But what if organizations changed their mindset? What if the end goal was, in fact, to eliminate adverse events? A hospital without patient safety events may seem like an impossibility, but as more and more organizations are learning, zero harm doesn’t have to be a miracle scenario.
“Many hospitals are embracing the values of high-reliability organizations and occupations like air traffic control towers, nuclear power plants, wildlife fire fighters and astronauts,” states the article 5 Traits of High Reliability Organizations: How to Hardwire Each in Your Organization. “The paradigm works remarkably well in the promotion of patient safety and efficient healthcare delivery.”
High reliability organizations are organizations that operate in complex, high-hazard domains for extended periods without serious accidents or catastrophic failures...High reliability organizations cultivate resilience by relentlessly prioritizing safety over other performance pressures. - Patient Safety Network’s Patient Safety Primer
Where to Start
According to Anne Marie Benedicto, vice president of the Joint Commission Center for Transformation Healthcare, although hospital and healthcare staff may desire to become a high-reliability organization, they often don’t know how to begin. "Transforming to high reliability is a multiyear process,” she said in a Q&A with Becker’s Hospital Review. “And it is probably the biggest change initiative any healthcare organization can undertake right now."
The change starts with an organization-wide commitment. Everyone from leadership down needs to buy into the concept, believe it can succeed, and commit to the work involved. This work includes making major shifts in processes and procedures typically used at hospitals, and using the right technology to collect quality data.
“It really is possible — with the right technology, mindset, skills and leadership — to create an organization that is so strong that zero harm is a byproduct of what they do,” Benedicto said.
Goal #1: Engage in Healthcare Data Analytics
In order to get out in front of incidents and prevent them from occurring, hospitals and healthcare organizations need access to a significant amount of data. The more data captured, the more insight that can be derived from it.
As stated in How Digital Health Solutions Can Help Hospitals Eliminate Opportunities for Error, “As hospitals move toward becoming high-reliability organizations, clinicians and staff need effective tools to gather critical insights on a patient’s condition (e.g., fall risk, infection control risk, NPO status) before entering a room. To actively create awareness of potential risks and points of failure, hospitals must ensure everyone has the information they need at their fingertips in real-time to prevent HAIs and injury and mitigate risk.”
Solution: Near Miss Reporting
An effective way to stop patient safety incidents before they happen is near-miss reporting. The OSHA and National Safety Council Alliance, a cooperative program, states: “History has shown repeatedly that most loss producing events (incidents), both serious and catastrophic, were preceded by warnings or near miss incidents.” An organization’s ability to track these types of events and quickly intervene can go a long way toward establishing a zero harm environment.
Origami Risk’s incident reporting functionality can improve the capture of near-miss details. Users can access customized forms via mobile device or web browser, from any location, to ensure data is captured accurately and intervention occurs as quickly as possible.
Solution: Reports and Dashboards
Origami Risk’s single, integrated healthcare risk management system allows for the consolidation of patient safety and risk data, making it possible for users to pinpoint where processes and procedures are most likely to break down.
Users can build customized charts, graphs, and dashboards that filter data points and signify potential adverse events. These actionable data points, known as leading indicators, foretell potential risks and spur stakeholders to take the right action. For example, a particular graph could show that adverse events spike on the days when the hospital is under-staffed. As a result, when next the hospital is under-staffed, there may be a greater sense of urgency to call in backup or provide other supportive resources.
Solution: Root Cause Analysis
Origami’s root cause analysis (RCA) tools help prevent future adverse events by using data-based insight to examine what went wrong at the outset of adverse events that previously occurred. These RCA tools include:
- Fishbone diagram: a visual display of contributing factors, broken down by category
- RCA2: the Root Cause Analysis and Action method aims to uncover what happened, why it happened, and the corrective actions needed. From corrective actions/action plan creation to timeline development to contributing factors to the assignment of the RCA team, healthcare organizations can pick and choose what tools work best for their process and workflow.
- 5 Whys: an exploration of the cause-and-effect relationships underlying a particular problem
The more that’s understood about why an event occurred, the better the processes that can be put in place to ensure the event doesn’t happen again.
Goal #2: Emphasize Operations and Processes
The Joint Commission’s Benedicto makes a point that the reason zero-harm environment approach isn’t working in hospitals is due to process failures, not people failures. “We all know that people enter healthcare committed and skilled,” she said. “It's really about healthcare's systems and structures. Let's get the right ones in place so that the people who work within them can perform at the top of their game.”
