High Reliability Organizations High Reliability Organizations ––The Key to Improving Quality and SafetyThe Key to Improving Quality and Safety

William B Munier, MD, MBAWilliam B Munier, MD, MBA

Acting DirectorActing Director

Center for Quality Improvement and Patient SafetyCenter for Quality Improvement and Patient Safety

Agency for Healthcare Research and QualityAgency for Healthcare Research and Quality

National Healthcare Leadership ConferenceNational Healthcare Leadership Conference

Toronto Toronto –– 11 June 200711 June 2007

AgendaAgenda

�� OverviewOverview

�� Healthcare HROsHealthcare HROs

�� AHRQ initiativesAHRQ initiatives

�� What you can do right nowWhat you can do right now

OverviewOverview

�� The concept of the high reliability The concept of the high reliability

organization (HRO) was developed by organization (HRO) was developed by

industries other than healthcareindustries other than healthcare

–– Highly complex organizations withHighly complex organizations with

–– Potential for catastrophic consequencesPotential for catastrophic consequences

�� HROs have fewer than normal accidentsHROs have fewer than normal accidents

HRO DevelopmentHRO Development

�� Industry examples include those that are Industry examples include those that are

highly dependent on technologyhighly dependent on technology

–– Nuclear plantsNuclear plants

–– Space shuttleSpace shuttle

–– Aircraft carriersAircraft carriers

–– Air traffic controlAir traffic control

�� Disasters are very rareDisasters are very rare

HRO HRO ““MindfulnessMindfulness””

�� Preoccupation with failurePreoccupation with failure

�� Reluctance to simplify interpretationsReluctance to simplify interpretations

�� Sensitivity to operationsSensitivity to operations

�� Commitment to resilienceCommitment to resilience

�� UnderUnder--specification of structures specification of structures

(willingness to organize around experts)(willingness to organize around experts)

HRO CharacteristicsHRO Characteristics

�� Organize socially around failureOrganize socially around failure

�� Establish a culture ofEstablish a culture of

–– Mindfulness (alert, aware, resilient)Mindfulness (alert, aware, resilient)

–– ReportingReporting

–– MeasurementMeasurement

–– InIn--depth analysis of all errors/near missesdepth analysis of all errors/near misses

–– Adaptive learningAdaptive learning

�� Establish system redundancyEstablish system redundancy

Healthcare ChallengeHealthcare Challenge

�� Hospitals & hospital systems continue to Hospitals & hospital systems continue to

have safety & quality problems that have safety & quality problems that

harm patients & make care more costly harm patients & make care more costly

& unreliable& unreliable

�� Healthcare, while complex, is Healthcare, while complex, is

significantly different from industries in significantly different from industries in

which the HRO concept was developedwhich the HRO concept was developed

�� Can principles & concepts of HROs be Can principles & concepts of HROs be

applied in healthcare?applied in healthcare?

Common PrinciplesCommon Principles

�� Decreases in accidents occur through a Decreases in accidents occur through a

change in organizational culturechange in organizational culture

�� Technology usually does not improve Technology usually does not improve

safety unless there is a concomitant safety unless there is a concomitant

change in culture (it can make it worse)change in culture (it can make it worse)

�� Critical values includeCritical values include

–– MindfulnessMindfulness

–– Reporting & measurementReporting & measurement

–– Root cause & other analysesRoot cause & other analyses

–– Adaptive learningAdaptive learning

Some DifferencesSome Differences

�� Errors combined with near misses in Errors combined with near misses in

healthcare are relatively commonhealthcare are relatively common

�� Focus on failure is not enough (quality is Focus on failure is not enough (quality is

important as well as safety)important as well as safety)

–– Quality & reliability can be in conflict in Quality & reliability can be in conflict in

HROs in other industriesHROs in other industries

�� Massively redundant systems, often Massively redundant systems, often

found in HROs in other industries, are found in HROs in other industries, are

not economically feasible in healthcarenot economically feasible in healthcare

Healthcare ChallengeHealthcare Challenge

�� As with other tools developed in nonAs with other tools developed in non--

healthcare industries, the HRO concept healthcare industries, the HRO concept

can be applied successfully in can be applied successfully in

healthcare thorough selection & healthcare thorough selection &

modificationmodification

�� HRO concepts/principles do not offer a HRO concepts/principles do not offer a

complete quality/safety solution but can complete quality/safety solution but can

make an important contribution to safer make an important contribution to safer

carecare

AHRQ InitiativesAHRQ Initiatives

�� HRO learning networkHRO learning network

�� Hospital Survey on Patient Safety Hospital Survey on Patient Safety

Culture (HSOPS)Culture (HSOPS)

