What Physician Leaders Need to Know About High Reliability

The concept of the high-reliability organization (HRO) — one that avoids catastrophe despite high levels of risk and complexity — is getting a second wind in healthcare. First applied in nuclear power plants, air traffic control centers, and other high-risk industries, high-reliability principles were introduced to healthcare nearly 15 years ago, but widespread adoption has been slow.

“It’s not lagging because people are ignorant or not willing,” says Jeff Norton, an engineer who has been teaching the AAPL Science of High Reliability course for more than a decade. “Healthcare people absolutely want to do the best for their patients every single day. Healthcare is just so complex that it’s hard to do that.”

A good example is hand hygiene, a seemingly simple activity with which almost all healthcare organizations struggle to comply consistently.

“We know the science, but across healthcare we struggle to make it happen with high reliability,” says Norton, vice president for Safety, Quality and Clinical Performance Improvement at TriHealth in Cincinnati. “What we are seeing now is that it’s time for healthcare to get a lot of things into a really highly reliable state.”

HRO Defined

Healthcare has unquestionably become safer since the Institute of Medicine’s 1999 report, "To Err Is Human: Building a Safer Health System," showed the distressing fallibility of America’s healthcare delivery system, according to Allan Frankel, MD, president and CEO of Safe & Reliable Healthcare. But during those two decades, the explosion in medical knowledge has made healthcare delivery ever more complicated.

As the patient-safety movement has evolved, many health systems have come to realize they need to become high-reliability organizations, but doing so is not easy.

“Anyone with the arrogance to call themselves highly reliable would pretty quickly get their comeuppance,” says Frankel, a faculty leader at the Institute for Healthcare Improvement since 1998. “But just about every large system is thinking about it. They might not be necessarily clear on what the path is, but the conversation about what it means and what it entails has started.”

The concept of an HRO was defined in Managing the Unexpected: Assuring High Performance in an Age of Complexity, a 2001 book by Karl Weick and Kathleen Sutcliffe. Focusing on industries other than healthcare, the authors listed five principles of an HRO: (1) preoccupation with failure; (2) reluctance to simplify; (3) sensitivity to operations; (4) commitment to resilience; and (5) deference to expertise.

In 2017, Frankel and IHI colleagues published “A Framework for Safe, Reliable, and Effective Care,” which describes the strategic, clinical, and operational components needed to become a healthcare HRO. They identify two “foundational domains” — an organization’s culture and its learning system — and nine components: leadership, psychological safety, accountability, teamwork and communication, negotiation, transparency, reliability, improvement and measurement, and continuous learning.

“The framework components that we have undervalued are the skills necessary to lead and manage well, including the skills necessary to understand the implications of a healthy versus unhealthy culture in a complex environment,” Frankel says.

Physicians, nurses, and other clinicians are promoted to leadership positions because of their clinical excellence rather than their ability to lead an organization’s journey to high reliability, he explains.

“All these wonderfully skilled clinicians who move from being nurses, pharmacists, and respiratory therapists and physicians into managers and directors and leaders of organizations have not been trained in the skills that they need to actually create self-reflecting, improvement-capable environments,” according to Frankel. “And that’s the challenge we have for 2021.”

Leading with Humility

While a culture of high reliability must be infused throughout the organization, physician leadership is essential for its success, Karen Frush, MD, BSN, chief quality officer at Stanford Health Care, says.

“In any organization, the person who has the title of chief medical officer is going to be looked at as a leader, and what the leader thinks is important, what the leader says is important, and the way the leader acts absolutely influences everyone else,” says Frush, co-executive director of the Stanford Medicine Center for Improvement.

When Houston Methodist, the health system that includes Texas Medical Center and six community hospitals, revamped its journey to high reliability, Executive Vice President and Chief Physician Executive Rob Phillips, MD, PhD, called it the “democracy project.”

“When I got to this role, which carries a lot of responsibility over such a big enterprise, I understood that I needed better information about what’s happening on the ground,” says Phillips, who also serves as president and CEO of Houston Methodist physician organization. “I think everything works better when you hear the voice of people who are doing the work.”

Trained as a cardiologist and a research scientist, Phillips held leadership positions at Mount Sinai Hospital and Lenox Hill Hospital in New York and at UMass Memorial Medical Center before joining Houston Methodist. He has found that leading an organization toward a culture of high-reliability requires humility, self-trust, and confidence in the organization’s commitment.

“You have to have enough strength so that you can look at things honestly,” he says. “And you have to have an organization that is going to support your efforts to detect things that are wrong before something bad happens — and, if something does happen, will give you the tools and its confidence in you to know that you’ll fix it.”

That type of humility does not always come naturally to physician leaders who have competed with their smartest and hardest-working peers throughout their lives, Frush says. When she served as chief patient safety officer at Duke Health in the mid-2000s, her responsibility extended to several small community hospitals affiliated with Duke via a partnership. A physician at one of those hospitals once told her, “You know, there’s a reason I’m in cowboy country.”

