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Bright Idea Series: Adopting High-Reliability Organization Principles

A high-reliability organization (HRO) is an organization that succeeds in avoiding catastrophes despite a high level of risk and complexity. Specific examples of HROs include nuclear power plants, air traffic control systems and naval aircraft carriers. Healthcare organizations have also moved to adopt the HRO mindset to improve care delivery, quality and patient safety.

In an HRO, even a minor error could have catastrophic consequences. But adverse outcomes in these organizations are rare. How is that possible?

The short answer? Follow the example set by St. James Parish Hospital, a critical access hospital in Lutcher, Louisiana, by implementing a team accountability process like safety huddles. The hospital’s patient safety committee promoted these huddles as a great way to pull together knowledge that the front-line team was already reporting, gathering and discussing on a monthly basis. It is also a way to present the whole team with information coming from the organization’s leaders on a daily basis.

The team defined the purpose of daily safety huddles as “a way to promote situational awareness of current issues that have the potential to impact the safety, quality and delivery of care for the day. It also functions to provide direction about the prioritization and responsibility for problem resolution.” After testing them for an extended time, safety huddles are now a must-have that bolster the organization’s high-reliability principles.

Principle #1: Become Preoccupied with Failure

While it may initially sound like a bad thing, it’s crucial for HROs to become focused on failure. Organizations must refuse to ignore any fault, no matter how small, because any deviation from the expected result can snowball into tragedy. It is necessary to address any level of technical, human or process failure wholly and as soon as a problem occurs.

St. James Hospital recognized that any process failures must be addressed immediately. By keeping employees engaged in thinking of ways that work processes could break down and developing the best plan of action if they do, a sense of shared alertness is ever-present. Team members become aware of everything, from small inefficiencies to dangerous failures. Hospital employees are also encouraged to report concerns as soon as they have them, which helps build best practices across the entire organization.

 

Principle #2: Refuse to Simplify

The second rule of a high-reliability organization is refusing to simplify. After all, registered nurse and chief quality officer at St. James Parish Hospital Geri Abadie asks, how much of a hospital’s daily work is because something has always been done in the same way? Through face-to-face reporting by front-line leaders, the team has become accountable regarding explanations about failed processes, errors or a potential risk to patients. The front line staff uses communication tools that leaders and the staff have designed for safety huddles.

Along with communication skills, these tactics have challenged the status quo. The safety huddles give front-line staff direct communication to leadership to report failures and opportunities to avoid failures in systems and processes. St. James realized that complex problems require complex solutions. Leaders must be willing to challenge long-held beliefs and commit to looking at data, benchmarks and other performance metrics continuously. To prevent simplification, which is tempting when trying to fast track success, leaders must seek information that challenges their current beliefs as to why problems exist.

HROs understand that the best picture of the current situation, especially an unexpected one, comes from the front line. Because front line employees are closer to the work than executive leadership, they are better positioned to recognize the potential failure and identify opportunities for improvement. There are no assumptions in an HRO. A consistent concentration on processes leads to observations that inform decision-making and new operational initiatives.

 

Principle #3: Sensitivity to Operations

The next rule is to establish sensitivity with operations and ensure that the team realizes that every voice matters. Safety huddles are a direct way to maintain situational awareness across the organization, which means gathering all departments of the hospital, both clinical and non-clinical, and having them sit at the same table. This allows the team to include all members of the healthcare team and give them a chance to speak up when something doesn’t seem right.

“We designed our safety huddles where reporting comes from our front line,” Geri says. “This allows us to pull a team, including the front line staff, together to problem solve, whether it’s a PDSA or RPIW, which is a rapid process improvement workout.”

 

Principle #4: Commit to Resilience

Leaders at high-reliability organizations stay the course, respond to failures and continually find new solutions. They might improvise more or quickly develop new ways to respond to unexpected events. While these organizations might experience numerous failures, it is their resilience and swift problem solving that prevents catastrophes.

