Leading a High Reliability Organization

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Leading a High Reliability Organization

• David Vaughan
• Executive Director Quality and Safety,
• Consultant Respiratory Paediatrician,
• Hamad Medical Corporation,
• Doha,
• Qatar

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Disclosures

• None, (But I have a lot of biases)

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Leaders are visionaries with a poorly developed
sense of fear and no concept of the odds against
them Robert Jarvik
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Learning Objectives

• Understand that successful organizations coalesce
  around a simple message that everyone understands
  and can articulate
• Be able to describe the features of HROs
• Be able to describe how to measure a unit, team
  or organizational level of high reliability
  according to Weick and Sutcliffe framework
• Be able to define how a HRO framework can assist
  healthcare in meeting many of the Berwick
  recommendations
• Commit to applying the lessons learned on a small
  scale

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(No Transcript)
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Leadership behaviours that increase risk and
make healthcare less safe
Make bad news unwelcome (too often silencing it)
Blame staff (even when they havent been given the conditions for success
Not heed signals and warnings that things are amiss
Fail to listen to staff
Diffuse responsibility and disguise who is in charge
Lead by rules and procedures alone in a disengaged way
Apply sanctions to errors
Game data and goals
Muffle the voice of the patient
Treat all problems as though they can be fixed with existing technologies or procedures writing clearer procedures
A promise to learn a commitment to act.
Improving the Safety of Patients in England.
National Advisory Group on the Safety of Patients
in England. P17
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Have we improved?

• Sustained attention to patient safety has failed
  to produce widespread reductions in rates of
  harm.
• Trends in adverse events over time why are we
  not improving? BMJ Qual Saf. 2013
  Apr22(4)2737.

Landrigan CP, Parry GJ, Bones CB, Hackbarth AD,
Goldmann DA, Sharek PJ. Temporal trends in rates
of patient harm resulting from medical care. N
Engl J Med. 2010 Nov 25363(22)212434.
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Would you prefer to undergo complex surgery
in....

• A hospital with a high rate of post-operative
  complications?
• A hospital with a low rate of post-operative
  complications?

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Patient safety problems exist throughout the NHS
as with every other health care system in the
world. NHS staff are not to blame in the vast
majority of cases it is the systems, procedures,
conditions, environment and constraints they face
that lead to patient safety problems. Incorrect
priorities do damage central focus must always
be on patients. Warning signals abounded and
were not heeded When responsibility is diffused,
it is not clearly owned Improvement requires a
system of support Fear is toxic to both safety
and improvement.
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I do not for a moment believe that those in
responsible positions in the Trust went about
their work knowing that by action or inaction
they were contributing to or condoning the
continuance of unsafe or poor care of patients.
What is likely to be less comfortable is the
possibility, and sometimes the likelihood, that
whatever they believed at the time, they were not
being sufficiently sensitive to signs of which
they were aware with regard to their implications
for patient safety and the delivery of
fundamental standards of care. Unhappily, the
word hindsight occurs at least 123 times in the
transcript of the oral hearings of this Inquiry,
and benefit of hindsight 378 times
Francis Report, Volume 1
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Normalisation of Deviance
Once you have accepted an anomaly or something
less than perfect, you have given up your
virginity. You cant go back. Youre at the point
when its very hard to draw the line. Next time
they say its the same problem, its just eroded
5 mm more. Once you accepted it, where do you
draw the line? Once you have done it, its very
difficult to go back now and get very hard nosed
and say Im not going to accept that
Diane Vaughan. The Challenger Launch Decision.
University of Chicago Press. 1996
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The Why of Healthcare
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There is no why here
.?.?.?I eyed a fine icicle outside the window,
within hands reach. I opened the window and
broke off the icicle but at once a large, heavy
guard prowling outside brutally snatched it away
from me. Warum? I asked him in my poor German.
Hier ist kein warum (there is no why here),
he replied, pushing me inside with a shove.
Primo Levi
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Why
How
What
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Question
In your organization, unit, department, can you
outline the Why And if so, is it consistent
across the organization? Is it simple
understood by everyone? If so, is it applied
from the top down consistently?
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High Reliability Organisations
HROs are organizations that function under very
demanding conditions and manage to have fewer
than their fair share of accidents
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Mindfulness
To be mindful is to have a rich awareness of
discriminatory detail and an enhanced ability to
discover and correct errors that could escalate
into a crisis
When it comes to mindfulness, its good to feel
bad, and bad to feel good
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HRO Features
Preoccupation with failure
Reluctance to simplify
Resilience
Mindfulness
Sensitivity to operations
Deference to expertise
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Mindlessness
When people function mindlessly, they dont
understand themselves or their environment, but
they think they do They dont know what they
dont know
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The situation in theatre appears to be fraught
and the Panel learned of serious problems. It
would appear that the surgeon concerned finds
it difficult to work under stress, when the
atmosphere becomes very tense. A number of
theatre staff will not work with X. The Panel
understand that there have been a number of
complaints made against X and at least three of
these were allegations of assault, which the
Trust has investigated and dealt with accordingly
... when X is not in a stressful situation X
is very charming and courteous when talking to
patients ... The surgeon has no idea as to why
there are these perceived problems
Report of the Mid Staffordshire NHS Foundation
Trust Public Inquiry Volume 1 Ch 1 Warning
Signs. P112
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Pre-occupation with failure
Failure implies something was not caught as soon
as it could have been
At that stage, therefore, neither SaSSHA nor the
DH, up to ministerial level, can have been in any
doubt that there were potentially serious
managerial issues, particularly in relation to
finance, and record systems, at the Trust and
that close supervision of its performance was
Necessary Francis Report. Volume 1. P60
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Pre-occupation with Failure Audit
What surprised you? How would a front line worker
answer? How frequently do you consider what might
go wrong?
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Reluctance to Simplify
Seek divergence in viewpoints multiple views,
especially from the front line.
The report was extremely damaging, more than
justifying the complaints that had been made. The
report noted that Ward 3 is known by reputation
to have had long-standing problems (many years)
in standards of patient care which are generally
put down to the heavy workload and poor
staffing. Francis Report. Vol 1. P64
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Reluctance to Simplify
Can you recall a serious safety event that with
hindsight was due to an inappropriate
simplification?
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Sensitivity to Operations
Being aware of current operational work enables
organisations to catch small errors and mistakes
which almost always manifest first at the front
line
were sinking under patients in AE. Any support
would be gratefully received. Weve tried to get
hold of the Community matrons but only got a
voicemail service. We have 12 ambulances
queuing Francis Report. Vol 1. P98
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Sensitivity to Operations
Outline an example where increased awareness of
front line operations in your area of
responsibility might reduce the risk of failure
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Commitment to Resilience
How well prepared are we to manage the unexpected
when it does happen?
The Board was made aware of the 2006 survey
figures at the meeting on 3 May 2007 when it was
reported that the Trust was in the worst 20.
Predictably, an action plan was said to have been
developed. Francis Report. Vol. 1. P
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Questions
What is your worst fear? How well prepared are
you to handle if this became reality?
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Questions

