The Pulse | Monday, December 19, 2022
A Closer Look at High Reliability Organizations in Endoscopy
What is a high reliability organization (HRO) and what does it look like in practice, particularly for endoscopy? Here, Lisa Heard, MSN RN CGRN CPHQ CPPS, shares her insights on HROs — their (healthy) preoccupation with failure, non-hierarchical approach, commitment to resilience and more. This conversation was edited for clarity and length.
High reliability organizations (HROs) are organizations that use deliberate design to effectively manage quality and safety across the continuum of their organization.
HROs focus on consistency and are constantly reviewing their processes. They have specific insights on how to continually keep safety at the highest level.
When you think about deliberate design, think about a company like Starbucks. If you go to a Starbucks in Seattle and one in Madrid, you’re getting the same cup of coffee. They understand how to be deliberate, how to be consistent, how to test their products to be reliable and safe — and they’re constantly measuring.
Healthcare started taking a cue from one of the strongest high reliability industries, aviation, back in the late 1990s. Dr. Lucian Leape is considered the father of the patient safety movement and was a pioneer who shone a light on aviation, an industry that operates in high-hazard conditions with few serious accidents or catastrophic failures. He asked, “How can we achieve this in healthcare?”
In the landmark report from the Institute of Medicine, “To Err is Human,” Leape discussed a 1994 review of patient injuries in New York hospitals. Of all the patients who were injured while in these hospitals, about 4% suffered an injury that made them stay in the hospital longer. That’s about 98,000 patients; of these patients, 14% died from their injuries.
Famously, Leape applied these rates to the entire country, which resulted in the statistic of approximately 180,000 people dying per year from hospital-based injury and error. To drive home the scope of this issue, he noted that this number was the equivalent to three jumbo jet crashes every two days. Those words have been echoing in patient safety’s ears for years and years. So how does the aviation industry do it so well?
They use high reliability principles. For example, they focus on the idea that error will happen. This preoccupation with failure is key, as it helps them understand the risks that may occur and provides them with the opportunity to proactively avoid them.
For healthcare to achieve this level of safety, a change of culture is necessary. We can no longer go with the status quo. We must be continuously involved in improvement activity, seeking out failures in process so we may study and learn from them.
This requires a culture of continuous change. When errors occur, we must perform a root cause analysis to look for system flaws that led to the occurrence and ask how to avoid the same problem in the future. We must always be thinking about process improvement science.
We also need to involve our clinical teams, teaching them to be safety advocates and change leaders. We want to raise their awareness that they’re part of the solution — not the problem.
There's a lot of work that healthcare professionals are doing to make our industry more transparent. Specifically, hospitals display their quality metrics and results for families and patients to see. If you go to a hospital’s website, it will be listed there too. It’s patient-centric and touches all members of staff: doctors, nurses, techs, nutrition services, environmental services — all these people coming together and asking, “How do we improve as a team?”
Breaking Down the Principles of HROs
HROs understand that healthcare is complex — and endoscopy extremely so. There’s so much that goes into a colonoscopy alone: the technology, the administration of sedation or anesthesia, the equipment, the therapeutic devices. There are so many complexities, and we have to be sensitive to that.
HROs recognize these complex systems and staff is made aware of what those complexities are — that’s one principle.
HROs work together as a team to eliminate potential issues. What that looks like in practice is twofold: The first is leadership being in touch with these complexities, understanding their unit practice and keeping in close contact with frontline workers. They’re hearing concerns directly and they’re working with their teams to make improvements.
For example, if you bring in new equipment or processes, the team should do a failure mode analysis. You’ll walk through the process before you actually initiate it, to see where all the issues could happen.
Another principle is a reluctance to simplify. HROs refuse to ignore explanations because it might be too complicated to fix. And HROs don’t shortchange using safety tools. In aviation, they don’t forgo a checklist just because the plane is late. In endoscopy, we don’t use a different endoscope because another one isn't available.
When errors and near misses do occur, HROs maintain a strong practice of reporting the event. Once we understand why it happened, we can prevent potential errors from happening again. This requires looking at the data and sharing that information with teams. It also requires creating a culture where people can speak up without consequence, report potential errors before they’ve even occurred and address a concern regardless of how big or small. That encourages a positive safety culture.
HROs also work against hierarchical structures. Everybody's on the same playing field — we embrace the idea that just because you're the chief of gastroenterology doesn't mean you're the best person to answer the question. We want that input, but we also want input from those at the patient’s bedside during cases.
Last, there’s the principle of resilience. If an error occurs, an HRO is ready to act in real-time. They don’t plan a meeting a month later to discuss it. It's usually done in the moment, doing a root cause analysis quickly with the team. Then that information is disseminated to the frontline. We can’t just hold it in the background because that's not going to prevent it from happening again.
Just as important, resilience means caring for our caregivers. We must be attentive to the needs of the team. When a patient suffers a medical error, is the team involved provided support? If and when errors happen, it can be devastating and life-altering. Nobody goes to work intending to harm a patient. HROs not only focus on the safety of the patient, but the well-being of their team as well.
As we approach a new world of staff shortages, capacity surges and increasing comorbidities in our patient population, using the principles of HRO industries will aid us in providing the safest care possible for our patients and our healthcare providers.