A Framework for High-Reliability Organizations in Healthcare

This report is based on a2018 webinar presentationgiven by Allan Frankel, MD, Founding Partner, Safe & Reliable Healthcare and Senior Faculty, Institute for Healthcare Improvement; and Michael Leonard, MD, Managing Partner, Safe & Reliable Healthcare and Adjunct Professor of Medicine, Duke University School of Medicine. entitled, “A Systematic Framework for the Delivery of Safety, Highly Reliable Care and Habitual Excellence.”

Despite a growing focus on quality improvement in healthcare, the skills needed to make measurable, sustainable improvements in care are not inherent, even among dedicated, smart healthcare professionals, because those skills were not baked into their DNA from medical school through residency through practice as many other skills were. But as anyone in healthcare knows, quality improvement is an essential piece of organizational evolution and development. Patients and their families are at the center of everything healthcare providers do. They entrust their lives and wellbeing with their providers, and that is a sacred trust.

To address the need for quality improvement skills, Drs. Allen Frankel and Michael Leonard, both experts with more than 23 years of experience across more than 1,300 hospitals, created a practical, systematic framework that can be applied in virtually any care setting, from neurosurgical ICU to office practices to pharmacies to home care organizations. Drs. Frankel and Leonard published a white paper in 2017 entitled “A Framework for Safe, Reliable, and Effective Care” with theInstitute for Healthcare Improvement(IHI) that delves deep into this framework.

In addition to developing the framework, Drs. Frankel and Leonard have put together the key components of High Reliability Organizations (HROs), including leadership, a safety-focused culture, and a dedication to continuous learning and improvement, and they offer practical tools and insights that enhance the ability to deliver optimal patient care in an environment focused on learning and quality improvement.

The necessary pieces for developing and sustaining a culture and system that delivers safe, highly reliable care are strong effective leadership,a culture of safety，以及无障碍的学习系统。图1展示了该框架的组成部分，以及每个方面如何归入三个类别:领导力、文化和学习系统。

The framework provides a clear roadmap to move forward and do the work of developing an organization focused onpatient safety. What Drs. Frankel and Leonard have learned through their decades in patient safety is that all aspects of the framework must exist, or learning won’t be sustainable. Improvement won’t be sustainable. The cultural maturity model helps illustrate the type of culture that is necessary to move forward toward becoming an HRO.

Cultural Maturity Model

文化成熟度模型的概念在1975年左右就已经出现了，自从它的发展以来，它已经发展到帮助组织思考如何从一种没有意识的文化到一种有生产力的文化。在医疗保健领域，框架的所有组成部分，从领导力到学习，都可以在文化成熟度量表上进行评级，如图2所示。

Historically, nurses and doctors have been trained and evaluated using the individual expert model. The idea behind that model is that if expert healthcare professionals are put in any healthcare environment, they’ll figure it out. The problem is that doesn’t work. Healthcare today is too complex to do that successfully across the board. The best, most effective solution to quality improvement is to work collaboratively and proactively. As Figure 2 shows, the tipping point for psychological safety is when an organization goes from a systematic model of managing hazards to a proactive one in which staff anticipates and prevents problems before they occur. The pinnacle of cultural maturity is a generative culture in which safety is the culture. It’s how business is done. It’s constantly vigilant and transparent.

Reactive cultures are like playing defense. They react to problems rather than trying to foresee them and get ahead of them before they become catastrophic. When people within an organization are simply reacting, they tend to make mistakes. They’re distracted, they need to multitask, and they forget things. And, much like distracted driving, distracted caregiving can have unintended negative consequences.

主动性和生动性并不是天生的，在今天的卫生系统中，这还不是常态。Drs。Frankel和Leonard和他们的团队评估了马萨诸塞州的30家社区医院，以帮助找出这些机构如何在一个充满系统合并和政治变化的不断变化的环境中维持高质量的社区护理。They found that only four out of the 30 hospitals were proactive to generative, and the overwhelming majority were reactive.