The safety huddles implemented by St. James are an excellent way to start a shift at the hospital, especially considering that the huddles include discussing ways of preparing for situations that are unlikely to happen but still possible. Leaders can build on a non-punitive environment knowing that mistakes could happen and focus on how preventable, harmful events can be minimized.

According to Geri, the agenda was designed to look for any issues regarding significant safety quality or service problems from the previous 24 hours. The team is expected to follow safety protocol, but they are also expected to anticipate quality, service or other issues that may occur within the next 24 hours and follow-up with the team if problems arise. Team members should report issues identified on previous days and determine how to solve them.

As St. James has completed its second year of safety huddles, the team is proud of how far they have come.

“Our leaders still attend safety huddles daily — or at a minimum, they can send a designee or ask another leader to report out for them, so that we have that daily report. Leaders openly discuss what type of information they want to hear and have even created standardized reports. Those who didn’t initially have a standardized report in their department started to model off of the other leaders,” Geri says. “We got better at gathering information from our front-line staff, so that way we can have our reports ready. We also have a binder of information with an agenda, so if we miss the safety huddle, it’s available for any leader to go in and see. If they needed data from the past, we have all that information, too.”

LHA Trust Funds supports member hospitals that provide quality care while sharing ideas to facilitate safe environments. If you think safety huddles can help your hospital organization, view the webinar link here: https://lhatrustfunds.com/event/bright-idea/.

Good morning, welcome to today’s “Bright Ideas” webinar.

My name is Stacie Jenkins and I’m the Senior Director for quality and patient safety at the LHA Trust Funds. Today, I just wanna say, that as the consultants travel throughout the state, visiting different hospitals, we really try to take note of unique and innovative projects that are being implemented to improve the safety of patients. We like to try and share these ideas and projects with members of the Trust Fund in hopes that maybe something will spark an idea or something, you might be able to do in your own organization.

So we call these our “Bright Ideas” from members in a trust fund and today I would like to introduce Geri Abadie. She is the Chief Quality Officer at St. James Parish Hospital, St. James Parish Hospital is a critical access hospital, in Lutcher, Louisiana. Geri has 32 years of experience at St. James care hospital and 27 years in nurse leadership roles and a current role that includes compliance, patient safety and quality. And this morning she is going to talk to us about their project called Safety Huddles.

Geri, go ahead.

Thanks, Stacie, welcome everyone.

As she said, I am from St. James Parish Hospital in Lutcher and I’m glad to be able to share bright ideas on safety. Here’s actually a picture of our safety huddle taking place in our hospital. I wish to share how we’re building resilience as a high-reliable organization through safety huddles.

A little bit about St. James Parish Hospital: we are a 25-bed critical access hospital. We have an eight-bed emergency department, two OR suites and one procedure room for endoscopy. We do have four provider-based physician clinics, urgent care and specialty physician clinics that are not provider-based.

Our mission, St. James Parish Hospital is committed to providing excellent quality and compassionate healthcare to our community and our vision is to unite the parish by being the community’s first choice for all health and wellness needs by leading innovations, to make care more convenient, coordinated, comprehensive and advanced in order to offer the very best value.

Our vision for leading innovation has been embraced by our organization and we often find ourselves eager to try new ways of delivering care — especially when the new ways are a positive impact to quality, and patient safety for our patients in our community. Quality and safe care are the very best value for our community.

Like many of you, we heard of safety huddles through team steps through HRET and Press Ganey, the National Patient Safety Foundation, plus others. Our patient safety committee really promoted the idea that it would be a great way to pull information that we were reporting, gathering and discussing on a monthly basis and with our leaders on a daily basis, directly from our front line reporting.

As we progress on our journey as a high reliable organization, safety huddles really became a must-have.

I know we’ve all been hearing a lot about the five principles of high reliability. I just, I wanted to tell you about how safety huddles really came forth in our high-reliable journey and how that kind of ties together, for us as an organization as we build our safety culture.

