A case of the birth and death of a high reliability healthcare organisation

Leveraging the Science of Teamwork to Sustain Handoff Improvements in Cardiovascular Surgery

BACKGROUND

Improving the reliability of handoffs and care transitions is an important goal for many health care organizations. Increasing evidence shows that human-centered design and improved teamwork can lead to sustainable care transition improvements and better patient outcomes. This study was conducted within a cardiovascular service line at an academic medical center that performs more than 600 surgical procedures annually. A handoff process previously implemented at the center was poorly adopted. This work aimed to improve cardiovascular handoffs by applying human factors and the science of teamwork.

METHODS

The study's quality improvement method used Plan-Do-Study-Act cycles and participatory design and ergonomics to develop, implement, and assess a new handoff process and bundle. Trained observers analyzed video-recorded and live handoffs to assess teamwork, leadership, communication, coordination, cooperation, and sustainability of unit-defined handoff best practices. The intervention included a teamwork-focused redesign process and handoff bundle with supporting cognitive aids and assessment metrics.

RESULTS

The study assessed 153 handoffs in multiple phases over 3 years (2016-2019). Quantitative and qualitative assessments of clinician (teamwork) and implementation outcomes were performed. Compared with the baseline, the observed handoffs demonstrated improved team leadership (p < 0.0001), communication (p < 0.0001), coordination (p = 0.0018), and cooperation (p = 0.007) following the deployment of the handoff bundle. Sustained improvements in fidelity to unit-defined handoff best practices continued 2.3 years post-deployment of the handoff bundle.

CONCLUSION

Participatory design and ergonomics, combined with implementation and safety science principles, can provide an evidence-based approach for sustaining complex sociotechnical change and making handoffs more reliable.

Interventions Into Reliability-Seeking Health Care Organizations: A Systematic Review of Their Goals and Measuring Methods

OBJECTIVES

Within the last 2 decades, numerous interventions making use of high-reliability theory have been implemented to increase reliability in healthcare organizations. This systematic literature review first explores the concrete goals on which such interventions focus. Second, the review captures how the achievement of these goals, or alternatively a change, generally an increase in organizational reliability, is measured across different contexts.

METHODS

Searches were conducted in PubMed, Academic Search Ultimate, Business SourcePremier, CINAHL, Communication Source, EconLit, ERIC, Medline, Political Science Complete, PsycArticles, APA PsycInfo, PSYNDEX, SocINDEX (via the resource hosterEbscoHost), and Web of Science (through November 22, 2021). Peer-reviewed, English language studies were included, reporting on the implementation of a concrete intervention to increase reliability in a medical context and referring to high-reliability theory.

RESULTS

The search first yielded 8896 references, from which 75 studies were included in the final sample. Important healthcare goals stated by the seminal report "Crossing the Quality Chasm" guided the analysis of the included studies. Most of the studies originated from the United States and report on interventions to increase reliability of either organizational units or whole organizations when aiming for safety (n = 65). Other goals reported on include effectiveness, and much less frequently timeliness, patient centeredness, and efficiency. Fifty-eight studies use quantitative measurement exclusively to account for the achievement of these goals; 7 studies use qualitative measurement exclusively, and 10 studies use a mixed-method approach. The operationalization of goals, including the operationalization of organizational reliability, and measurement methods do not follow a unified approach, despite claiming to be informed by a coherent theory. Instead, such operationalizations strongly depend on the overall objective of the study and the respective context.

CONCLUSIONS

Measuring the outcomes of high-reliability interventions into healthcare organizations is challenging for different reasons, including the difficult operationalization of partly overlapping goals, the complex, processual nature of achieving reliability, and the limited ability of organizations striving for more reliability if they are already performing on a high level. This review critically assesses the adoption of the goals stated in the seminal report "Crossing the Quality Chasm" and provides insights for organizations and funding providers that strive to evaluate more reliable service provision.

Striving for high reliability in healthcare: a qualitative study of the implementation of a hospital safety programme

BACKGROUND

Healthcare leaders look to high-reliability organisations (HROs) for strategies to improve safety, despite questions about how to translate these strategies into practice. Weick and Sutcliffe describe five principles exhibited by HROs. Interventions aiming to foster these principles are common in healthcare; however, there have been few examinations of the perceptions of those who have planned or experienced these efforts.

OBJECTIVE

This single-site qualitative study explores how healthcare professionals understand and enact the HRO principles in response to an HRO-inspired hospital-wide safety programme.

METHODS

We interviewed 71 participants representing hospital executives, programme leadership, and staff and physicians from three clinical services. We observed and collected data from unit and hospital-wide quality and safety meetings and activities. We used thematic analysis to code and analyse the data.

RESULTS

Participants reported enactment of the HRO principles 'preoccupation with failure', 'reluctance to simplify interpretations' and 'sensitivity to operations', and described the programme as adding legitimacy, training, and support. However, the programme was more often targeted at, and taken up by, nurses compared with other groups. Participants were less able to identify interventions that supported the HRO principles 'commitment to resilience' and 'deference to expertise' and reported limited examples of changes in practices related to these principles. Moreover, we identified inconsistent, and even conflicting, understanding of concepts related to the HRO principles, often related to social and professional norms and practices. Finally, an individualised rather than systemic approach hindered collective actions underlying high reliability.

