Creating Highly Reliable Health Care Organizations: Evidence from the Field

Timothy J. Vogus

Vanderbilt Owen Graduate School of Management

November 2, 2011

High Reliability...

Conveys the idea that high risk and high effectiveness can coexist.

Refers to the fact that some organizations must perform effectively under very trying conditions.

Reflects the intensive effort that some high-risk organizations sustain over time to achieve their goals, promote safe operations, and prevent the occurrence of adverse outcomes.

Where Do We Observe High Reliability?

High Reliability Organizations (HROs) Organizations that have nearly error-free

operations in extremely trying environmentsAircraft carrier flight decks (Weick & Roberts, 1993)Nuclear power plants (Schulman, 1993)Air traffic control (Rochlin, 1997)

Medicine aspires to be high reliability (HSR, 2006; IOM, 2000)The model for JCAHO (Chassin & Loeb, 2011)

Basic HRO Characteristics

Operate in unforgiving social and political environments

Have limited opportunities to learn through experimentation

Have potential for adverse consequences Have potential for surprise and unexpected

events

Why Use HROs as a Template?

HROs have mastered ways to perform nearly error-free in uncertain, unknowable environments Aircraft carrier flight decks, nuclear power

plants, and air traffic control HRO operational insights can inform the practices

of all organizations Pressures for “reliability and quality” are building

for all organizations (e.g., operational, reputational, legal)

How Do HROs Do It?

They don’t just value reliability per se, they disvalue mis-specifying, mis-estimating, and misunderstanding things

They organize so that people are more likely to become aware of discriminatory detail and they work to develop people’s capacities so that they can act on what they see

What Behaviors Underlie High Reliability?

Mindful organizing (Weick, et al., 1999) Preoccupation with failure Reluctance to simplify interpretations Commitment to resilience Sensitivity to operations Deference to expertise

Mindful organizing allows for the rapid detection and correction of emerging errors

8

Being Mindful Means to Pay Attention in a Different Way

You STOP concentrating on those things that confirm your hunches, are pleasant, feel certain, seem factual, are explicit, and that others agree on!

You START concentrating on things that disconfirm, are unpleasant, feel uncertain, seem possible, are implicit, and are contested!

Concept Definition Survey Item(s)

Preoccupation with failure Operating with a chronic wariness of the possibility of unexpected events that may jeopardize safety by engaging in proactive and preemptive analysis and discussion.

When giving report to an oncoming nurse, we usually discuss what to look out for.

We spend time identifying activities we do not want to go wrong.

Reluctance to simplify interpretations Taking deliberate steps to question assumptions and received wisdom to create a more complete and nuanced picture of ongoing operations.

We discuss alternatives as to how to go about our normal work activities.

Sensitivity to operations Ongoing interaction and information sharing about the human and organizational factors that determine the safety of a system as a whole.

We have a good “map” of each other’s talents and skills.

We discuss our unique skills with each other so we know who on the unit has relevant specialized skills and knowledge.

Commitment to resilience Developing capabilities to detect, contain, and bounce back from errors that have already occurred, but before they worsen and cause more serious harm.

We talk about mistakes and ways to learn from them.

When errors happen, we discuss how we could have prevented them.

Deference to expertise During high-tempo times (i.e., when attempting to resolve a problem or crisis), decision-making authority migrates to the person or people with the most expertise with the problem at hand, regardless of their rank.

When attempting to resolve a problem, we take advantage of the unique skills of our colleagues.

When a patient crisis occurs, we rapidly pool our collective expertise to attempt to resolve it.

Mindful Organizing Occurs When

People (e.g., nurses) are Spending time identifying what could go wrong Discussing alternatives as to how to go about

everyday activities Developing an understanding of who knows what Talking about mistakes and ways to learn from

them Taking advantage of the unique skills of one’s

colleagues (even if the person is of lower status in the organization)

Research Questions

Does mindful organizing lead to patient safety? How do nurses behaviorally enact mindful

organizing? Do other safety-oriented practices enhance the

benefits of mindful organizing? What facilitates the emergence of mindful

organizing? Is mindful organizing responsive to interventions?

