Becoming a High Reliability Organization (HRO)

Operational advice for Hospital Leaders

PROF DR. HESHAM ELKHOLY - Chairman of the Chamber of Private

Sector Healthcare ProvidersPresented By

Prof Dr NAGWA El HOSSEINY 1

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Contents

• Definition of high reliable organization (HRO)

• How have HROs been defined? • What are the key features of HRO

model?• Are there any studies of healthcare

HROs? • What are the practical considerations

for leaders in healthcare? • Current Challenges in Egypt • Conclusion

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DEFINITION

• High reliability organizations (HRO) are organizations that work in situations that have the potential for large-scale risk and harm, but which manage to balance effectiveness, efficiency and safety.

• They also minimize errors through teamwork, awareness of potential risk and constant improvement.

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How have HROs been defined ?

‘High reliability organization’ is a consistently reliable organization that operates in a complex environment where accidents might be expected to occur frequently, but which manages to avoid or seeks to minimize catastrophes.

• Energy• Aviation and transport• Military and space• Fires and disasters• Healthcare• Education.

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WHAT ARE THE KEY FEATURES OF HRO MODEL

1. High reliability organizations operate in complex physical environments as well as unforgiving social and political environments.

2. High reliability organizations use processes and technologies that have the potential for risk and error.

3. There is a focus on continuous improvement.

4. There is a good safety culture, with leadership and frontline staff taking shared responsibility.

5. Risk Management – whether or not the organization correctly perceives operational risks and takes corrective action

6. Leadership and Supervision -- policies and procedures and communication processes used to proactively mitigate risks

7. Teams are adept at quickly building creative responses to failure.

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What about HRO in healthcare?

• There are a small number of case studies outlining how specific healthcare services might fit the definition of high reliability organizations.

• High reliability in HEALTHCARE means that at your hospital ,patients always receive exactly the care they need and the care is provided in systems that have no inefficiencies or waste.

• High reliability is an ongoing process that is never perfect, complete, or total.

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Hospital leaders

must juggle many operational factors that affect their facilities

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The five specific concepts that help create the state of Mindfulness that is

needed for ReliabilityMindful organization means that individuals to interact continuously , and proactively triggers actions that prevent errors and crises.

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1-Sensitivity to operations

Sensitivity to operations encompasses more than checks of patient identity, vital signs, and medications. It includes awareness by staff, supervisors, and management of broader issues that can affect patient care, ranging from how long a person has been on duty, to the availability of needed supplies,

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2-Reluctance to simplify

• Oversimplifying explanations for how things work is risky, could lead to errors , or failing of the system, that ends up by placing a patient at risk.

• HROs refuse to simplify or ignore the explanations for difficulties and problems that they face

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3-Preoccupation with failure

• A preoccupation with failure means that near misses are viewed as invitations to improve rather than as proof that a system has enough checks to prevent a catastrophic failure.

• HROs are focused on predicting and eliminating catastrophes rather than reacting to them

4-Deference to expertise

• Decisions should be made on the front line staff where the best knowledge of the situation exists .

• HROs cultivate a culture in which team members and organizational leaders defer to the person with the most knowledge relevant to the issue they are confronting , irrespective to the hierarchy

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5-Resilience

• A good boater never leaves the dock without preparing for many situations that are unlikely but possible. Oars, pump, lifejacket, and fire extinguisher ensure that the boater can quickly respond to unexpected system failures

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what are the practical considerations for leaders in

healthcare?

High Reliability can be achieved through:

• Improved operational efficiency, • Consistent excellence in patient

care • And therefore, high reliability.

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Consistent excellence in patient care

• DAFH is always striving for excellence in services given to the patients since it was opened,1999

• For this vision ,the strategy DAFH is to follow the JCI quality standards of care

• DAFH hospital staff were able to achieve JCI accreditation 3 time( in the years 2005,2008,2011)

The CONCEPT is Continuous Quality Improvement

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NO

.

In Patient Census Activity

DAFH, 2000 - 2012

Out Patient Census Activity

DAFH, 2000 - 2012

Bed Occupancy Rate

DAFH, 2000 - 2012

Average Length of Stay

DAFH, 2000 - 2012

4.84.9

5.4

5.5

4.9 4.94.94.9

5.6

6.16.4

6.15.9

0

1

2

3

4

5

6

7

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

93

84 8788

79

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6875

75

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0

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2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

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2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

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Num

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17

NO

.