“To claim this autonomy and hierarchy that is the traditional culture of medicine is something that must be wrestled with,” she says. “If we want to provide the best possible care to patients, we need to create relationships with one another and acknowledge that some of the ways we did things before — being autonomous, doing our own thing, believing in hierarchy — that’s not leadership anymore.”

Countering Resistance

Norton says the tug-of-war between “better” and “even better” is a common conflict on the road to high reliability. That occurs when a physician refuses to endorse an evidence-based best-practice intervention, such as the five components of care needed to prevent ventilator-associated pneumonia (VAP). Many hospitals have virtually eliminated VAP through the consistent use of the intervention “bundle” of practices, according to the IHI. But that consistency is not universal, and VAP continues to be one of the most frequent intensive care unit-acquired infections.(1)

“I see very well-intentioned physicians arguing against a specific intervention because there is a paper that shows a complication or perhaps a better result with an alternative,” he remarks. “When we have a known solution, like the VAP-prevention bundle, arguing about which paper is more right does not seem to be in the best interest of the patient. If we know we’re hurting people and we know how to stop it, let’s do that.”

Norton shares a few other common challenges when health systems seek to systematically pursue high reliability:

Railing against the cookbook. “We run into ‘I don’t want to do cookbook medicine. I want to use my training — whether it’s a nursing or medical degree — at the highest level,’ ” he says.

The counter to that, in his view, is that medical care is both science and art, and everyone needs to see the line of demarcation. “Once the science is clear and you know what you need to do, that’s not the art of medicine anymore — that’s the science,” he explains. “You are causing harm if you don’t do the thing that you know works. But we still do sometimes get ‘I don’t want to be told what to do.’ ”

Using policy to drive behavior. When errors occur, it is common to find that safety policies and protocols were not being followed. The process for developing and rolling out the policies may be at fault, Norton says.

“We misuse policies and procedures in so many ways that people will bypass them instead of following them,” he says, adding that “policies should not be used to drive behavior; rather, they should be used to lock in the desired behavior and provide a reference.

“You’ve got to get some level of agreement on the behaviors that you really need to change to improve results,” he says. “Then you need examples you can point to, where people did certain things reliably and got different results. As a leader, why would you not do that? Even if you think you’ve got a better mousetrap, while you’re working on it, use something that has already demonstrated the ability to get a great result.”

Reference

1. Papazian L, Klompas M, Luyt, CE. Ventilator-associated Pneumonia in Adults: A Narrative Review. Intensive Care Med. 2020;10:1–19. www.ncbi.nlm.nih.gov/pmc/articles/PMC7095206/#:~:text=Ventilator%2Dassociated%20pneumonia%20(VAP),mechanical%20ventilation%20and%20ICU%20stay .

Adventhealth’s Path Toward High Reliability

AdventHealth, which operates 50 hospital campuses in nine states, is three years into its journey to become a high-reliability organization, and the finish line is not in sight.

Brent Box, MD, the health system’s chief medical officer and associate chief clinical officer, says patience and a long-term view are essential for physician executives who are leading their organizations to high-reliability status.

“Plan for the long run because this is ongoing work,” he says. “It will continue to get better and high-reliability will be increasingly woven into the fabric of the organization. But you have to spend a lot of time teaching and educating your leaders about why this is important and how it works.”

AdventHealth, based in Altamonte Springs, Florida, has about 360,000 discharges a year from its acute care facilities and serves about 5 million people in its ambulatory settings. Like all leading health systems, it has been working to improve patient safety and the quality of care for decades.

About five years ago, the organization adopted several external measures to benchmark its performance: the Centers for Medicare & Medicaid Services (CMS) Star Ratings Program measures; the Leapfrog Hospital Safety Grade measures; and mortality measures based on Premier Inc. data.

“Even as we did that work, there was a recognition that, at the unit level, at the place where you take care of patients, there has to be this culture of learning and a culture of high reliability,” Box says.

Since 2017, AdventHealth has been building a program called “Unit Culture” that uses the Institute for Healthcare Improvement Framework for Safe, Reliable, and Effective Care to teach staff members how to work toward high reliability. By the end of this year, 272 units, both inpatient and outpatient, will have been trained.

Building this culture takes patience, he says, because physician leaders have to be committed to psychological safety — ensuring that anyone in the organization, including patients and families, feels safe to express concerns, suggestions, and ideas for change — and to the fact that everybody on the team is important. Equally important, the frontline team must embrace those ideas as the cultural norm.

“Ownership at the front line is absolutely imperative,” he stresses.

Advent Health uses a technology platform to capture ideas and make sure they are acknowledged and acted upon. “They have to be known by leadership and something has to happen after an idea is suggested,” he says. “Otherwise, the cycle of improvement just dissipates.”

Ideas are also captured on leadership boards. When a team member puts forth an idea at one of the twice-daily huddles, that idea gets amplified up the chain so that it can be quickly discussed in leadership huddles.

“We have stories upon stories of really impactful ways that ideas that nurses, unit managers and others have had that have made a difference in safety,” he says. “That’s how we as an organization have begun to put high reliability into action.”

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