CONCLUSION

Our findings demonstrate that the safety programme supported some HRO principles more than others, and was targeted at, and perceived differently across professional groups leading to inconsistent understanding and enactments of the principles across the organisation. Combining HRO-inspired interventions with more targeted attention to each of the HRO principles could produce greater, more consistent high-reliability practices.

Evaluating the safety and patient impacts of an artificial intelligence command centre in acute hospital care: a mixed-methods protocol

INTRODUCTION

This paper presents a mixed-methods study protocol that will be used to evaluate a recent implementation of a real-time, centralised hospital command centre in the UK. The command centre represents a complex intervention within a complex adaptive system. It could support better operational decision-making and facilitate identification and mitigation of threats to patient safety. There is, however, limited research on the impact of such complex health information technology on patient safety, reliability and operational efficiency of healthcare delivery and this study aims to help address that gap.

METHODS AND ANALYSIS

We will conduct a longitudinal mixed-method evaluation that will be informed by public-and-patient involvement and engagement. Interviews and ethnographic observations will inform iterations with quantitative analysis that will sensitise further qualitative work. Quantitative work will take an iterative approach to identify relevant outcome measures from both the literature and pragmatically from datasets of routinely collected electronic health records.

ETHICS AND DISSEMINATION

This protocol has been approved by the University of Leeds Engineering and Physical Sciences Research Ethics Committee (#MEEC 20-016) and the National Health Service Health Research Authority (IRAS No.: 285933). Our results will be communicated through peer-reviewed publications in international journals and conferences. We will provide ongoing feedback as part of our engagement work with local trust stakeholders.

Improving long-term care services: insights from high-reliability organizations

PURPOSE

Long-term care (LTC) organizations have struggled to protect their vulnerable clients from the ravages of the COVID-19 pandemic. Although various suggestions on containing outbreaks in LTC facilities have gained prominence, ensuring the safety of residents is not just a crisis issue. In that context, the authors must reasses the traditional management practices that were not sufficient for handling unexpected and demanding conditions. The purpose of this paper is to suggest rethinking the underlying attributes of LTC organizations and drawing insight from the parallels they have to high-reliability organizations (HROs).

DESIGN/METHODOLOGY/APPROACH

The authors analyzed qualitative data collected from a Canadian LTC facility to shed light on the current state of reliability practices and culture of the LTC industry and to identify the strengths and weaknesses of the traditional management approaches.

FINDINGS

To help the LTC industry develop the necessary crisis management capacity to tackle unexpected future challenges, there is an urgent need for adopting a more systemic top-down approach that cultivates mindfulness, learning and resilience.

ORIGINALITY/VALUE

This study contributes by applying the HRO theoretical lens in the LTC context. The study provides the LTC leaders with insights into creating a unified effort at the industry level to give rise to a high-reliability-oriented industry.

Intervening in Interruptions: What Exactly Is the Risk We Are Trying to Manage?

ABSTRACT

Interruptions are thought to be significantly associated with medication administration errors. Researchers have tried to reduce medication errors by decreasing or eliminating interruptions. In this article, we argue that interventions are often (perhaps unreflectively) based on one particular model of risk reduction-that of barriers placed between the source of risk and the object-to-be-protected. Well-intentioned interventions can lead to unanticipated effects because the assumptions created by the risk model are not critically examined. In this article, we review the barrier model and the assumptions it makes about risk and risk reduction/prevention, as well as the model's incompatibility with work in healthcare. We consider how these problems lead to interruptions interventions with unintended negative consequences. Then, we examine possible alternatives, viz organizing work for high reliability, preventing safety drift, and engineering resilience into the work activity. These all approach risks in different ways, and as such, propose interruptions interventions that are vastly different from interventions based on the barrier model. The purpose of this article is to encourage a different approach for designing interruptions interventions. Such reflection may help healthcare communities innovate beyond old, ineffective, and often counterproductive interventions to handle interruptions.

Veränderte Kompetenzanforderungen an Mitarbeitende infolge zunehmender Automatisierung – Eine Arbeitsfeldbetrachtung

Basierend auf einer Arbeitsfeldbetrachtung im Bereich der Flugsicherung in Österreich und der Schweiz liefert dieser Artikel der Zeitschrift Gruppe. Interaktion. Organisation. (GIO) einen Überblick über automatisierungsbedingte Veränderungen und die daraus resultierenden neuen Kompetenzanforderungen an die Beschäftigten im Hochverantwortungsbereich. Bestehende Tätigkeitsstrukturen und Arbeitsrollen verändern sich infolge zunehmender Automatisierung grundlegend, sodass Organisationen neuen Herausforderungen gegenüberstehen und sich neue Kompetenzanforderungen an Mitarbeitende ergeben. Auf Grundlage von 9 problemzentrierten Interviews mit Fluglotsen sowie 4 problemzentrierten Interviews mit Piloten werden die Veränderungen infolge zunehmender Automatisierung und die daraus resultierenden neuen Kompetenzanforderungen an die Beschäftigten in einer High Reliability Organization dargestellt. Dieser Organisationskontext blieb bisher in der wissenschaftlichen Debatte um neue Kompetenzen infolge von Automatisierung weitestgehend unberücksichtigt. Die Ergebnisse deuten darauf hin, dass der Mensch in High Reliability Organizations durch Technik zwar entlastet und unterstützt werden kann, aber nicht zu ersetzen ist. Die Rolle des Menschen wird im Sinne eines Systemüberwachenden passiver, wodurch die Gefahr eines Fähigkeitsverlustes resultiert und der eigene Einfluss der Beschäftigten abnimmt. Ferner scheinen die Anforderungen, denen sie sich infolge zunehmender Automatisierung gegenüberstehen sehen, zuzunehmen, was in einem Spannungsfeld zu ihrer passiven Rolle zu stehen scheint. Die Erkenntnisse werden diskutiert und praktische Implikationen für das Kompetenzmanagement und die Arbeitsgestaltung zur Minimierung der identifizierten restriktiven Arbeitsbedingungen abgeleitet.