Data

Sample 13 hospitals from a large Catholic health system 125 nursing units, 93 with outcomes data (10 hospitals) 1,685 RNs (51% response rate)

Method – survey and archival data Archival dependent variables – medication errors, patient

falls Nurse manager survey – managerial practices, unit

characteristics RN survey – mindful organizing, respectful interaction

Does Mindful Organizing Improve Safety?

A one unit increase in mindful organizing leads to 35% fewer medication errors on a nursing unit 7 fewer errors per year per unit

A one unit increase in mindful organizing leads to 69% fewer patient falls on a nursing unit 13 fewer falls per year per unit

Mindful organizing also positively related to manager ratings of safety and quality

Do Other Safety-Oriented Practices Augment These Effects?

Mindful organizing doesn’t exist in a vacuum Enhanced by complementary practices

Care pathways Standardization of care according to best practice

- structure interactions, build connections (Feldman and Rafaeli, 2002), and facilitate coordination (Gittell, 2002)

Joint Effects – Mindful Organizing and Care Pathways

0

2

4

6

8

10

12

Low Mean High

Re

po

rte

d M

edi

cati

on

Err

ors

Level of Mindful Organizing

Minimal use of Pathways

Extensive use of Pathways

Which Work Practices Enable Mindful Organizing?

HR practices Selective staffing

Hiring for interpersonal as well as technical skills Extensive training

Preceptor programs, training in interpersonal skills, ongoing informal training

Developmental performance appraisalOngoing, 360-degree, and focused on learning

Employee involvementDiscretion over work practice

Reward suggestions Job Security

How Do HR Practices Help?

Through signaling Signaling the behaviors expected, supported, and

rewarded Signaling about what?

How work is to be carried outDevelopmental performance appraisal and coaching

signal the importance of learning and feedback seekingHiring for interpersonal skills signals they are valued and

an important part of everyday work They foster a psychological contract

Employees are valued and treated fairly, so they reciprocate and generalize

What Enables Mindful Organizing and Patient Safety?

HR Practices

Respectful Interaction

Mindful Organizing

+

+

+

Patient Safety  

+

HR enhances the quality of interrelating

Dyadic interactions – trust, honesty, and self-respect

Capabilities for detecting and correcting the unexpected

+

Employee Commitment

OCB+

+

Findings – Medication Errors

HR Practices

MindfulOrganizing

Respectful Interaction

Med. Errors

OCB

+*

+***

+**

-*

+**Commit

+*

-*

Findings – Patient Falls

HR Practices

MindfulOrganizing

Respectful Interaction

Pat. Falls

OCB

+*

+***

+**

-**

-**

+*

Commit+**

Which Employee Characteristics Enable Mindful Organizing?

Mindful organizing is a function of the skilled efforts of “reliability professionals” (Roe & Schulman, 2008)

Interconnected knowledge base (Roe & Schulman, 2008) Communication Motivation and commitment

How Employee Characteristics Enable Mindful Organizing

Workgroup professional tenure Increases the pool of expertise and experience Up to a point, diminishing returns

Professional tenure variability Increase amount of communication needed Decreases workgroup willingness and ability to

engage in communication Workgroup professional commitment

Increases altruism and extra-role behaviors

Mindful Organizing and Professional Tenure

MINDFULORGANIZING

PROFESSIONAL TENURE (YEARS)

Mindful Organizing, Tenure, and Tenure Variability

Mindful Organizing, Tenure, and Commitment

Implications

Professional tenure important for hiring Effectively manage entry and exits

Think about how affects the workgroup composition

Increase professional commitment Campaigns to foster pride in the profession Redesign work to foster connection to

professional ideals

What About VHVI/VUMC?

