Health care organizations have increasingly adopted the principles of high-reliability organizations to improve their safety and quality. These principles must be built into the culture of the organization as well as into the systems and frameworks used to improve processes and evaluate outcomes in a learning health care system.
On the basis of its experience responding to disasters — including emerging diseases, tropical storms, and the Covid-19 pandemic — Houston Methodist has established a culture of continual improvement and a learning health care system that supports this goal.
Houston Methodist’s leadership reviews the principles of high-reliability health care organizations, describes the tools and systems that Houston Methodist has used to adopt these principles, and explains how these efforts aided in operations during the pandemic.
Foundational Elements
The journey begins with a commitment to become a health care learning system and by embracing the five principles of HRO theory. Those principles must be applied to the health care envionment
1.
Deference to expertise. Within an HRO, all subject matter experts should have a voice. In the health care setting, the nurses, medical trainees, physicians, and other staff on the front lines often have the most insight into an organization’s operations. Leaders should therefore consider that input essential for situational assessment, engagement, and action. HROs must also acknowledge and incorporate the expertise of another group of individuals integral to the organization: patients. Patients are the most qualified to tell us about their needs in the care process.
2.
Sensitivity to operations. Highly complex organizations have many interconnected systems that must function cohesively for day-to-day operations, and this is even more crucial in times of crisis. Being sensitive to operations means having both a detailed understanding of the state of current processes in play as well as a big-picture understanding of operational complexity and how those processes intersect. In health care, those on the front lines are often most sensitive to flaws in the system and are critical to making improvements in workflows and processes.
3.
Preoccupation with preventing failure. HROs dedicate significant time and resources to proactively preventing failures. Scenarios are carefully planned to anticipate defects in both current processes and in planned improvements that could lead to failure or misunderstandings. Through auditing, collecting, and analyzing data, as well as by building dashboards, organizations can identify processes requiring improvement. Small failures and near-misses are treated as serious symptoms of larger problems in the system that must be identified and resolved in a timely manner.
4.
Reluctance to simplify. It is tempting to simplify processes in a system as complex as a multihospital health care system by developing workarounds and universal solutions to failures. However, HROs accept that complex systems have numerous areas for potential failure and seek to understand new and unexpected failures. They look as far upstream as possible for the root cause to best prevent failures in the future.
5.
Promotion of resilience. When major challenges arise, HROs are prepared to respond as effectively as possible to detect and contain errors. This depends on having the structure, resources, and culture in place to anticipate trouble spots, improvise during unexpected situations, and correct errors in real time.
Source:
Development and Expression of a High-Reliability Organization
Published November 17, 2021
NEJM Catal Innov Care Deliv 2021;2(12)
DOI: 10.1056/CAT.21.0314