Understanding the Ecological Validity of Relying Practice as a Basis for Risk Identification

Understanding the reliability of hazardous organizations and their protective systems is central to understanding the risk they produce. Work on "high reliability organization" has done much to illuminate the conditions in which social organization becomes reliable in highly demanding conditions. But risk depends just as much on how relying entities do their relying as it does on the reliability of the entities they rely on. Patterns of relying are often opaque in sociotechnical systems, and processes of relying and being relied on are mutually influencing in complex ways, so the relationship between relying and risk may not be at all obvious. This study was an attempt to study relying as a social practice, in particular analyzing how it had ecological validity in a social organization-how practice was responsive to the conditions in which it took place. This involved observational fieldwork and inductive, qualitative analysis on an offshore oil and gas production platform that was nearing the end of its design life and undergoing refurbishment. The analysis produced four main categories of ecological validity: responsiveness to formal organization, responsiveness to situational contingency, responsiveness to information asymmetry, and responsiveness to sociomateriality. This ecological validity of relying practice should be a primary focus of risk identification, assessing how relying can become mismatched to reliability in certain ways, both when relying practice is responsive to circumstances and when it is not.

Spanish validation of the mindful organizing scale: A questionnaire for the assessment of collective mindfulness

INTRODUCTION

Mindful organizing (also known as collective mindfulness) is a team level construct that is said to underpin the principles of high-reliability organizations (HROs), as it has shown to lead to almost error-free performance. While mindful organizing research has proliferated in recent years, studies on how to measure mindful organizing are scarce. Vogus and Sutcliffe (2007) originally validated a nine-item "Mindful Organizing Scale" but few subsequent validation studies of this scale exist. The present study aimed to validate a Spanish version of the Mindful Organizing Scale.

METHOD

The sample included 47 teams (comprising of a total of 573 workers with an average team size of 12.19) from a Spanish nuclear power plant. A confirmatory factor analysis (CFA), reliability analysis, and an analysis of aggregation indices were carried out. A correlation analysis and CFA were used to further validate the scale in terms of its distinctiveness from, and relationship with, other team-related variables such as safety culture, team safety climate, and team learning. Finally, evidence of criterion-related validity was collected by testing the incremental validity of the mindful organizing scale in the association with various workplace safety outcomes (safety compliance and safety participation).

RESULTS

The results confirmed a unidimensional structure of the scale and indicated satisfactory internal consistency. Aggregation of the scores to the team level was justified while significant positive correlations between mindful organizing and other team-related variables (safety culture, team safety climate, team learning) were found. Moreover, mindful organizing showed distinctiveness from safety culture, team safety climate and team learning. Finally, incremental validity of the scale was supported, as it shows to be associated with safety compliance and safety participation above and beyond other related constructs.

CONCLUSIONS

The Spanish version of the Mindful Organizing Scale has shown to be a valid and reliable scale that can be used to measure mindful organizing.

CONTRIBUTIONS

The validation of the unidimensional Spanish version of Vogus and Sutcliffe's (2007) Mindful Organizing Scale provides researchers and practitioners with a reliable and valid tool to use in Spanish speaking organizations to measure mindful organizing, which has been shown to result in more reliable performance. Theoretically, this study offers four contributions. Firstly, it validates a scale that operationalizes the 'mindful organizing' construct in a traditional high-reliability organization (nuclear power plant) which has never been done before. Secondly, it offers evidence that a mindful organizing scale can be validated in a new cultural context and language (Spanish) to any of the previous studies done before it. Thirdly, it adds to our understanding of mindful organizing's nomological network by distinguishing it from other team and safety-related variables. Lastly, it builds on current research showing sound psychometric properties of a one-dimensional, quantitative measure of mindful organizing.

Simulation Training Improves Resuscitation Team Leadership Skills of Nurse Practitioners

INTRODUCTION

In the current era of limited physician trainee work hours, limited nurse practitioner orientation times, and highly specialized care settings, frontline providers have limited opportunities for mentored resuscitation training in emergency situations. We aimed to evaluate the effectiveness of a pilot program to improve resuscitation team leadership skills of nurse practitioners using simulation-based training.

METHODS

Seven nurse practitioners underwent a 4-hour simulation course in pediatric cardiac emergencies. Pre- and post-course surveys were conducted to evaluate previous emergency leadership experience and self-reported comfort in the team lead role. The time to verbalization of a shared mental model to the team was tracked during the simulations.

RESULTS

The increases in self-reported comfort level in team leading, sharing a mental model, and differential diagnosis were statistically significant. Average time to shared mental model significantly decreased between simulations.

