How does a healthcare organization pursuing high reliability respond to a sentinel event? Mark Chassin, president and CEO of The Joint Commission, shared his insights with HRMR.
The pursuit of high reliability is a growing phenomenon in healthcare. By seeking to create a safety culture similar to that employed in high risk professions such as commercial aviation or nuclear power, healthcare providers have set themselves the ambitious goal of zero harm.
The Joint Commission has engaged with these efforts through its Center for Transforming Healthcare, and has seen substantial improvements among healthcare organizations working towards high reliability.
The Memorial Hermann Healthcare System in Texas, for instance, has seen a dramatic reduction system-wide in healthcare associated infections since it adopted the Center for Transforming Healthcare’s Hand Hygiene Targeted Solutions Tool® (TST®). Participating in another Center initiative, one if its hospitals has also seen a major decline in the number of patient falls with injury.
Changes in culture are harder to measure (The Joint Commission is working on a solution for this) but culture change is key to a successful approach to high reliability, and underpins all other advances made by organizations on this path. An example of its value can be seen in the way a healthcare provider pursuing high reliability reacts to a sentinel event or near miss.
“First, this type of organization will have done everything they could—in advance of experiencing a sentinel event—to prevent it from happening,” says Chassin. “That means recognizing that when a series of errors almost harms a patient (a near miss), this is a ‘free lesson’.
“If your organization does not have a fully safe culture, when you identify a near miss, there is a strong temptation to celebrate when harm is avoided and to believe your systems are strong because the patient didn’t get hurt. However, if you don’t work hard to find out why you ended up nearly hurting a patient then you will miss the opportunity to find weaknesses in your safety systems.”
Organizations pursuing high reliability have procedures in place to prevent patient harm, including identifying unsafe conditions and proactively assessing safety systems. If an adverse event occurs, then they are very assiduous in looking at all the contributing causes and putting safeguards in place to prevent a similar problem in the future.
“It’s not about blaming the person that made the last mistake, it’s about looking back all the way to leadership and even to governance to see if there is an opportunity for improving their roles in these systems,” says Chassin.
Tools for change
Another powerful component of driving toward high reliability is deploying the most effective process improvement tools throughout a healthcare organization: Lean, Six Sigma and Change Management. The Joint Commission has found that these tools can also be extremely useful in analysing sentinel events.
“Together those three sets of tools create Robust Process Improvement® (RPI®). It is very difficult for a single organization to look at a sentinel event like an operating room fire, wrong site procedure, infant abduction or patient suicide and uncover all of the risks that they may have for a similar event occurring.
“Our Center for Transforming Healthcare has used these very powerful tools to examine these types of problems from start to finish, and it can lead to really quite amazing discoveries because they offer a sophisticated way of solving these problems.”
For example, in addressing the prevention of wrong site surgery, the project to develop a TST for safe surgery revealed that many of the risks for wrong site surgery occurred before the patient even reached the operating room.
“In looking at samples of all surgical cases for the five hospitals and three ambulatory surgery centers that did this project with us, we found that 39 percent of cases had risks for wrong site surgery introduced when surgery was scheduled; 52 percent had more risks introduced during the pre-op assessment of the patient, and 59 percent had more and different risks introduced in the operating room. From this project we created the Safe Surgery TST, a set of tools that leads you through a way to identify and address every single one of those risks.”
Committing to the goal
What steps does a healthcare provider need to take when pursuing high reliability?
The first, and hardest step, according to Chassin, is to get the entire leadership of the organization, from the governing body to the physicians, nurse leaders and management, all aligned and all committed to the ultimate goal of zero harm—not zero preventable harm, but zero harm for both patients and caregivers.
Second, one of the most important obligations for leadership is to create a high reliability culture inside the organization; that is, a fully embedded culture of safety.
“This is one of the most important protections that high reliability organizations have,” says Chassin. “High reliability organizations don’t have sentinel events—they have a culture in which every individual is looking for the smallest thing that deviates from a safety protocol, that’s an unsafe condition, way before it causes harm. Those problems are reported and solved when they small, and easy to fix. That’s one of the most important mechanisms they have for staying safe and avoiding adverse events.”
Third, the organization needs to use the very powerful measurement-driven improvement tools of Robust Process Improvement.
“Highly reliable organizations, unlike healthcare, do not have safety processes that fail 50 or 60 percent of the time,” says Chassin. “Healthcare is riddled with those, from the failure to identify patients properly to hand hygiene non-compliance, failures to communicate well across transitions of care—the percentages of processes that fail are in the range of 40 to 60% in a lot of instances, so we need much better improvement tools.”
When setting out on a high reliability journey, organizations can expect to meet certain challenges.
The first of these is the hesitancy of leaders to seriously commit to the goal of zero harm.
“Physicians in particular are often convinced that bad things will always happen—but they don’t have to happen,” says Chassin.
Another challenge is to commit to quality and safety as the number one strategic priority of the organization.
“Organizations that have been pursuing this for a long time will tell you that once they have seriously made this commitment, all the other targets they wished to achieve—market share, financial strength, patient satisfaction, staff satisfaction, reduced turnover—follow behind the intense focus on quality and safety.”
The third challenge is how to address the issue of blame.
“One of the ways a high reliability organization looks at a close call or adverse event is to look very carefully at the pattern of errors that people made—we often hear talk about blame-free culture in healthcare,” says Chassin.
However, this does not mean denying blame in all instances.
“These organizations have figured out how to identify blameless errors, which occur in healthcare most often because we put well trained, well-meaning caregivers in broken processes that make it very difficult for them to do the right thing—and they have to break protocols and policies to get care to patients.
“Those are the kinds of errors that need to be dealt with in a blame free manner, and we can learn from them where the deficiencies in safety systems are.”
However, highly reliable organizations also have a very clear, transparent and equitable way of approaching blameworthy behaviors—the serial violators who, for example, routinely fail to follow the gown and glove routine for central line placement, or who don’t wash their hands according to the protocol.
“Those behaviors need to be teed up for disciplinary procedures—and we are not very good in healthcare either at the blame free approach to blameless errors or in holding people accountable for consistent adherence to safe practices,” says Chassin.
Beyond these hurdles lies the exciting prospect of zero harm. The gauntlet thrown down by high reliability is to refocus the entire organization around that goal. Big leaps have been made by healthcare providers adopting this approach; The Joint Commission has seen that in action. A new era in patient safety could now be on the horizon.
Mark Chassin is president and CEO of The Joint Commission.
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