They also found that even within the reactive cultures there were pockets of proactive units – departments within the hospitals that were getting it right some of the time. And what they learned about those departments was that they worked collaboratively. They didn’t do it all the time, but it was a start, a foundation.

The ability to come together, think ahead, and play as a team is critical for the ability to deliver safe care. Novices on the team can turn to the experts for valuable information, and thus learn how to deliver excellent care, eventually becoming experts themselves. It creates a huge library of experience for the entire team to draw from that will create predictability. One of the most basic concepts of high reliability is anything that can be made predictable should be made predictable. This helps avoid surprises. And avoiding surprises helps improve cultural maturity.

Key Components of High Reliability Organizations

HROs thrive because their leadership takes charge of the culture, engages staff, promotes a culture of safety, and embeds continuous learning and improvement processes into the everyday lives of everyone within the organization. Effective leadership is the primary component of an HRO.

Effective Leadership

一个具有主动或生成文化的组织必须有有效的领导，在高级和地方层面，与组织的目标一致。强大、有效的人力资源管理者在组织和系统管理的几个方面都有参与和知识，如组织发展、整个系统的变化和管理的测量。他们还必须坚持不懈地关注过程，并知道文化是一个过程，而不是一个目的地。

Cultural Maturity and Senior Leadership

安全文化从最高领导层开始。一个组织的强大取决于它的领导者，所以让领导者来指导企业文化是很重要的。下面的图3提供了领导者在不同文化成熟度水平下是如何参与的例子。在一种漫不经心的文化中，员工不知道谁是领导者。领导们缺席，他们没有与现场的医生和护士接触，为病人提供护理。从漫不经心到有创造力，领导者越来越投入。在主动性和生成型文化中，领导者是存在的。他们在和员工交谈。他们倾听、支持、学习。在最好的文化中，他们会为信息的循环流动创造空间，鼓励反馈和跨组织学习。

Local Leadership

Next in the top-down culture of safety is local leadership. In unmindful organizations, local leadership is mostly absent, but in proactive and generative organizations, local leaders model the behaviors that drive a culture of safety and create an atmosphere that provides for psychological safety and accountability. They play offense, think ahead, and wire the whole organization for safety and quality improvement.

There is plenty of data about the effects of leadership on overall culture and staff engagement. One example is a survey of staff at 30 Michigan hospitals. The data collected shows the importance of leaders being present and listening to the frontline staff and how their presence and engagement can have significant positive effects on culture, safety, and burnout.

Michigan Hospitals – A Study of Cultural Data

Drs。Frankel and Leonardpublished a study in 2017该研究调查了密歇根30家医院的1.7万人，并收集了他们的数据。该调查考察了七个具体领域。

• Learning environment.
• 当地的领导。
• Teamwork climate.
• Safety climate.
• Burnout climate.
• 个人的倦怠。
• 工作与生活的平衡。

At the beginning of the survey, there were two questions. The first was: “Do your leaders participate in walk-arounds in your organization?” Ten thousand of 17,000 people said yes. The second question was: “Did you get feedback on the issues you raised?” And 4,500 said yes, and 5,500 said no.

Figure 5 illustrates the effect of leadership not only asking for feedback, but actually acting on it, closing the loop, so to speak, of ideas and concerns brought up by staff on the frontline of patient care. The graph in Figure 5 represents the seven areas surveyed. The red bar represents scores when leadership did not close the loop. The green bar represents scores when leadership did close the loop. And the blue bar represents the mean.

The takeaway here is that providing feedback after leadership walk-arounds is associated with better patient safety culture, higher employee engagement, and lower burnout. The scores for people who felt listened to and heard are dramatically higher than those who didn’t.

For statistical significance, there must be a five to seven-point difference in scores. In this survey, the difference is more than 30 points in some cases, and in all cases, it’s at least nine points.

