High Reliability Organizations are organizations that operate in a complex,
high hazard industries like healthcare for extended periods without serious
accidents or catastrophic failures.
High reliability is simply the probability that the work we do every day
achieves the outcomes we want every single time.
High-reliability work includes staff in all roles within the health system.
What if we could significantly reduce our errors?
What if there were more tools and not just more rules?
What if we came to work knowing exactly what is expected of us?
What if we always felt empowered to voice a concern related to patient or
personal safety?
What if we could leave work feeling absolutely confident that we delivered the
best possible care and service to our patients and customers?
High reliability is based on principles.
This first group of principles involves anticipation and helps us to stay out of
trouble. Preoccupation with failure,
pay attention to small inconsequential errors.
And those small things can be a sign that something is wrong.
Sensitivity to operations,
paying attention to what is happening at the front line.
This is where the work is done and our team members know what is or isn't
working. Reluctance to simplify.
In complex organizations there's often more to events than we know.
High reliability organizations work to simplify procedures, to improve safety,
but are reluctant to accept simple explanations for problems and their causes.
Different perspectives and opinions are encouraged to test our assumptions.
And we think about how proposed solutions will impact other areas of care
delivery and operations.
Team members that challenge simple explanations and solutions help us to improve
safety and reliability. Your opinion matters.
The second set of principles involve containment and help us to get out of
trouble. Commitment to resilience.
This principle helps to develop methods to detect, contain,
and recover from harm events that do occur.
Value all expertise.
We commit to pushing decision making to the person with the
most related knowledge and expertise.
So what does high reliability look like at Henry Ford Health System?
We created a model to help show how our principles for high reliability are
linked to the work we do every day and how we use systems to help us learn and
sustain our work.
At the core of this model is psychological safety and trust.
In order to work in a highly reliable way,
team members must feel safe to speak up about problems or errors so that we can
learn and correct system problems.
A great example of speaking up for safety involves a recent event where one of
our transporters recognized a serious safety problem.
The transporter was moving a discharged patient when she noticed a change in
that patient. He was slumped slightly to one side and his coloring looked off.
This is quite different from when she had picked him up in his room.
While transferring the patient to his vehicle,
she felt the change in the patient's physical strength,
his coloring and mentation.
These changes were significant enough to stop the discharge.
The transporter called the nurse on the floor and explained the situation.
The transporter then asked the nurse to assess the patient while sharing her
concerns.
The transporter did not feel that her concerns were being heard and proceeded to
elevate up her chain of command to her supervisor.
Her supervisor then contacted the nurse who came to assess the patient.
After an assessment by the nurse,
the patient was taken to the emergency department where a CT scan showed a
subdural hematoma or bleeding on the brain.
Thanks to the transporters se of rely on us behaviors and a tool called ARCC,
this patient was able to quickly receive the treatment he needed. The ARCC tool,
ask a question, request a change, communicate a concern,
If no success use the chain of command.
Our model also includes leader learning systems,
so leaders can understand what is happening at the front line.
Leaders learn in a multitude of ways.
We learn through report incidences and near misses.
We learn by talking to frontline staff and patients during leader rounds.
We also learn by setting up systems of learning,
such as an incident command structure,
which coordinates emergency responses and major disruptions to clinical
operations during a crisis.
Another great example of a leader learning system is our tiered huddles.
Henry Ford Health System has a safety huddle system that is tiered throughout
the enterprise. These huddles are brief, focused,
daily conversations about key safety and operational issues.
It's a way to get important information from frontline staff to our leaders.
Huddles occur at the department or unit level,
operational unit or hospital level, and market level and system level.
Critical issues are escalated through the tiered huddle system to be solved and
to share learnings between our operating units.
Another important element of the model includes local learning systems.
These systems involve our frontline teams and allow you to identify and solve
problems at your unit, clinic, or department.
There are different names for these teams,
such as lean teams or comprehensive unit based safety programs known as CUSP
teams.
We have had a long history of process improvement at Henry Ford Health System,
and we are very proud that our teams have shared their work at our annual
quality expo for more than 25 years.
Robust process improvement involves using tools to improve our systems of care.
Some tools include, PDCA, or plan, do, check,
act to do rapid cycle improvement.
Other tools you may have used include learning from defects,
lean six Sigma methods, and root cause analysis.
These tools help us to plan and focus our improvement efforts.
Outcomes measurement is how we know how we're doing.
We have dashboards with metrics that are important to us.
We use visible metrics,
such as huddle boards to communicate how we're doing with our improvement work.
We collect patient experience, safety culture,
and employee engagement information through surveys.
All of these metrics tell us how we're doing and where we need to focus our
efforts.
Zero harm, and a hundred percent reliability is our ultimate target.
By working together and using our high reliability systems and tools,
we can improve safety and reliability for our team members,
patients and customers.
Thank you for the work you do every day to keep our patients and team members
safe.