Hospitals often use separate, or even competing, systems for storing data and managing processes. As stated in 3 reasons to integrate healthcare claims management, “When data is fragmented in disparate systems, staff may miss key parts of the underlying story. Or, staff may spend extended time trying to compile volumes of data through unrepeatable processes. Regardless, these efforts open the door to data errors, incomplete or missing information, or outdated data sets—all of which increase the potential for missed opportunities in the risk decision making process.”
A high-reliability organization depends upon buttoned-up processes that rely on a single source of shared information and communicates effectively to all parties.
Solution: Automation
As Cleveland Clinic has learned first-hand, a high-reliability organization relies on standardizing policies and processes. Broken-down processes and communication deficiencies inevitably lead to diagnostic errors and frustration among clinicians and staff. Edmund Sabanegh, MD, of Cleveland Clinic stated in Health Systems and Hospitals in Pursuit of High Reliability, “We have worked hard to standardize our policies to make sure that a nurse who works in one ward, then works in another location in our system has a similar expectation and similar understanding of processes."
Origami’s automation functionality allows for widespread, consistent communication across an organization. Let’s say, for example, a nurse reports that an erroneous dosage was caught before being administered to a patient. By notifying all units of this occurrence and the subsequent actions to be taken, all staff members become familiar with the appropriate response.
Automation functionality does more than inform. It also spurs action by communicating next steps to the appropriate stakeholders. Using the example of the near-miss incident above, Origami’s reporting system can be set to automatically notify specific parties immediately after the near miss has been reported, allowing said parties to not only take preventative action (such as sending someone to double-check on the patient), but also set up a time to discuss what happened. These discussions are crucial to learning from the event, and make it possible to adjust processes to make sure they don’t happen again. Without automation alerting key staff during critical moments, a unified approach fails. Without a unified approach, a high-reliability culture is not possible.
Sabanegh summarizes this point in the HealthLeaders article: “Real-time operational management gives us both an early warning system for problems and challenges for the entire enterprise, and a great venue to communicate up and down the organization. Everybody is hearing about challenges at other places and how those challenges are being solved.”
Solution: Rounding Tool
Through in-person conversation and the cataloging of on-the-floor events, the process of rounding helps expose an organization’s safety and quality issues that other reporting processes might miss.
Origami’s Rounding tool can help make rounding assignment, reporting, and data assessment more efficient and effective. From anywhere within a facility, the tool can be used to quickly identify problem areas and create corrective action plans. By automating workflows the system can send out notifications to all relevant parties, and users can create customizable reports to send to leadership, ensuring everyone from top to bottom is vigilant about risks and understands how to prevent them.
Solution: HFMEA Tool
Healthcare Failure Mode and Effects Analysis (HFMEA) is an insightful way to identify where a process breaks down and, as a result, has the greatest potential to cause harm. Often, due to the time it takes to identify, organize, and conduct a proper HFMEA, organizations bypass the process or conduct “mini” HFMEAs instead.
A healthcare risk management system with automation tools can simplify the process and shorten the HFMEA lifecycle, thus allowing users to focus on the real impact of each step in the process and generate more accurate scores to understand where a process failed. Further, a solution like Origami Risk can help users identify corrective actions and process improvements that prevent the recurrence of process breakdowns.
Goal #3: Align Goals
Gathering the right data and establishing solid processes are keys to building a high-reliability organization. But unless leadership is united, none of that matters. “A leadership team that is aligned on what high reliability looks like is really important,” Benedicto said in her Q&A with Becker’s Hospital. “When we engage with organizations and talk to senior leaders, we quickly recognize they have many different definitions of what high reliability means. Making sure they are aligned in those concepts, along with their assessments of the organization's strengths and opportunities for improvement, is a critical first step. Nothing else happens without that.”
A solid starting goal for most healthcare organizations is building a patient safety culture. As Stephen Muething, MD, chief quality officer at Cincinnati Children's Hospital Medical Center told HealthLeaders, “You are not going to get anywhere near your [patient-safety] goal unless you build a culture where people are talking about safety and are focused on safety everywhere they go. It's not as simple as creating processes or getting the right equipment—everybody in the organization needs to be thinking about safety every day.”