Generating High Reliability

Little is known about how to move from reliable to highly reliable

Longitudinal intervention with VHVI Heart and Vascular – inpatient units, labs (e.g.,

Cath Lab), and clinics (~900 employees)

Focus groups, survey data (2 waves) Interventions and consulting Resurvey

Baseline Data

Qualitative “Failing to close the loop”

Quantitative Underdeveloped processes of mindful organizing

Reluctance to simplify interpretations, commitment to resilience

Weak psychological safetyUnsafe to take an interpersonal risk

Poor leader-member exchange

Interventions

Change the conversation Leader rounding

Managers on their unitsTop management on all units

HuddlesPost-event cross-profession debriefs; what, why, and

lessons to learn

Create mechanisms for change Safety action teams

Emerging Evidence

Increased leader engagement Regular rounding Immediate follow up actions

Institutionalization of huddles Increased reporting of errors and threats to safety

“The list” Safety action teams a mechanism for frontline

change and dissemination of safety and reliability information

Conclusions

Mindful organizing improves performance Reduces medication errors Reduces patient falls

The benefits of mindful organizing are enhanced when coupled with complementary practices Use of care pathways

HR practices provide powerful signals that shape mindful organizing and patient safety

Professional tenure, homogeneity of tenure, and professional commitment also enable mindful organizing

A well-designed organization is not a stable solution to achieve, but a developmental process to

keep active.

(Starbuck & Nystrom, 1981, p. 14)

That means:You NEVER get

High Reliability Organizing behind you!

35

Leadership Matters

“Only in the upper levels of the system can we begin to get to grips with the ‘parent’ failures...that create the downstream ‘problem children’. If these [conditions] remain unchanged then efforts to improve things at the workplace and worker level will be largely in vain.”

(James Reason, 1997, p. 121)

High Reliability and Mindful Organizing Resources

Roberts, K. H. and R. G. Bea (2001). "When Systems Fail." Organizational Dynamics 29(3): 179-191.

Rosenthal, M. M., and K. M. Sutcliffe (2002). Medical Error: What Do We Know? What Do We Do? San Francisco, CA, Jossey-Bass.

Sutcliffe, K. M., E. Lewton, et al. (2004). "Communication Failures: An Insidious Contributor to Medical Mishaps." Academic Medicine 79(2): 186-194.

Vogus, T. J. and K. M. Sutcliffe (2007). "The Safety Organizing Scale: Development and Validation of a Behavioral Measure of Safety Culture in Hospital Nursing Units." Medical Care 45(1): 46-54.

Weick, K. E. (1987). "Organizational Culture as a Source of High-Reliability." California Management Review 29: 112-127.

Weick, K. E. and K. M. Sutcliffe (2001). Managing the Unexpected: Assuring High Performance in an Age of Complexity. San Francisco, Jossey-Bass.

Weick, K. E. and K. M. Sutcliffe (2003). "Hospitals as Cultures of Entrapment: A Reanalysis of the Bristol Royal Infirmary." California Management Review 45(2): 73-84.

Weick, K. E. and K. M. Sutcliffe (2007). Managing the Unexpected: Resilient Performance in and Age of Uncertainty, Second Edition. San Francisco, CA, Jossey-Bass.

Why High Reliability?

Safety (IOM 2000, 2001, 2004) Medical Error

Up to 98,000 deaths annually (Kohn, et al., 2000)

Problem has not improved (Landrigan, et al., 2010)

And may be even larger (Classen et al., 2011)

A Cultural Solution

Safety culture A safety culture is the product of the shared

values, attitudes, and patterns of behavior that determine the observable degree of effort with which all organizational members direct their attention and actions towards minimizing patient harm that may result from the process of care delivery

EnactingFrontline actions that• Surface latent and

manifest threats to safety

• Mobilize resources to reduce threats

MINDFUL ORGANIZING

Safety Culture

EnablingLeader actions that • Direct attention to

safety• Create contexts safe to

speak up and act in ways that improve safety

Safety Outcomes

ElaboratingLearning practices that • Develop comprehensive

representations of safety outcomes

• Provide feedback that modifies enabling and enacting