Culture of Safety

人力资源管理的另一个组成部分是安全文化。患者安全是这种文化的重要组成部分，但它更多的是一种结果和目标，而不是文化的决定性部分。安全文化必须解决职业倦怠问题，鼓励不同方面的安全。

Addressing Burnout

医疗行业的职业倦怠会导致许多负面影响，包括错误、感染、更高的死亡率和患者满意度下降。它还会导致高流动率，这对利润有很大的影响。

Burnout Versus Resilience

The opposite of burnout is resilience. And a culture of safety tends to have low burnout rates and encourage resilience. Going back to the cultural maturity model, resilience goes up and burnout goes down as the culture becomes more proactive and generative.

Factors That Encourage Resilience

There are several factors that encourage resilience and decrease burnout. Each factor revolves around the employee being heard and supported:

• 感觉受到组织的重视。
• Believing that their voice can be heard and matters.
• 在工作中感到被支持。
• 相信自己有足够的资源来完成工作。

Psychological Safety

安全、最佳的护理需要心理上的安全感，需要有安全感，需要有发言权。当一线医护人员感到不安全，感到赋权时，如果他们注意到有什么不太对的地方，他们可能不太愿意说出来。错误的手术部位和保留异物是两个在医疗保健中非常常见的医疗错误，它们完全可以预防。研究表明，当手术室的工作人员感到安全和赋权时，就会有更少的手术从未发生过这样的事件。

Accountability

问责制是安全文化的另一个重要方面。在追究个人责任时，该框架强调区分个人问题和系统问题。创造一个公平公正的工作环境也很重要。

Teamwork and Communication

A culture of safety requires teamwork and effective communication. Much like psychological safety, successful teamwork is correlated with improved patient safety. Going back to the cultural maturity scale, a generative culture values teamwork and continuous learning. These things are deeply embedded in the culture, and teamwork is taught and modeled across the organization.

有效的团队合作有四个原则。

• 计划前进。
• Reflect back.
• Communicate clearly.
• Resolve conflict.

The last tenet of effective teamwork, resolving conflict, leads into the next aspect of a culture of safety: negotiation.

Negotiation

Conflict is unavoidable. Whenever there are more than two people involved in an organization, there will be conflict. But conflict does not have to be negative or degenerative. With collaboration and negotiation, conflict can be addressed effectively, thus encouraging a more robust culture of safety.

谈判应该包括合作形式的谈判。没有人会在真空中谈判。它还应该区分立场和兴趣，应该使用欣赏式询问。

要发展和培养一种安全文化、心理安全、责任、团队合作、沟通和谈判，必须处理这四个概念，所有这些共同创建一个为彼此和为病人工作的团队。所有医疗保健组织也必须解决职业倦怠问题。如果领导层关注这些事情，并把它们作为企业文化的核心部分，他们就很有可能成为人力资源经理。

Learning System

Another vital component of an HRO is continuous learning. HROs have one thing in common when it comes to learning: a visible and transparent learning system. An effective learning system must be transparent. It must be reliable. It must focus on continuous learning. And it must provide for improvement and measurement in order to learn and grow.

A learning system, when well developed and rolled out, can have measurable positive effects throughout the organization.

例如,Drs。弗兰克尔和伦纳德花了大约25年的时间在医院和卫生系统进行干预。One of their significant interventions started atMayo Clinic. After working to integrate the framework into their organization, including a transparent learning system, Mayo now has local leadership, local managers, and power workers who give staff a voice and make them feel cared about. From there, they can successfully layer on the improvement process.

About 18 months into the work with Mayo, one senior surgeon talked to Dr. Frankel about the transformation he saw throughout the organization. He said, “Before we started this program, my biggest concern when I went home in the evening was that I didn’t know what I didn’t know. In other words, nurses weren’t comfortable coming and talking to me about the issues they were running into with the patients on the unit. Now that nurses and staff are comfortable about speaking up about their concerns, I know what I need to know to help the services run smoothly and safely. I go home in the evening with great assurance that we are on track.”