We recently had an employee forum, and we talked about high-reliable organizations and helping them understand how we’re doing that in our building of a safety culture.

And so, we broke down our five principles of high-reliable organization into two categories. The first three are those things that we do in anticipation of staying out of trouble, so that preoccupation with failure. We’ve always used like our near-misses as opportunities to improve, part of our improvement plan from our patient safety culture survey has been to look out for what can go wrong instead of only reacting to, say, the events after they occur. Through safety huddles, engaging our leaders on a daily basis to look for what can potentially go wrong has broadened our preoccupation with failure beyond our patient safety team, or our quality program.

There is a value to reporting face-to-face that has made us reluctant to simplify, which is the second principal of high reliable organizations. A high reliable organization refuses to simplify. the front line staff uses leadership through communication tools that leaders and the staff had designed for our safety huddles, And that, with communication skills, they really do challenge the status quo. The safety huddles give front-line staff the direct communication to leadership, to report failures and opportunities to avoid failures in our systems and in our processes.

How much of our daily work is because we’ve always done it in the same way? As an employee of this hospital for so many years. It seems like I can really relate to that.

So, this face-to-face reporting by our leaders from the frontline really keeps us all accountable to not simplify our explanations about failed processes, or when errors occur, or when patients may be at risk.

And the third one is sensitivity with operations. The safety huddles are a direct way to maintain situational awareness across our organization, including all departments of the hospital, both clinical and non-clinical, sitting at the table. It gives us an opportunity to include all members of our healthcare team and patients and families in the environment. So it really gives us a reason to speak up when something doesn’t seem right.

And then the second group of categorizing the high reliable organization is containment. “Hey, how do you get out of trouble?” And that one is the difference to expertise.

We designed our safety huddles where reporting comes from our front line. This gives us the opportunity to pull a team, including the front line staff, together to problem solve, whether it’s a PDSA or RPIW, which is a rapid process improvement workout.

And then the last part of the principles of high-reliable organizations, is that commitment to resilience. The safety huddles are preparing. It is preparing for a day at our hospital, so we are like a good voter who’s preparing for situations that are unlikely to happen, but possible before leaving the dock, leaders are able to build on our non-punitive environment knowing that mistakes could happen and focus in on how we can minimize preventable, harmful events. We identify gaps and we put structures in place so that we can respond.

so we define our purpose, of a daily safety “Huddle as to promote situational awareness of current issues that have the potential to impact the safety, quality and service of the care delivered for this day, and to provide direction about the prioritization and responsibility for problem resolution.”

Our resource for beginning was a 2013 video published by HURT that was provided by the advocate healthcare demonstrating the importance and key components of daily safety huddles.

We shared that with our leadership team back in August of 2016, and we made a decision. “Hey, let’s give it a go.” And it really was a best-practice initiative to improve our safety culture. And so we are an organization within their alive and well team steps programs. So situational awareness was well-versed within our organization in a good place for us to kind of aim from.

So we adopted this closed-loop communication mode for constructive ways for our staff to bring concerns and issues encountered to the daily huddles on their units, and then for the leaders to bring information from the staff to the safety huddle and then leaders bring in information back from the huddle to the staff.

Our agenda was set up to really like, “Hey let’s look back for significant safety quality or service issues from the past 24 hours. Look ahead, like where we can anticipate and plan for safety, quality or service issues that may occur within the next 24 hours, and then follow-up. Report on issues identified on previous days and what we’re doing to solve them.

So in our building of resilience, we scheduled it. “Hey, we all agree that nine-am would be a good time to start.” We scheduled it in our boardroom, as a good central place for us to meet. Those leaders that are off campus, they join in on our conference line. We wanted to keep our safety huddle for a 15 minute max, and for each departmental leader, both clinical and non-clinical, or their designee to attend the daily safety huddles.