DISCUSSION

Simulation can improve code leadership skills of nurse practitioners. These preliminary findings require confirmation in larger studies.

Mindful organizing in patients' contributions to primary care medication safety

Background

There is a need to ensure that the risks associated with medication usage in primary health care are controlled. To maintain an understanding of the risks, health‐care organizations may engage in a process known as “mindful organizing.” While this is typically conceived of as involving organizational members, it may in the health‐care context also include patients. Our study aimed to examine ways in which patients might contribute to mindful organizing with respect to primary care medication safety.

Method

Qualitative focus groups and interviews were carried out with 126 members of the public in North West England and the East Midlands. Participants were taking medicines for a long‐term health condition, were taking several medicines, had previously encountered problems with their medication or were caring for another person in any of these categories. Participants described their experiences of dealing with medication‐related concerns. The transcripts were analysed using a thematic method.

Results

We identified 4 themes to explain patient behaviour associated with mindful organizing: knowledge about clinical or system issues; artefacts that facilitate control of medication risks; communication with health‐care professionals; and the relationship between patients and the health‐care system (in particular, mutual trust).

Conclusions

Mindful organizing is potentially useful for framing patient involvement in safety, although there are some conceptual and practical issues to be addressed before it can be fully exploited in this setting. We have identified factors that influence (and are strengthened by) patients’ engagement in mindful organizing, and as such would be a useful focus of efforts to support patient involvement.

Integrating High-Reliability Principles to Transform Access and Throughput by Creating a Centralized Operations Center

High-reliability organizations (HROs) demonstrate unique and consistent characteristics, including operational sensitivity and control, situational awareness, hyperacute use of technology and data, and actionable process transformation. System complexity and reliance on information-based processes challenge healthcare organizations to replicate HRO processes. This article describes a healthcare organization's 3-year journey to achieve key HRO features to deliver high-quality, patient-centric care via an operations center powered by the principles of high-reliability data and software to impact patient throughput and flow.

Seeking high reliability in primary care: Leadership, tools, and organization

BACKGROUND

Leaders in health care increasingly recognize that improving health care quality and safety requires developing an organizational culture that fosters high reliability and continuous process improvement. For various reasons, a reliability-seeking culture is lacking in most health care settings. Developing a reliability-seeking culture requires leaders' sustained commitment to reliability principles using key mechanisms to embed those principles widely in the organization.

PURPOSE

The aim of this study was to examine how key mechanisms used by a primary care practice (PCP) might foster a reliability-seeking, system-oriented organizational culture.

METHODOLOGY

A case study approach was used to investigate the PCP's reliability culture. The study examined four cultural artifacts used to embed reliability-seeking principles across the organization: leadership statements, decision support tools, and two organizational processes. To decipher their effects on reliability, the study relied on observations of work patterns and the tools' use, interactions during morning huddles and process improvement meetings, interviews with clinical and office staff, and a "collective mindfulness" questionnaire. The five reliability principles framed the data analysis.

FINDINGS

Leadership statements articulated principles that oriented the PCP toward a reliability-seeking culture of care. Reliability principles became embedded in the everyday discourse and actions through the use of "problem knowledge coupler" decision support tools and daily "huddles." Practitioners and staff were encouraged to report unexpected events or close calls that arose and which often initiated a formal "process change" used to adjust routines and prevent adverse events from recurring. Activities that foster reliable patient care became part of the taken-for-granted routine at the PCP.

PRACTICE IMPLICATIONS

The analysis illustrates the role leadership, tools, and organizational processes play in developing and embedding a reliable-seeking culture across an organization. Progress toward a reliability-seeking, system-oriented approach to care remains ongoing, and movement in that direction requires deliberate and sustained effort by committed leaders in health care.

Interprofessional team management in pediatric critical care: some challenges and possible solutions

BACKGROUND

Aiming for and ensuring effective patient safety is a major priority in the management and culture of every health care organization. The pediatric intensive care unit (PICU) has become a workplace with a high diversity of multidisciplinary physicians and professionals. Therefore, delivery of high-quality care with optimal patient safety in a PICU is dependent on effective interprofessional team management. Nevertheless, ineffective interprofessional teamwork remains ubiquitous.

METHODS

We based our review on the framework for interprofessional teamwork recently published in association with the UK Centre for Advancement of Interprofessional Education. Articles were selected to achieve better understanding and to include and translate new ideas and concepts.

FINDINGS

The barrier between autonomous nurses and doctors in the PICU within their silos of specialization, the failure of shared mental models, a culture of disrespect, and the lack of empowering parents as team members preclude interprofessional team management and patient safety. A mindset of individual responsibility and accountability embedded in a network of equivalent partners, including the patient and their family members, is required to achieve optimal interprofessional care. Second, working competently as an interprofessional team is a learning process. Working declared as a learning process, psychological safety, and speaking up are pivotal factors to learning in daily practice. Finally, changes in small steps at the level of the microlevel unit are the bases to improve interprofessional team management and patient safety. Once small things with potential impact can be changed in one's own unit, engagement of health care professionals occurs and projects become accepted.

CONCLUSION

Bottom-up patient safety initiatives encouraging participation of every single care provider by learning effective interprofessional team management within daily practice may be an effective way of fostering patient safety.