What’s notable and important about this comment is that it’s illustrative of the idea that when people are comfortable speaking to each other, it can be an essential piece of creating operational excellence and delivering safe, reliable care.

Similar results can be seen at other organizations when the three components of the framework are in place: culture, leadership, and a learning system. Leadership is the key component. Without effective, engaged leadership that supports a generative culture, it becomes difficult to have holistic change. Local leadership must work hand in hand with senior leadership to create a culture where psychological safety is manifest, where people feel like they’ll be held accountable fairly, and where the team behaviors, like briefings and debriefings, are robust regardless of care setting.

最终,Drs。弗兰克尔和伦纳德看到了真正的改变是可能的，如果团队、单位和组织都能自我反省和改进，文化成熟就能发生。文化必须足够强大，使自我反省成为文化的一部分，他们必须有足够的改进能力，他们可以看到弱点和裂缝，并以有效的、文化健康的方式采取行动，关注整体安全。

Getting to that point takes more than people and processes. It also takes tools that can take the components of HROs from theories to action.

Practical Tools and Insights

除了框架之外，dr。Frankel和Leonard开发了实用工具，增强了在持续学习的环境中提供最佳患者护理的能力。最有效的工具是实时学习板。这些学习板有几个好处。

• 他们倾向于提高效率。例如，护士经理报告说，他们花在非临床工作上的时间减少了75%。
• They lead to two to three times more engagement and completed projects.
• They offer an avenue for more consistent communication and transfer of information between shifts.
• They help facilitate conversations aimed at improving psychological safety.

A well-designed learning board encourages a culture of safety in key ways:

• They lead to better huddles and help staff connect about important issues between huddles and shifts.
• They increase self-reflection.
• They give management more effective, real-time tools.
• They help leaders understand issues across care types.

Putting it All Together

Through their years of experience, Drs. Frankel and Leonard have found that doing this work and creating a culture of safety is critical. It provides a framework to integrate all initiatives and a foundation to successfully carry them out. It also gives a clear focus on culture, and a proactive, generative culture is essential to creating sustainable value and providing world class care. Culture is the social glue. It reflects the attitudes and behaviors of the people delivering care. So, a generative culture enhances patient care – and care for the caregivers, the frontline personnel–which can go a long way to addressing burnout and increasing psychological safety.

图6显示了人力资源管理的各个组成部分是如何整合到临床和卓越运营框架中的。

With this framework in place and patients and their family always at the center of care, it is possible to become an organization that delivers safe, highly reliable care across the board. But to do this successfully and sustain improvement, all pieces of the puzzle must be in place. A culture change starts at the top with strong, engaged, system-wide leadership that encourages a culture of safety and pursues continuous improvement by implementing a transparent, robust learning system. And to get there, organizations must be open to feedback and must have avenues of measuring improvement.

Drs。Frankel和Leonard，以及他们在安全可靠医疗中心的团队，已经在1300多家医院研究这个过程超过20年。就像人力资源管理公司的文化一样，他们的流程已经发展成熟。这是一个有效的过程。这是一个导致重大变化的过程，可以对患者护理和患者安全产生真正的、积极的、可衡量的影响。当组织遵循框架提供安全、可靠的护理，员工福利。前线供应商受益。该组织的好处。患者受益。每次投资都是值得的。

Additional Reading

Would you like to learn more about this topic? Here are some articles we suggest:

1. A Systematic Framework for the Delivery of Safe, Highly Reliable Care and Habitual Operational Excellence
2. Healthcare Safety Culture: A Seven-Step Success Framework
3. Boosting Readiness and Change Competencies Key to Successfully Reducing Clinical Variation
4. Transforming Healthcare Analytics: Five Critical Steps

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