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Leonard C, Gilmartin H, Starr L, Anderson T. Leadership and the high reliability transformation: A qualitative study at Truman VA medical center. J Healthc Risk Manag 2024; 44:17-23. [PMID: 39046927 DOI: 10.1002/jhrm.21580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 07/08/2024] [Indexed: 07/27/2024]
Abstract
The Department of Veterans Affairs (VA) has committed to becoming a High Reliability Organization (HRO). The Truman VA Medical Center (VAMC) successfully implemented and sustained foundational HRO elements over a period with several changes in facility executive leadership. We interviewed current and past leaders at Truman to understand how they retained fidelity to the HRO transformation. We conducted 16 interviews with 14 leaders involved in the HRO transformation and identified three themes related to the Truman HRO transformation: (1) Leadership visibly drove culture change through intentional communication and modeling HRO principles; (2) Leadership deferred to frontline expertise and empowered staff to make changes and to fail; (3) Hiring the right team members for the organizational culture and investing in training can support HRO principles and values. Our findings highlight key actions for leaders in the context of HROs: regularly communicate the significance of HRO, demonstrate behavior consistent with what they hope to see from staff, celebrate failure, allocate time and resources to the creation of hiring frameworks that identify employee skillsets conducive to HRO principles, and substantial and recurring investments in employee development. Importantly, successive executive leaders at Truman VAMC modeled these skills to promote and sustain the HRO transformation.
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Affiliation(s)
- Chelsea Leonard
- Denver-Seattle Center of Innovation for Veteran-Centered & Value-Driven Care (COIN), VA Eastern Colorado Healthcare System, Aurora, USA
- Division of Health Care Policy and Research, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Heather Gilmartin
- Denver-Seattle Center of Innovation for Veteran-Centered & Value-Driven Care (COIN), VA Eastern Colorado Healthcare System, Aurora, USA
- Health Systems, Management and Policy, University of Colorado, School of Public Health, Aurora, USA
- Colorado Clinical & Translational Sciences Institute, Aurora, Colorado, USA
| | - Leigh Starr
- VHA High Reliability Enterprise Support, VHA Quality and Patient Safety, Veterans Health Administration (VHA)
| | - Timothy Anderson
- Department of Veterans Affairs, VISN 15 Heartland Network, Kansas City, USA
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Incze T, Pinkney SJ, Li C, Hameed U, Hallbeck MS, Grantcharov TP, Trbovich PL. Using the Operating Room Black Box to Assess Surgical Team Member Adaptation Under Uncertainty: An Observational Study. Ann Surg 2024; 280:75-81. [PMID: 38193296 PMCID: PMC11161221 DOI: 10.1097/sla.0000000000006191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
OBJECTIVE Identify how surgical team members uniquely contribute to teamwork and adapt their teamwork skills during instances of uncertainty. BACKGROUND The importance of surgical teamwork in preventing patient harm is well documented. Yet, little is known about how key roles (nurse, anesthesiologist, surgeon, and medical trainee) uniquely contribute to teamwork during instances of uncertainty, particularly when adapting to and rectifying an intraoperative adverse event (IAE). METHODS Audiovisual data of 23 laparoscopic cases from a large community teaching hospital were prospectively captured using OR Black Box. Human factors researchers retrospectively coded videos for teamwork skills (backup behavior, coordination, psychological safety, situation assessment, team decision-making, and leadership) by team role under 2 conditions of uncertainty: associated with an IAE versus no IAE. Surgeons identified IAEs. RESULTS In all, 1015 instances of teamwork skills were observed. Nurses adapted to IAEs by expressing more backup behavior skills (5.3× increase; 13.9 instances/hour during an IAE vs 2.2 instances/hour when no IAE) while surgeons and medical trainees expressed more psychological safety skills (surgeons: 3.6× increase; 30.0 instances/hour vs 6.6 instances/hour and trainees: 6.6× increase; 31.2 instances/hour vs 4.1 instances/hour). All roles expressed fewer situation assessment skills during an IAE versus no IAE. CONCLUSIONS OR Black Box enabled the assessment of critically important details about how team members uniquely contribute during instances of uncertainty. Some teamwork skills were amplified, while others dampened when dealing with IAEs. The knowledge of how each role contributes to teamwork and adapts to IAEs should be used to inform the design of tailored interventions to strengthen interprofessional teamwork.