The Safer Delivery of Surgical Services Program (S3): Explaining Its Differential Effectiveness and Exploring Implications for Improving Quality in Complex Systems

OBJECTIVE

To analyze the challenges encountered during surgical quality improvement interventions, and explain the relative success of different intervention strategies.

SUMMARY BACKGROUND DATA

Understanding why and how interventions work is vital for developing improvement science. The S3 Program of studies tested whether combining interventions addressing culture and system was more likely to result in improvement than either approach alone. Quantitative results supported this theory. This qualitative study investigates why this happened, what aspects of the interventions and their implementation most affected improvement, and the implications for similar programs.

METHODS

Semistructured interviews were conducted with hospital staff (23) and research team members (11) involved in S3 studies. Analysis was based on the constant comparative method, with coding conducted concurrently with data collection. Themes were identified and developed in relation to the program theory behind S3.

RESULTS

The superior performance of combined intervention over single intervention arms appeared related to greater awareness and ability to act, supporting the S3 hypothesis. However, we also noted unforeseen differences in implementation that seemed to amplify this difference. The greater ambition and more sophisticated approach in combined intervention arms resulted in requests for more intensive expert support, which seemed crucial in their success. The contextual challenges encountered have potential implications for the replicability and sustainability of the approach.

CONCLUSIONS

Our findings support the S3 hypothesis, triangulating with quantitative results and providing an explanatory account of the causal relationship between interventions and outcomes. They also highlight the importance of implementation strategies, and of factors outside the control of program designers.

Rationalizing Violation: Ordered Accounts of Intentionality in the Breaking of Safety Rules

Regulative rules are central to the efforts made in organizations to ensure orderliness in the presence of physical danger. The reportedly routine violation of safety rules in organizations therefore brings into question the longstanding association of rules with organizational order, and the literature is sharply divided on whether rule violation represents a dangerous disorder or a reasonable way of getting by. This study is an attempt to carry out a more interpretive analysis, looking at how organizational members construct a sense of order in the presence of rule violation – and in particular how they do so by using a concept of intentionality to maintain accountability yet avoid rules becoming taboos. We find that the way people explain intentions attests to several senses of order that otherwise appear to be lost when rules are violated, such as predictability, purposefulness and progressiveness. This indicates that rules do not maintain, symbolize and constitute order simply because they are normative restraints on behaviour – but act as nuclei for discourses that can repair order even when they are violated. The order that is repaired in this way is both a mechanistic and a moral one.

High performing hospitals: a qualitative systematic review of associated factors and practical strategies for improvement

BACKGROUND

High performing hospitals attain excellence across multiple measures of performance and multiple departments. Studying high performing hospitals can be valuable if factors associated with high performance can be identified and applied. Factors leading to high performance are complex and an exclusive quantitative approach may fail to identify richly descriptive or relevant contextual factors. The objective of this study was to undertake a systematic review of qualitative literature to identify methods used to identify high performing hospitals, the factors associated with high performers, and practical strategies for improvement.

METHODS

Methods used to collect and summarise the evidence contributing to this review followed the 'enhancing transparency in reporting the synthesis of qualitative research' protocol. Peer reviewed studies were identified through Medline, Embase and Cinahl (Jan 2000-Feb 2014) using specified key words, subject terms, and medical subject headings. Eligible studies required the use of a quantitative method to identify high performing hospitals, and qualitative methods or tools to identify factors associated with high performing hospitals or hospital departments. Title, abstract, and full text screening was undertaken by four reviewers, and inter-rater reliability statistics were calculated for each review phase. Risk of bias was assessed. Following data extraction, thematic syntheses identified contextual factors important for explaining success. Practical strategies for achieving high performance were then mapped against the identified themes.

RESULTS

A total of 19 studies from a possible 11,428 were included in the review. A range of process, output, outcome and other indicators were used to identify high performing hospitals. Seven themes representing factors associated with high performance (and 25 sub-themes) emerged from the thematic syntheses: positive organisational culture, senior management support, effective performance monitoring, building and maintaining a proficient workforce, effective leaders across the organisation, expertise-driven practice, and interdisciplinary teamwork. Fifty six practical strategies for achieving high performance were catalogued.

CONCLUSIONS

This review provides insights into methods used to identify high performing hospitals, and yields ideas about the factors important for success. It highlights the need to advance approaches for understanding what constitutes high performance and how to harness factors associated with high performance.

Safety organizing, emotional exhaustion, and turnover in hospital nursing units

CONTEXT

Prior research has found that safety organizing behaviors of registered nurses (RNs) positively impact patient safety. However, little research exists on how engaging in safety organizing affects caregivers.

OBJECTIVES

While we know that organizational processes can have divergent effects on organizational and employee outcomes, little research exists on the effects of pursuing highly reliable performance through safety organizing on caregivers. Specifically, we examined whether, and the conditions under which, safety organizing affects RN emotional exhaustion and nursing unit turnover rates.

SUBJECTS

Subjects included 1352 RNs in 50 intensive care, internal medicine, labor, and surgery nursing units in 3 Midwestern acute-care hospitals who completed questionnaires between August and December 2011 and 50 Nurse Managers from the units who completed questionnaires in December 2012.