We had said from the beginning, to refrain from the urge to discuss or to really dig into the problems at the table, rather we just wanted to focus on surfacing, not solving issues. Refrain from sidebar conversations and connect the shift huddles to the whole house huddles.

Our biggest issue in the beginning was refraining from digging deep into problem solving in the safety huddle. As an organization, we tend to be all problem solvers. So we were really quick to just wanna talk more and more about the issues at hand.

We also had a challenge of working through defensiveness, when another department reported issues involving our departments, so it really worked on breaking down silos between departments, as well.

About a year into our safety huddles, we had some habits that were forming in our safety huddles where we were adding a lot of general topics, like announcements of what was going on in discussions about maybe even personal issues and stuff in the huddle started to last about 30 minutes.

We also had a lot of departments who, just there were non-clinical departments who had nothing to report, but we were going through the whole list of our leaders. And so, day after day, they were like… “I have nothing to report no safety issues or that type of thing.” The representation from the departments were no longer consistent and there was some lag in our starting on time. So what we did is, we conducted a survey with our leadership and we asked a series of questions based on our purpose and what were some of our aim of doing safety huddles and how we were doing.

And so, I have a summary of our results on this slide.

Our leaders themselves stated that on a weekly basis that they were hearing in safety concerns, being reported, and that weekly they were hearing key safety information.

They also stated that their front line staff, was contributing to the safety huddle, and on a weekly basis, and that they were committed to routinely reporting back to the frontline staff.

And when we shared these results with our leadership, So like it was almost easy for me as a patient safety officer. When I put this information up it was like, “wait, We should be doing this.”

So this was really critical data that we were reporting at these meetings and leaders really started to see that this was worthwhile. And so we knew we had a process that was an impact in our safety culture.

So our CEO, reviewed our ground rules with us again in our safety huddles, we talked about arriving on time, appointing a designee, if we can’t be present, being prepared for our meetings so that we can have, from our department teams, what they had huddled before and gather that information before the leadership safety huddle. Know the information that we would bring into the Hutto and presenting it clearly and concisely and know the order of reporting.

We have a routine of which department reports when, so it helps to move along. And then also to request time for follow-up further discussion outside of the huddleOtto meeting. So whenever we reviewed this and the purpose of conducting the safety huddles, we really defined our expectations. It really helped us to have our safety huddles more productive.

We keep this information available at our safety Huddle so that if we need just in time reminder for our team as well.

So the worthwhile work. now we’ve completed our second year of doing safety huddles so we really feel like we sustained this worthwhile work. Our leaders do attend safety huddles on a daily basis — or at a minimum, they can send a designee or ask another leader to report out for them, so that we have that daily report.

Leaders openly discuss what type of information that they wanna hear. Leaders created standardized reports, they really, those that didn’t have a standardized report in their department whenever we did our survey, some of those departments started to model off of the other leaders to say, “Hey how are you getting this information?” So we really got better at gathering information from our front line staff, so that way we can have our reports ready.

And then sustaining mindful infrastructure. This is something that our CEO had talked to us about in that employee forum that I had talked about, we did that in September of this year, and it was really aimed around our safety culture and high reliability. She used these two definitions, and first she said “mindfulness is the quality or state of being conscious or aware of something”, and then she uses our safety Huddles as an example of how we share a daily practice of mindfulness in this second definition. that “it’s a rich awareness of discriminatory detail and an enhanced ability to discover incorrect errors that could escalate into a crisis.” Really, whenever you start thinking about what we’ve done in this progression over two years, our safety huddle has really become worthwhile work in our culture of safety.

It was just the types of reporting that we do in safety huddles.

I had pulled our data; we have a binder of information from our safety us with an agenda so we can go back if we miss the safety huddle it’s available for any leader to go in and see. Or, if they needed data from the past, we have all that information, so it’s just really some of our constant things that we will hear about.