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Affiliation(s)
- Taylor Incze
- Dalla Lana School of Public Health, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Sonia J. Pinkney
- Dalla Lana School of Public Health, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Cherryl Li
- Dalla Lana School of Public Health, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Usmaan Hameed
- Department of Surgery, North York General Hospital, Toronto, ON, Canada
| | - M. Susan Hallbeck
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN
- Department of Surgery, Mayo Clinic, Rochester, MN
| | - Teodor P. Grantcharov
- Department of Surgery, Clinical Excellence Research Centre, Stanford University, Stanford, CA
| | - Patricia L. Trbovich
- Dalla Lana School of Public Health, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- HumanEra, Office of Research and Innovation, North York General Hospital, Toronto, ON, Canada
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Conroy SA, Vogus TJ. Pay practices and safety organizing: Evidence from hospital nursing units. Health Care Manage Rev 2024; 49:68-73. [PMID: 38019465 DOI: 10.1097/hmr.0000000000000392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
BACKGROUND Our understanding of how highly reliable care delivery is brought about remains elusive, in part, because there is limited evidence regarding the organizational practices that enable safety organizing-the behaviors and processes underlying high reliability. PURPOSE Because safety organizing relies on discretionary effort and lowering barriers to sharing expertise and discussing threats to safety and errors, we investigate three pay practices and their effects on information sharing and, in turn, safety organizing. Specifically, we examine average pay level, minimum pay rates, and pay dispersion on nursing units and their relationship with information sharing and safety organizing. METHOD Cross-sectional analyses of survey data from 1,461 registered nurses in 45 nursing units in three Midwestern hospitals on safety organizing linked to administrative data on pay practices from the organization's human resource systems. Pay data and survey responses were aggregated to the nursing unit level. PROCESS and structural equation modeling were used to simultaneously test for direct and indirect effects of pay variables on information sharing and safety organizing. RESULTS PROCESS and Mplus path analysis indicated that paying a higher minimum rate in the unit and having lower pay dispersion have indirect, desirable associations with safety organizing through information sharing. CONCLUSION Pay practices can help organizations enhance safety organizing. In particular, higher pay rates for the lowest level nurses and lower pay dispersion among nurses are associated with unit-level information sharing and safety organizing. PRACTICE IMPLICATIONS Having pay practices associated with lower within-unit variation and higher pay for the lowest paid members of a unit may be viable strategies for greater information sharing and safety organizing.
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Sutcliffe KM. Building Cultures of High Reliability: Lessons from the High Reliability Organization Paradigm. Anesthesiol Clin 2023; 41:707-717. [PMID: 37838378 DOI: 10.1016/j.anclin.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
Safety models from disciplines outside of health care have begun to diffuse into the health care safety arena. This article explores high reliability organizing (HRO) theory, which privileges culture as means to adaptively learn and reliably perform. A brief history of the HRO paradigm and factors that contribute to cultures of high reliability is provided, followed by review of existing research to discern which HRO ideas have diffused into research on anesthesiology and perioperative care. High reliability research is growing and concepts seem useful; but there is a long way to go before the benefits of HRO are fully realized.
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Affiliation(s)
- Kathleen M Sutcliffe
- Johns Hopkins University, Carey Business School, 100 International Drive, Room 1217, Baltimore, MD 21202, USA.
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Page B, Irving D, Amalberti R, Vincent C. Health services under pressure: a scoping review and development of a taxonomy of adaptive strategies. BMJ Qual Saf 2023:bmjqs-2023-016686. [PMID: 38050158 DOI: 10.1136/bmjqs-2023-016686] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 11/07/2023] [Indexed: 12/06/2023]
Abstract
OBJECTIVE The objective of this review was to develop a taxonomy of pressures experienced by health services and an accompanying taxonomy of strategies for adapting in response to these pressures. The taxonomies were developed from a review of observational studies directly assessing care delivered in a variety of clinical environments. DESIGN In the first phase, a scoping review of the relevant literature was conducted. In the second phase, pressures and strategies were systematically coded from the included papers, and categorised. DATA SOURCES Electronic databases (MEDLINE, Embase, CINAHL, PsycInfo and Scopus) and reference lists from recent reviews of the resilient healthcare literature. ELIGIBILITY CRITERIA Studies were included from the resilient healthcare literature, which used descriptive methodologies to directly assess a clinical environment. The studies were required to contain strategies for managing under pressure. RESULTS 5402 potential articles were identified with 17 papers meeting the inclusion criteria. The principal source of pressure described in the studies was the demand for care exceeding capacity (ie, the resources available), which in turn led to difficult working conditions and problems with system functioning. Strategies for responding to pressures were categorised into anticipatory and on-the-day adaptations. Anticipatory strategies included strategies for increasing resources, controlling demand and plans for managing the workload (efficiency strategies, forward planning, monitoring and co-ordination strategies and staff support initiatives). On-the-day adaptations were categorised into: flexing the use of existing resources, prioritising demand and adapting ways of working (leadership, teamwork and communication strategies). CONCLUSIONS The review has culminated in an empirically based taxonomy of pressures and an accompanying taxonomy of strategies for adapting in response to these pressures. The taxonomies could help clinicians and managers to optimise how they respond to pressures and may be used as the basis for training programmes and future research evaluating the impact of different strategies.