Gross Unadjusted Mortality Rate

DAFH, 2008 – 2012 Target <3

%

Hospital Acquired Infection/1000 Patient Days, 2009 – Jan 2013

May

7.9

8.3

6.8

5.9

4.4

7.7

6.8

5.9

3.7

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3.53.2

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4.44.5

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3.8

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JAN

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20102009 2011 2012

Jan-11 Feb Mar Apr May Jun Jul Aug0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

76%73%

82%

88% 87%90% 92%

95%

HH% Compliance among Health care workers

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RATE OF BED SORES; DAFH, 2008 - 2012

1.6

1

1.6

2

1.2

1.51.5

1.3 1.3

1.1

0.4

1.7

1.3

1.4

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0.7

0.2

0.4

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0.4

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0.7

0.6

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0.60.6

0.5

0.7

0.3

0.5

0.3

1.31.3

1.4

1.11.1

1.2

1.6

1.8

1.7

1

1.7

2

1.6

1.2

1.6

1

1.2

1.5

1.4

1.81.8

1.1

2.1

1.5

1.8

0

0.5

1

1.5

2

2.5

1 2 3 4 5 6 7 8 9 1011 12 1 2 3 4 5 6 7 8 9 10 1112 1 2 3 4 5 6 7 8 9 10 1112 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 1011 12

2010MEAN = 1.27

2011MEAN = 0.74

2012MEAN = 0.48

2009MEAN = 1.47

2008MEAN = 1.53

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Medication Errors per 1000 Doses DAFH, JAN-DEC 2012

7.887.65

7.4 7.37

4.61

5.41

1.72

3.1

4.82

1.91

4.22

3.42

0.88

4.96

9.04

0.79

1.79

2.79

3.79

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5.79

6.79

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9.79

0 1 2 3 4 5 6 7 8 9 10 11 12 13

Ind

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ed

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ors

per

1000 d

oses

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Dispensing Error Doses DAFH, 2006 - 2010

2006 20092007 2008 2010

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Total No. of Patient ComplaintsJa

n 2

007 –

DEC

. 2012

2007 2008 2009 2010 2011 2012Mean= 288 Mean= 266 Mean= 204 Mean= 149 Mean= 83 Mean =89.2

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Current Challenges

• Egypt now , there are many progressively increasing challenges facing All healthcare managers.

• The increase risk of high cost:1. Increase price and unavailability of supplies2. Currency instability that affect the buying

the supplies3. The country political situation that’s

affecting the economic status of the country

Successful Risk Management Culture Proactive Risk Preparedness

• Proactive Risk Identification– Expecting the possible Risks in each division in the organization (e.g.

Finance, Security Dept., HR, Medical Supplies, IT,.. etc)

• Proactive Risk Analysis– Prioritization of the defined Risks according to high volume and high

risk (using different tools like Brain Storming, Multi-voting, etc.) and dividing the defined risks into 3 phases (Yellow – Orange – Red) according to severity.

• Proactive Risk reduction strategies and Control– Putting action plans with clear responsibilities for each defined Risk in

each phase

• Financing Proactive Risks– Securing the costs of the risk exposures (e.g. securing a budget in a

safe place in the organization in case the Banks are closed for long period)

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Why Healthcare Leaders Need to Act Now

All leaders need to use the concept of HRO because of 3 specific trends that are available:

1-Public awareness of medical errors and quality

2-Health information technology; that can assist in monitoring performance , adjusting medications…..

3-Emergence of quality improvement methodologies which is an important step for continuous improvement

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CONCLUSIONS

• Health care organizations are at different stages of maturity on the path to high reliability.

• The first step is to conduct a self-assessment of the current state of leadership, safety culture, and capacity to execute Robust Process Improvement.

• By performing an assessment, health care

organizations can gain an overall understanding on where to focus their improvement efforts.

• According to “The Ongoing Quality Improvement Journey: Next Stop, High Reliability,”

HRO

Continuous Quality ImprovementIndicators – Auditing - Improvement

Improve Quality & SafetyTraining – Standards compliance

Self AssessmentCulture and practice of quality and safety

Pyramid of Excellence of Healthcare Organizations

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Thank You