RESEARCH DESIGN

Cross-sectional analyses of RN emotional exhaustion linked to survey data on safety organizing and hospital incident reporting system data on adverse event rates for the year before survey administration. Cross-sectional analysis of unit-level RN turnover rates for the year following the administration of the survey linked to survey data on safety organizing.

RESULTS

Multilevel regression analysis indicated that safety organizing was negatively associated with RN emotional exhaustion on units with higher rates of adverse events and positively associated with RN emotional exhaustion with lower rates of adverse events. Tobit regression analyses indicated that safety organizing was associated with lower unit level of turnover rates over time.

CONCLUSIONS

Safety organizing is beneficial to caregivers in multiple ways, especially on nursing units with high levels of adverse events and over time.

Organizational sensemaking about risk controls: the case of offshore hydrocarbons production

In the same way that individuals' risk perceptions can influence how they behave toward risks, how organizational members make sense of risk controls is an important influence on how they apply and maintain such controls. In this article, we describe an analysis of sensemaking about the control of risk in offshore hydrocarbons production, an industry that continues to produce disasters of societal significance. A field study of 80 interviews was conducted in five offshore oil and gas companies and the agency that regulates them. The interviews were analyzed using qualitative template analysis. This provided a categorization of the many ways of acting through which informants made sense of the risk control task, and indicated that the organizations placed substantially different emphases on different ways of acting. Nevertheless, this sensemaking fell into two broad classes: that which tended to limit or be pessimistic about organizational controls, and that which tended to extend or be optimistic about organizational controls. All the participating organizations collectively placed a balanced emphasis on these two classes. We argue that this balanced sensemaking is an adaptation rather than a deliberate choice, but that it is an important element of controlling risk in its own right.

Huddling for high reliability and situation awareness

BACKGROUND

Studies show that implementing huddles in healthcare can improve a variety of outcomes. Yet little is known about the mechanisms through which huddles exert their effects. To help remedy this gap, our study objectives were to explore hospital administrator and frontline staff perspectives on the benefits and challenges of implementing a tiered huddle system; and propose a model based on our findings depicting the mediating pathways through which implementing a huddle system may reduce patient harm.

METHODS

Using qualitative methods, we conducted semi-structured interviews and focus groups to obtain a deeper understanding of the huddle system and its outcomes as implemented in an academic tertiary care children's hospital with 539 inpatient beds. We recruited healthcare providers representing all levels using a snowball sampling technique (10 interviews), and emails, flyers, and paper invitations (six focus groups). We transcribed recordings and analysed the data using established techniques.

RESULTS

Five themes emerged and provided the foundational constructs of our model. Specifically we propose that huddle implementation leads to improved efficiencies and quality of information sharing, increased levels of accountability, empowerment, and sense of community, which together create a culture of collaboration and collegiality that increases the staff's quality of collective awareness and enhanced capacity for eliminating patient harm.

CONCLUSIONS

While each construct in the proposed model is itself a beneficial outcome of implementing huddles, conceptualising the pathways by which they may work allows us to design ways to evaluate other huddle implementation efforts designed to help reduce failures and eliminate patient harm.

Current medical staff governance and physician sensemaking: a formula for resistance to high reliability

PURPOSE

To offer a theoretical explanation for observed physician resistance and rejection of high reliability patient safety initiatives.

DESIGN/METHODOLOGY/APPROACH

A grounded theoretical qualitative approach, utilizing the organizational theory of sensemaking, provided the foundation for inductive and deductive reasoning employed to analyze medical staff rejection of two successfully performing high reliability programs at separate hospitals.

FINDINGS

Physician behaviors resistant to patient-centric high reliability processes were traced to provider-centric physician sensemaking.

RESEARCH LIMITATIONS/IMPLICATIONS

Research, conducted with the advantage that prospective studies have over the limitations of this retrospective investigation, is needed to evaluate the potential for overcoming physician resistance to innovation implementation, employing strategies based upon these findings and sensemaking theory in general.

PRACTICAL IMPLICATIONS

If hospitals are to emulate high reliability industries that do successfully manage environments of extreme hazard, physicians must be fully integrated into the complex teams required to accomplish this goal.

SOCIAL IMPLICATIONS

Reforming health care, through high reliability organizing, with its attendant continuous focus on patient-centric processes, offers a distinct alternative to efforts directed primarily at reforming health care insurance. It is by changing how health care is provided that true cost efficiencies can be achieved. Technology and the insights of organizational science present the opportunity of replacing the current emphasis on privileged information with collective tools capable of providing quality and safety in health care.

ORIGINALITY/VALUE

The fictions that have sustained a provider-centric health care system have been challenged. The benefits of patient-centric care should be obtainable.

[Patient safety in anesthesiology and intensive care medicine. Measures for improvement]

Technical improvements as well as various strategies for error detection and error prevention have made intensive care medicine and anesthesiology a safe medical specialty. Due to the introduction of "Patient safety in the ICU: the Vienna declaration" of the European Society of Intensive Care Medicine (ESICM) from October 2009 and the "Helsinki declaration on patient safety" of the European Society of Anaesthesiology (ESA) and the European Board of Anaesthesiology (EBA) from June 2010, there are now specific recommendations for all hospitals in Europe concerning the safety measures that are considered to be of essential importance. Many of today's well-known safety strategies have been originally developed in non-medical environments, as for instance civil aviation. Such high reliability organizations may serve as examples in the medical domain. Critical incident reporting systems, crisis resource management and checklists, e.g. the World Health Organization (WHO) checklist, are safety approaches of this kind. In addition to these, standardized drug labelling, hand disinfection, techniques for patient handover and simulation-based training have been exemplarily selected for this article as measures that can increase patient safety.