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Affiliation(s)
- Bethan Page
- Department of Experimental Psychology, University of Oxford, Oxford, UK
- Cicely Saunders Institute, King's College London, London, UK
| | - Dulcie Irving
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Rene Amalberti
- Foundation for Industrial Safety Culture, FONCSI, Toulouse, France
| | - Charles Vincent
- Department of Experimental Psychology, University of Oxford, Oxford, UK
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Pozzobon LD, Lam J, Chimonides E, Perkins-Meingast B, Luk WS. Adopting high reliability organization principles to lead a large scale clinical transformation. Healthc Manage Forum 2023:8404704231162785. [PMID: 37025027 DOI: 10.1177/08404704231162785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Building high reliable healthcare systems to reduce avoidable patient harm is a global priority. However, there is variability in the application and understanding of the previously identified High Reliability Organization (HRO) principles to make improvements. We describe specific organizational activities exemplifying the five HRO principles during the planning and go-live periods of the new Electronic Health Record (EHR) system at a multi-site academic health sciences centre in Ontario, Canada. Further, we describe a case example where all five HRO principles were exemplified during EHR implementation. Overall, 23 activities exemplifying organizational anticipation and resiliency were identified. Of the 23 activities, 12 occurred during the preparing for go-live and 11 activities occurred during the go-live periods. This paper demonstrates how HRO principles can be used in healthcare to detect and adapt to patient safety threats, in order to prevent avoidable patient harm during large scale change.
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Affiliation(s)
| | - Jessica Lam
- 7989University Health Network, Toronto, Ontario, Canada
| | | | | | - Wing-Si Luk
- 7989University Health Network, Toronto, Ontario, Canada
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Huang H, Tang Y, Yu Y, Yu A, Wu D, Fang H, Wang S, Sun C, Wang X, Fan Q, Fang Y, Tang Q, Jiang N, Du J, Miao H, Bai Y, Ma P, Xing S, Cui D, Miao S, Jiang Y, Zhu J, Zhu Q, Leng Y, Guo LW, Liao S, Shao Y, Song Y, Liu Z, Hong M, Luo S, Xu B, Lan G, Li N. The reliability and integrity of overall survival data based on follow-up records only and potential solutions to the challenges. THE LANCET REGIONAL HEALTH - WESTERN PACIFIC 2023; 31:100624. [DOI: 10.1016/j.lanwpc.2022.100624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/20/2022] [Accepted: 10/13/2022] [Indexed: 11/19/2022]
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Goldman J, Rotteau L, Flintoft V, Jeffs L, Baker GR. Measurement and Monitoring of Safety Framework: a qualitative study of implementation through a Canadian learning collaborative. BMJ Qual Saf 2022:bmjqs-2022-015017. [PMID: 36598000 DOI: 10.1136/bmjqs-2022-015017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 11/04/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The Measurement and Monitoring of Safety Framework (MMSF) aims to move beyond a narrow focus on measurement and past harmful events as the major focus for safety in healthcare organisations. There is limited evidence of MMSF implementation and impact. OBJECTIVE We aimed to examine participants' perspectives and experiences to increase understanding of the adaptive work of implementing the MMSF through a learning collaborative programme in diverse healthcare contexts across Canada. METHODS The Collaborative consisted of 11 teams from seven provinces. We conducted a qualitative study involving interviews with 36 participants, observations of 5 sites and learning sessions, and collection of documents. RESULTS Collaborative sessions and coaching allowed participants to explore reliability, sensitivity to operations, anticipation and preparedness, and integration and learning, in addition to past harm, and move beyond a project and measurement oriented safety approach. Participants noted the importance of time dedicated to engaging stakeholders in talk about MMSF concepts and their significance to their settings, prior to moving to implementing the Framework into practice. While participants generally started with a small number of ways of integrating the MMSF into practice such as rounds or huddles, many teams continued to experiment with incorporating the MMSF into a range of practices. Participants reported changes in thinking about safety, discussions and behaviours, which were perceived to impact healthcare processes. However, participants also reported challenges to sharing the Framework broadly and moving beyond its surface implementation, and difficulties with its sustained and widespread use given misalignments with existing quality and safety processes. CONCLUSION The MMSF requires a dramatic departure from traditional safety strategies that focus on discrete problems and emphasise measurement. MMSF implementation requires extensive discussion, coaching and experimentation. Future implementation should consider engaging local leaders and coaches and an organisation or system approach to enable broader reach and systemic change.
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Affiliation(s)
- Joanne Goldman
- Centre for Quality Improvement and Patient Safety, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Leahora Rotteau
- Centre for Quality Improvement and Patient Safety, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Virginia Flintoft
- Health Policy, Management and Evaluation, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Lianne Jeffs
- Health Policy, Management and Evaluation, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada.,Institute for the Science of Care and Innovation, Sinai Health System, Toronto, Ontario, Canada
| | - G Ross Baker
- Health Policy, Management and Evaluation, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
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Myers CG, Sutcliffe KM. High reliability organising in healthcare: still a long way left to go. BMJ Qual Saf 2022; 31:845-848. [DOI: 10.1136/bmjqs-2021-014141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2022] [Indexed: 12/23/2022]
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