�� TeamSTEPPSTeamSTEPPS

�� Patient Safety and Quality Improvement Patient Safety and Quality Improvement

Act of 2005Act of 2005

HRO Learning NetworkHRO Learning Network

�� PurposePurpose: to support: to support patient safety leaders & to patient safety leaders & to

provide a forum forprovide a forum for

–– Sharing experiencesSharing experiences

–– Learning about & identifying ways to implement Learning about & identifying ways to implement

research findings & promising practices that can research findings & promising practices that can

lead to high reliabilitylead to high reliability

�� CompositionComposition: patient safety leaders & some C: patient safety leaders & some C--

suite leaders from 19 health care systemssuite leaders from 19 health care systems

–– 31 States & the District of Columbia31 States & the District of Columbia

–– Mix of experienced patient safety activists & less Mix of experienced patient safety activists & less

experienced participants experienced participants

Work with the Willing Work with the Willing

HRO Network is made up of Innovators, HRO Network is made up of Innovators,

Early Adopters, and some Early MajorityEarly Adopters, and some Early Majority

Cooperative ActivityCooperative Activity

�� Working together, the senior leadership Working together, the senior leadership

of these hospitals systems is focusing of these hospitals systems is focusing

on HRO activitieson HRO activities

�� The learning network provides the The learning network provides the

opportunity for technical assistance from opportunity for technical assistance from

AHRQ as well as sharing of knowledge AHRQ as well as sharing of knowledge

from one member system to another, from one member system to another,

creating a mutual learning communitycreating a mutual learning community

ActivitiesActivities

�� Site visits & conferencesSite visits & conferences

�� Collaborative improvement projects Collaborative improvement projects

undertaken by subgroups of participants undertaken by subgroups of participants

�� Joint projects, such as assessing safety Joint projects, such as assessing safety

culture, improving teamwork, & aligning culture, improving teamwork, & aligning

policies & procedures to establish a policies & procedures to establish a ““just just

cultureculture””

Hospital Survey on Patient Hospital Survey on Patient Safety Culture (HSOPS)Safety Culture (HSOPS)

�� HSOPS is designed for HSOPS is designed for

hospitals or systems; they hospitals or systems; they

administer an assessment administer an assessment

of their own safety cultureof their own safety culture

�� AHRQAHRQ’’s survey is one of s survey is one of

several that are available several that are available

�� Information on culture is Information on culture is

critical to establishing a critical to establishing a

comprehensive patient comprehensive patient

safety programsafety program

TeamSTEPPSTeamSTEPPS

�� Team work & Team work &

communications are communications are

essential components of essential components of

achieving high reliabilityachieving high reliability

�� The easiest way to improve The easiest way to improve

teamwork is through teamwork is through

training training

�� AHRQ provides AHRQ provides

TeamSTEPPS, a complete TeamSTEPPS, a complete

package of training package of training

materials developed in materials developed in

conjunction with the DoDconjunction with the DoD

Reporting & Just CultureReporting & Just Culture

ItIt’’s important tos important to

�� Encourage reporting of Encourage reporting of

safety eventssafety events

�� Move beyond blame & Move beyond blame &

train syndrometrain syndrome

�� Recognize that there is a Recognize that there is a

need to modify policies & need to modify policies &

procedures to ensure a just procedures to ensure a just

cultureculture

You have had three reported errorsOff With Your Head

MeasurementMeasurement

�� HROs document performance & improve HROs document performance & improve

reliability through measurementreliability through measurement

�� Measurement historically has been a Measurement historically has been a

difficult issue in healthcaredifficult issue in healthcare

–– Fear of reportingFear of reporting

–– Limited focus for what is measuredLimited focus for what is measured

�� Measure only that for which data already existMeasure only that for which data already exist

�� Measure only limited processes (Measure only limited processes (““rifle shotsrifle shots””))

�� Report results in silosReport results in silos

TodayToday’’s Baselines Baseline

““Are patients safer now? Data from Are patients safer now? Data from

neither the entire US health care system neither the entire US health care system

nor the individual hospitals can yield a nor the individual hospitals can yield a

credible answer.credible answer.””

JAMAJAMA -- August 9, 2006August 9, 2006

Pronovost PJ, Miller MR, Wachter RM.Pronovost PJ, Miller MR, Wachter RM. Tracking Progress in Patient Tracking Progress in Patient

Safety: an elusive target. Safety: an elusive target. JAMA. 2006;296:696JAMA. 2006;296:696--699.699.