A Mixed-Methods Study of the Quality of Care Provided to Patients Boarding in the Emergency Department

Concern exists regarding care patients receive while boarding (staying in the emergency department [ED] after a decision to admit has been made). This exploratory study compares care for such ED patients under “Inpatient Responsibility” (IPR) and “ED Responsibility” (EDR) models using mixed methods. The authors abstracted quantitative data from 1,431 patient charts for ED patients admitted to two academic hospitals in 2004-2005 and interviewed 10 providers for qualitative data. The authors compared delays using logistic regression and used provider interviews to explore reasons for quantitative findings. EDR patients had more delays to receiving home medications over the first 26 hours of admission but fewer while boarding; EDR patients had fewer delayed cardiac enzymes checks. Interviews revealed that culture, resource prioritization, and systems issues made care for boarded patients challenging. A theoretically better responsibility model may not deliver better care to boarded patients because of cultural, resource prioritization, and systems issues.

Bridging the gap between problem recognition and treatment: the use of proactive work behaviors by experienced critical care nurses

Delayed access to physicians has been identified as a factor in preventable adverse patient events during hospitalization. Nurses as front-line providers are well positioned to provide a timely response to the needs of patients. Yet legal regulations and hospital policies limit the actions nurses can initiate without physician authorization. The purpose of this qualitative study was to describe what experienced critical care nurses do when they recognize a problem that warrants treatment but lack physician authorization to intervene. The 13 nurses who participated in this study bridged the gap between problem recognition and treatment by communicating proactively, being persistent, running interference for other nurses, and, in some situations, acting without physician authorization. Revising legal regulations and hospital policies to incorporate greater acknowledgment of the overlapping functions between medicine and nursing and recognition of the knowledge and expertise of experienced nurses may be important in reducing unnecessary treatment delays during hospitalization.

The impact of safety organizing, trusted leadership, and care pathways on reported medication errors in hospital nursing units

CONTEXT

Prior research has found that safety organizing behaviors of registered nurses (RNs) positively impact patient safety. However, little research exists on the joint benefits of safety organizing and other contextual factors that help foster safety.

OBJECTIVES

Although we know that organizational practices often have more powerful effects when combined with other mutually reinforcing practices, little research exists on the joint benefits of safety organizing and other contextual factors believed to foster safety. Specifically, we examined the benefits of bundling safety organizing with leadership (trust in manager) and design (use of care pathways) factors on reported medication errors.

SUBJECTS

A total of 1033 RNs and 78 nurse managers in 78 emergency, internal medicine, intensive care, and surgery nursing units in 10 acute-care hospitals in Indiana, Iowa, Maryland, Michigan, and Ohio who completed questionnaires between December 2003 and June 2004.

RESEARCH DESIGN

Cross-sectional analysis of medication errors reported to the hospital incident reporting system for the 6 months after the administration of the survey linked to survey data on safety organizing, trust in manager, use of care pathways, and RN characteristics and staffing.

RESULTS

Multilevel Poisson regression analyses indicated that the benefits of safety organizing on reported medication errors were amplified when paired with high levels of trust in manager or the use of care pathways.

CONCLUSIONS

Safety organizing plays a key role in improving patient safety on hospital nursing units especially when bundled with other organizational components of a safety supportive system.

Workforce perceptions of hospital safety culture: development and validation of the patient safety climate in healthcare organizations survey

OBJECTIVE

To describe the development of an instrument for assessing workforce perceptions of hospital safety culture and to assess its reliability and validity.

DATA SOURCES/STUDY SETTING

Primary data collected between March 2004 and May 2005. Personnel from 105 U.S. hospitals completed a 38-item paper and pencil survey. We received 21,496 completed questionnaires, representing a 51 percent response rate.

STUDY DESIGN

Based on review of existing safety climate surveys, we developed a list of key topics pertinent to maintaining a culture of safety in high-reliability organizations. We developed a draft questionnaire to address these topics and pilot tested it in four preliminary studies of hospital personnel. We modified the questionnaire based on experience and respondent feedback, and distributed the revised version to 42,249 hospital workers.

DATA COLLECTION

We randomly divided respondents into derivation and validation samples. We applied exploratory factor analysis to responses in the derivation sample. We used those results to create scales in the validation sample, which we subjected to multitrait analysis (MTA).

PRINCIPAL FINDINGS

We identified nine constructs, three organizational factors, two unit factors, three individual factors, and one additional factor. Constructs demonstrated substantial convergent and discriminant validity in the MTA. Cronbach's alpha coefficients ranged from 0.50 to 0.89.

CONCLUSIONS

It is possible to measure key salient features of hospital safety climate using a valid and reliable 38-item survey and appropriate hospital sample sizes. This instrument may be used in further studies to better understand the impact of safety climate on patient safety outcomes.

