High Reliability – a Road or an Endpoint

Reviewed by Lia Lowrie, MD

SPS Plenary Session | May 20, 2019 8:00 am | Daniel Hyman

Dan Hyman is Chief Medical and Patient Safety Officer for Children’s Hospital Colorado.  He provided us with a quick but meaty overview of what high reliability really means as it applies to institutional culture and change.  He started with the definition of reliability, freedom from operational process failure over time, and reminded us of how that freedom can be measured over time mathematically. For those of us with more clinically oriented thinking processes, he did an effective job describing related measures of how the organization is progressing in eliminating failure – time between events or counts of successful events between failed events.  Sometimes the language of safety science is hard to apply to clinical operations.

Dr. Hyman also gave examples of appropriate reliability measures for each of the six IOM quality domains:

1. Safety: No sedation adverse events/sedation episodes
2. Efficiency: Lag days between scheduling of sedated test and completing the test
3. Effectiveness: Success achieving target sedation state/sedation episode
4. Equitable: Lag days are the same for one zip code as another
5. Timely: Days between late start for first sedated MRI
6. Patient centered: Patient satisfaction survey results

He then went on to highlight how important organizational culture change is in achieving high reliability within a microsystem, organization, institution or healthcare system.  Once an organization can identify errors or flaws in system processes that might result in harm, there are ways to respond to “fix” the process problem.  Educating employees on processes, new techniques, expectations and why following policy is important is a first step that can help reduce harm.  There is evidence that the effect of education is short lived, doesn’t always result in organizational resilience, and may be somewhat reactive.  The next level of response includes addressing awareness across all employees of how to recognize risk, how to report potential errors, and how to encourage problem solving at the bedside.  The highest level of response involves true human factors engineering.  When teaching about organizational reliability it’s important to avoid using the high reliability science jargon.

Dr. Hyman gave us great examples of practical safety practices that are becoming commonplace in healthcare organizations.  Your organization may be practicing some of these high reliability techniques already

1. Sensitivity to operations: Paying attention to operations in an effective and mindful way: daily safety huddles
2. Preoccupation with failure: Actively looking for error and learning from analysis of processes involved in the error; Incident reporting and follow up
3. Reluctance to simplify: More than superficial analysis of error cause
4. Resilience: Developing capabilities to grow and improve despite adverse events; Change management training
5. Deference to expertise: Seeking information and analysis from people involved in the processes rather than from hierarchical chains of command; Active involvement of front line staff in error analysis, effective leadership rounding

Dr. Hyman reminded us all that becoming a high-reliability organization is a journey that may or may not have a specific destination – it’s hard to define when the organization has reached optimal culture change.  He encouraged us all to try to employ some of these principles in our own microsystems of procedural sedation.  It was a great way to lead off a conference committed to learning from each other in order to provide quality procedural sedation.