and appropriate. An extensive review of the literature from 2017 until January 2022 was conducted for the most current evidence describing the principles and practices of "just culture" in health care organizations. Additionally, recommendations were sought on how health care organizations can go about implementing "just culture" principles. Twenty sources of evidence on "just culture' were retrieved and reviewed. The evidence was used to describe the concept and principles of "just culture" in health care organizations. Furthermore, five strategies for implementing "just culture" principles were identified. Improving patient safety requires that high-reliability organizations strive to ensure that the culture of the organization is trusting and just. In a trusting and just culture, adverse events are recognized as valuable opportunities to understand contributing factors and learn rather than immediately assign blame. Moving away from a blame culture is a paradigm shift for many health care organizations yet critically important for improving patient safety.

Leadership Through Organizational High Reliability During the COVID-19 Pandemic — Navy Medicine’s Experience

The U.S. Navy medical establishment, also known as Navy Medicine, began working toward operating as a high-reliability organization in 2014. The results have paid dividends in the current COVID-19 pandemic. This article provides a case study of the use of high-reliability organization (HRO) principles to support continued health of U.S. Navy and U.S. Marine Corps operational forces in a pandemic. The authors provide examples of how adherence to the five traits of an HRO allowed Navy Medicine to be agile and responsive and ultimately to prevent significant disruption to Naval operations worldwide during the pandemic.

Abstract 59: Increasing Participation In Improvement Work Through Heart Center Performance Rounds

Excellence in congenital cardiac care requires team resilience, complex decision-making, analysis of errors to adjust practice, and continuous targeted improvement. Medicine has learned from other high reliability organizations, but effective team communication and awareness of improvement opportunities remain challenging. We describe how our Heart Center Performance Rounds (HCPR) meeting addresses these gaps, and provides attention to quality improvement (QI) work, which in turn leads to increased participation and improved clinical outcomes. Our HCPR is a weekly review of one week’s worth of surgical and catheterization cases. Each patient’s course is reviewed against both internal and external benchmarks, such as length of stay (LOS) and markers of clinical progression. Eligibility for multidisciplinary improvement projects is reviewed for each patient. A committee tracks trends in discussion, assessing areas for improvement work and team learning. This committee then organizes methods for follow up and arranges presentation back to the Heart Center (HC) audience. Over the course of 12 months, we tracked LOS data and participation for two multidisciplinary QI projects to assess project participation and outcomes. Projects featured in HCPR included reduction of chest tube duration and awareness of median clinical targets. Patients undergoing specific operations were eligible, but could be excluded at the request of the clinical team. We noted a decrease in exclusion over 12 months, as teams became more aware of eligibility criteria and early results. As participation in these projects improved, both variability and overall length of stay decreased for 2 of 4 studied operations. Updates on outcomes were periodically presented to HC audience. Survey responses and interviews demonstrated increased awareness of projects and their potential for improved care metrics. Our HCPR has promoted knowledge of benchmarks and increased participation in quality improvement projects, leading to improved clinical outcomes. Transparency in data and communication of ongoing work is essential for success. Challenges include dedicated time and resources for spreading and sustaining improvement.

High-Reliability Organizing (HRO) for the Color of Noise: Forcing Functions, Collaboration, and Safety

High-Reliability Organizing (HRO) for the Color of Noise: Forcing Functions, Collaboration, and Safety

A simulation study on the association of HRO communication patterns and surgical team performance.

The hallmarks of high-reliability organizations (HROs) have been broadly embraced by health-care organizations as a path to achieve greater reliability in patient care. A simulation study was conducted to investigate the hypothesis that surgical teams whose intraoperative communication displayed the HRO hallmarks had a greater capacity to detect and resolve surgical complications in less time. The study consisted of presenting four simulations to five surgical teams using a within-subject experimental design. In each simulation, the patient would manifest a complication in which the detection and/or resolution was either obscure or obvious. Communication patterns related to the frequency and sustained duration of HRO content were extracted from coded transcripts using recurrence quantification analysis (RQA), which were paired with the teams' elapsed time to detect or resolve a surgical complication. Spearman's rank-order statistics was then used to test for a monotonically decreasing association between these variables. Data consisting of the RQA metrics and elapsed times are reported for each surgical team in each simulation in addition to statistical tests for association between these variables and inter-rater reliability statistics of the coded communication. The study suggests that surgical teams whose communication espouses the HRO hallmarks of commitment to resilience and deference to expertise in both frequency and duration are able to resolve surgical complications with an obscure corrective action in less time. The study did not provide confirming evidence that these are associated with their ability to resolve a complication with an obvious corrective action in less time or that patterns of sensitivity to operations are associated with their ability to detect an obscure surgical complication in less time.