The structure of quality systems is important to the process and outcome, an empirical study of 386 hospital departments in Sweden

BACKGROUND

Clinicians, nurses, and managers in hospitals are continuously confronted by new technologies and methods that require changes to working practice. Quality systems can help to manage change while maintaining a high quality of care. A new model of quality systems inspired by the works of Donabedian has three factors: structure (resources and administration), process (culture and professional co-operation), and outcome (competence development and goal achievement). The objectives of this study were to analyse whether structure, process, and outcome can be used to describe quality systems, to analyse whether these components are related, and to discuss implications.

METHODS

A questionnaire was developed and sent to a random sample of 600 hospital departments in Sweden. The adjusted response rate was 75%. The data were analysed with confirmatory factor analysis and structural equation modeling in LISREL. This is to our knowledge the first large quantitative study that applies Donabedian's model to quality systems.

RESULTS

The model with relationships between structure, process, and outcome was found to be a reasonable representation of quality systems at hospital departments (p = 0.095, indicating no significant differences between the model and the data set). Structure correlated strongly with process (0.72) and outcome (0.60). Given structure, process also correlated with outcome (0.20).

CONCLUSION

The model could be used to describe and evaluate single quality systems or to compare different quality systems. It could also be an aid to implement a systematic and evidence-based system for working with quality improvements in hospital departments.

Developing a culture of safety in ambulatory care settings

The focus on medical error prevention has prompted forward-thinking healthcare providers to increasingly support an organizational culture that supports and promotes patient safety. A culture of safety is necessary before other patient safety practices can be introduced successfully. Various elements of a culture of safety are discussed. Some organizations have implemented survey tools to assess their safety culture. Assessing an organization's culture of safety is just the beginning. Setting priorities for action and identifying strategies to improve healthcare safety must follow with support of the organization's leaders and frontline staff. Recommendations for action are provided.

The Safety Organizing Scale: development and validation of a behavioral measure of safety culture in hospital nursing units

BACKGROUND

Evidence that medical error is a systemic problem requiring systemic solutions continues to expand. Developing a "safety culture" is one potential strategy toward improving patient safety. A reliable and valid self-report measure of safety culture is needed that is both grounded in concrete behaviors and is positively related to patient safety.

OBJECTIVE

We sought to develop and test a self-report measure of safety organizing that captures the behaviors theorized to underlie a safety culture and demonstrates use for potentially improving patient safety as evidenced by fewer reported medication errors and patient falls.

SUBJECTS

A total of 1685 registered nurses from 125 nursing units in 13 hospitals in California, Indiana, Iowa, Maryland, Michigan, and Ohio completed questionnaires between December 2003 and June 2004.

RESEARCH DESIGN

The authors conducted a cross-sectional assessment of factor structure, dimensionality, and construct validity.

RESULTS

The Safety Organizing Scale (SOS), a 9-item unidimensional measure of self-reported behaviors enabling a safety culture, was found to have high internal reliability and reflect theoretically derived and empirically observed content domains. The measure was shown to discriminate between related concepts like organizational commitment and trust, vary significantly within hospitals, and was negatively associated with reported medication errors and patient falls in the subsequent 6-month period.

CONCLUSIONS

The SOS not only provides meaningful, behavioral insight into the enactment of a safety culture, but because of the association between SOS scores and reported medication errors and patient falls, it also provides information that may be useful to registered nurses, nurse managers, hospital administrators, and governmental agencies.

Reliability science and patient safety

Reliability is failure-free operation over time--the measurable capability of a process, procedure, or service to perform its intended function. Reliability science has the potential to help health care organizations reduce defects in care, increase the consistency with which care is delivered, and improve patient outcomes. Based on its principles, the Institute for Health care Improvement has developed a three-step model to prevent failures, mitigate the failures that occur, and redesign systems to reduce failures. Lessons may also be learned from complex organizations that have already adopted the principles of reliability science and operate with high rates of reliability. They share a preoccupation with failure, reluctance to simplify interpretations, sensitivity to operations, commitment to resilience, and underspecification of structures.

Improving patient safety in hospitals: Contributions of high-reliability theory and normal accident theory

OBJECTIVE

To identify the distinctive contributions of high-reliability theory (HRT) and normal accident theory (NAT) as frameworks for examining five patient safety practices.

DATA SOURCES/STUDY SETTING

We reviewed and drew examples from studies of organization theory and health services research.

STUDY DESIGN

After highlighting key differences between HRT and NAT, we applied the frames to five popular safety practices: double-checking medications, crew resource management (CRM), computerized physician order entry (CPOE), incident reporting, and root cause analysis (RCA).

PRINCIPAL FINDINGS

HRT highlights how double checking, which is designed to prevent errors, can undermine mindfulness of risk. NAT emphasizes that social redundancy can diffuse and reduce responsibility for locating mistakes. CRM promotes high reliability organizations by fostering deference to expertise, rather than rank. However, HRT also suggests that effective CRM depends on fundamental changes in organizational culture. NAT directs attention to an underinvestigated feature of CPOE: it tightens the coupling of the medication ordering process, and tight coupling increases the chances of a rapid and hard-to-contain spread of infrequent, but harmful errors.

CONCLUSIONS

Each frame can make a valuable contribution to improving patient safety. By applying the HRT and NAT frames, health care researchers and administrators can identify health care settings in which new and existing patient safety interventions are likely to be effective. Furthermore, they can learn how to improve patient safety, not only from analyzing mishaps, but also by studying the organizational consequences of implementing safety measures.