Same name alerts, like our registration which own staff usually give this, if there’s any same name alerts on the inpatient or outpatient pharmacy.
Lets us know about drug shortages.
If there’s a need for team adaptability because of a high census, acuity or staffing issue, that’s a very common report.
Alerts to projects by IT or environmental services, or maintenance and how we might need to all coordinate.
The first time performing a new procedure test. Or treatment or using a new piece of equipment or instrument,
A new physicians on duty in our emergency room or in our specialty clinics that they may be consulting.
An update in our information systems or e-form, definitely our reporting of zero harm or if there is an occurrence of a harm-vent a near misses and good catches.
The days since events, like how many days it’s been since fall or isolation.
Our NDRO Precautions on our units, our swallow precautions, our suicide precautions in the emergency room
our resources that may be needed to support other departments.
Any downtime on equipment or test
opportunities, identify by our frontline staff
coordination or throughput issues
alarms and failures evaluation of it is reported.
Any watches or warnings, whether it’s our environment, like our weather or anything that’s going on within the hospital
reminders of changing time on our clock.
I just had to put that in for HSLI
Completing tasks before Deadline
and then follow up on previous opportunities,
and then any administrative support requests that we have

We do have some really well-defined reporting tools that we have in different departments that really are departmental specific so we would be glad to share any of that information, or our actual safety agenda that we use on a daily basis and how that’s kind of changed over time.

So I know that if you have any questions, Stacie will be open to any of those questions. Here’s my contact information, you’re welcome to reach out to us and we’ll be glad to share the work we’ve done and safety huddles in building the resilience here at St. James Parish Hospital. Thanks!

Stacie: Thank you so much, Geri. That was a wonderful presentation. I just have a couple of questions about the huddles.

Who exactly do you guys include in the huddle? I know the clinical nurse managers, but you also include pharmacy and therapy and ABS supervisors and is it all managers?

Geri: Yeah, we have, of course, we have our nurse leaders from each one of our departments, the OR the ER and our inpatient unit, our case managers there, cardiopulmonary lab rehab, radiology leader, dieticians, our nutrition leader, pharmacy. Our clinic leader is also there, facilities security, so our security card representative is there, materials is there. So then it becomes like, all of our resource people, patient access, our PSS manager, of course, I’m there as a quality, and Sabrina Anderson is also our documentation improvement specialist. She’s there, our safety officer is there, IT, HIM, Employee Health, HR, marketing, they’re all at the table.

So, you did it at a set time every day?

Yeah, we do it at 9 AM, we do Monday through Friday. And so, it’s part of our routine that will meet in the boardroom each morning.

One of the questions I have about the team is medical staff involved?

Whenever we have medical directors meeting, which a lot of times those meetings start at 8 AM, we will break in that meeting and have our huddle. So our physicians who are attending that meeting will stay in for the safety huddle. So they do know of our safety huddle in a departmental level, you know they’re in our department, a lot of times on our rounds. So, they’re gathering information from the front line, which includes our physicians who’s in-house.

So a lot of times we may have information that’s coming up that very much could have physician involvement, or reporting, or a concern from them because it’s coming from the front line.

Okay, okay, and how long is your meeting?

What’s your goal for the length of the meeting to not go over?

Our goal is for 15 minutes, and they really stick to it. It’s rare that we go over 15 minutes.

Yeah, it is kind of amazing that you can do all that in 15 minutes. I can see how you really have to stick to an agenda and be very focused because you could go off on a lot of different trails. I can see how you could get deep.

So, yeah, well, that’s a really great project, and I wanna thank everybody for attending the presentation this morning, and I hope that you’ll be able to take some of the information that Geri has shared, and incorporate it into maybe a project that you’re working on in your organization.

If you have any questions after this presentation, please feel free to get in touch with Geri directly, or feel free to contact myself or your patient safety consultant, and we can always get you connected with Geri, or we can help get an answer to your question, but thank you very much and have a nice day.

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