Creating High Reliability in Health Care Organizations

In the years 1999 and 2001, landmark reports from the Institute of Medicine (IOM) made deficiencies in quality of care and patient safety inescapably visible to health care professionals and the public (Institute of Medicine 1999, 2001). What have we accomplished since these reports? Are we safer; and if so, how do we know? Many say we lack empiric evidence to demonstrate improved safety (Wachter 2004; Brennan et al. 2005; Leape and Berwick 2005), with few measures to broadly evaluate our progress with improvements. Current publicly reported performance measures are likely insufficient for providers to evaluate safety. In many hospitals, these performance measures apply to <10 percent of a hospitals' discharges (Jha et al. 2005). We need scientifically sound and feasible measures of patient safety. In light of these challenges, health care has turned to “high-reliability organizations” (HRO) (e.g., aviation), who achieved a high degree of safety or reliability despite operating in hazardous conditions (Weick and Sutcliffe 2001). Exactly what does reliability mean in health care and how do we know if we are reliable? These answers remain elusive. Reliability is often presented as a defect rate in units of 10 and generally represents the number of defects per opportunity for that defect. In health care, an opportunity for a defect usually translates to a population of patients at risk for the medical error or adverse event. For example, within a health care institution, failure to use evidence-based interventions may occur in five of 10 patients, or a catheter-related blood stream infection (CRBSI) in four of 1,000 catheter days (McGlynn et al. 2003; CDC 2004). A fundamental principle in measuring reliability is focusing on defects that can be validly measured as rates, which is not possible for most patient safety defects. Rates need a clearly defined numerator (defect) and denominator (population at risk) and must be devoid of reporting biases (see framework below). In addition to valid measures, HRO and health care safety experts recognize that the context in which work occurs, called “organizational culture,” has important influences on patient safety (Donald and Canter 1994 Hofmann and Stetzer 1996; Zohar 2000; Barling Loughlin and Kelloway 2002; Hofmann, Morgeson, and Gerras 2003; Sexton, Thomas, and Pronovost 2005). For example, the ability of staff to raise concerns or senior leaders to listen and act on those concerns can influence safety. In health care, communication failures are a leading contributing factor in all types of sentinel events reported to the Joint Commission on the Accreditation of Health Care Organizations (http://www.jcaho.org), with poor communication often occurring between the caregivers who interact most often—physicians and nurses (Sexton, Helmreich, and Thomas 2000). Valid measures of safety climate constructs can be made by systematically eliciting frontline caregivers' perceptions of the organizations commitment to safety (i.e., “safety climate”) using questionnaires (Sexton et al. 2004). Early evidence demonstrates that safety climate is responsive to interventions (Pronovost 2005). As such, strategies to improve reliability must occur in a culture that is conducive to change. A clear framework to measure safety within a health care organization is lacking. Federal agencies, organizations, and some institutions have developed “score cards” or performance measurement reports. However, some have scores of measures and most measures either lack validity (e.g., overall hospital mortality) or target-specific patient populations (e.g., congestive heart failure), preventing generalizability of results to the entire organization (Thomas and Hofer 1999; Hayward and Hofer 2004; Lilford et al. 2004). A comprehensive approach to evaluate an organization's progress with patient safety efforts has not been clearly articulated. In this paper, we describe a comprehensive approach for health care organizations to measure patient safety and then present an example of how this approach was applied to eliminate CRBSIs and improve safety culture in intensive care units (ICUs) in the state of Michigan (Pronovost and Goeschel 2005). Through this improvement example, we hope to highlight the importance of balancing the use of scientifically sound and feasible measures of patient safety with wisdom from front-line staff, noting that both are necessary and equally important.