The Patient Safety and Quality The Patient Safety and Quality Improvement Act of 2005Improvement Act of 2005

•• Creates Creates ““Patient Safety Patient Safety

Organizations (PSOs)Organizations (PSOs)

•• Establishes Establishes ““Network of Patient Network of Patient

Safety DatabasesSafety Databases””

•• Requires reporting of findings Requires reporting of findings

annually in AHRQannually in AHRQ’’s National s National

Health Quality/Disparities ReportsHealth Quality/Disparities Reports

•• Mandates Comptroller General to Mandates Comptroller General to

study effectiveness of Act (by study effectiveness of Act (by

2010)2010)

What Does Law Address?What Does Law Address?

�� Fear of malpractice litigationFear of malpractice litigation

�� Inadequate protection by state lawsInadequate protection by state laws

–– PrivilegePrivilege

–– Confidentiality Confidentiality

�� Inability to aggregate data on a large Inability to aggregate data on a large

scalescale

Patient Safety OrganizationsPatient Safety Organizations

�� Collect, analyze patient safety (PS) dataCollect, analyze patient safety (PS) data

�� Assist providers to improve quality & safetyAssist providers to improve quality & safety

�� Develop & disseminate PS informationDevelop & disseminate PS information

�� Encourage culture of safety & reduce risks Encourage culture of safety & reduce risks

to patientsto patients

�� Operate PS evaluation systems; provide Operate PS evaluation systems; provide

feedback to participantsfeedback to participants

�� Maintain confidentiality & security of dataMaintain confidentiality & security of data

Network of Patient Safety DatabasesNetwork of Patient Safety Databases

�� Facilitates exchange of data among PSOsFacilitates exchange of data among PSOs

�� Employs Employs common formats (definitions, data common formats (definitions, data

elementselements, etc.); promotes interoperability, etc.); promotes interoperability

�� Generates deGenerates de--identified information relevant to identified information relevant to

preventing harm to patientspreventing harm to patients

–– Aggregation of dataAggregation of data

–– Analysis of events, profiles, reportsAnalysis of events, profiles, reports

–– Dissemination of results, best practicesDissemination of results, best practices

�� Provides benchmarking & trend reportsProvides benchmarking & trend reports

AHRQ Inventory of Reporting SystemsAHRQ Inventory of Reporting Systems

�� Begun in January 2005Begun in January 2005

�� Establishes evidence base for Establishes evidence base for

developing common formats & developing common formats &

definitions for patient safety eventsdefinitions for patient safety events

�� Represents many operating systems & Represents many operating systems &

other stakeholdersother stakeholders

–– Federal & stateFederal & state

–– Collaboratives, chainsCollaboratives, chains

–– InternationalInternational

PSERS* MetaPSERS* Meta--databasedatabase

61 PSERS

>100

PSE reporting forms

>1,000 Definitions of PSE terms

>10,000 PSE reporting variables

Supporting documentation(PSERS descriptions, PSE reporting forms, encoding schemes, patient safety reports, etc.)

* Patient Safety Event Reporting System

Inventory FindingsInventory Findings

�� Few systems collect information on the Few systems collect information on the

complete improvement cyclecomplete improvement cycle

�� Commonality found for some definitionsCommonality found for some definitions

�� Variability found for manyVariability found for many

–– Clinical event, e.g., drug reactionClinical event, e.g., drug reaction

–– Accident, e.g., fallAccident, e.g., fall

–– Demographic, e.g., provider type, facility typeDemographic, e.g., provider type, facility type

Next StepsNext Steps

�� Develop & publish proposed rules Develop & publish proposed rules

governing certification & operation of governing certification & operation of

PSOsPSOs

�� Review PSO applications & publish list of Review PSO applications & publish list of

PSOs whose certifications are acceptedPSOs whose certifications are accepted

�� Finish inventory; coordinate development Finish inventory; coordinate development

of initial common formats & definitionsof initial common formats & definitions

�� Develop plan for supporting a network of Develop plan for supporting a network of

patient safety databasespatient safety databases

What You Can Do Right NowWhat You Can Do Right Now

�� Become (further) educated about what it Become (further) educated about what it

takes to be an HROtakes to be an HRO

�� Assess your institutionAssess your institution’’s culture of safetys culture of safety

�� Commit to the concept of teamwork & Commit to the concept of teamwork &

undergo team trainingundergo team training

�� Commit to the concepts ofCommit to the concepts of

–– A just cultureA just culture

–– A culture of measurementA culture of measurement

For Additional InformationFor Additional Information

�� AHRQ Website:AHRQ Website:

–– http://www.ahrq.govhttp://www.ahrq.gov

�� EE--mail address:mail address:

–– William.Munier@ahrq.hhs.govWilliam.Munier@ahrq.hhs.gov