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."