• Can you identify the following characteristics on
  the video shown?
• Pre-occupation with failure
• Reluctance to simplify
• Sensitivity to operations
• Commitment to resilience

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Deference to Expertise
HROs shift their work in moments of crisis to
those best placed to understand the work
A clear deficit in trained emergency medicine
consultants and the department was not covered
24/7 by an accredited emergency department
consultant. The report was greeted with a
somewhat laconic response by Dr Moss, who, in
circulating it to colleagues saidSuggest we all
have a read and if there are any burning problems
identified please can you let me know Francis
Report. Vol 1. Warning Signs. P130
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(No Transcript)
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Muething SE, Goudie A, Schoettker PJ, Donnelly
LF, Goodfriend MA, Bracke TM, et al. Quality
Improvement Initiative to Reduce Serious Safety
Events and Improve Patient Safety Culture.
PEDIATRICS. 2012 Aug 1130(2)e42331.
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Leadership behaviours that increase risk and
make healthcare less safe

• Make bad news unwelcome (too often silencing it)
• Blame staff (even when they havent been given
  the conditions for success
• Not heed signals and warnings that things are
  amiss
• Fail to listen to staff
• Diffuse responsibility and disguise who is in
  charge
• Lead by rules and procedures alone in a
  disengaged way
• Apply sanctions to errors
• Fail to focus on the patient (often signalling
  instead that targets and costs are centre
  stage)
• Muffle the voice of the patients, their carers
  and their families and largely ignore their
  complaints
• Offer no systematic support for improvement
  capability

A promise to learn a commitment to act.
Improving the Safety of Patients in England.
National Advisory Group on the Safety of Patients
in England. P17
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Leadership behaviours that increase risk and
make healthcare less safe
Berwick Behaviours HRO Framework
Make bad news unwelcome (too often silencing it) Deference to expertise pre-occupation with failure
Blame staff (even when they havent been given the conditions for success Deference to expertise sensitivity to operations
Not heed signals and warnings that things are amiss Sensitivity to operations reluctance to simplify
Fail to listen to staff Deference to expertise reluctance to simplify
Diffuse responsibility and disguise who is in charge Deference to expertise reluctance to simplify
Lead by rules and procedures alone in a disengaged way Commitment to resilience deference to expertise
Apply sanctions to errors Sensitivity to operations deference to expertise
Game data and goals Pre-occupation with failure sensitivity to operations
Muffle the voice of the patient Pre-occupation with failure sensitivity to operations
Treat all problems as though they can be fixed with existing technologies or procedureswriting clearer procedures Pre-occupation with failure commitment to resilience
A promise to learn a commitment to act.
Improving the Safety of Patients in England.
National Advisory Group on the Safety of Patients
in England. P17
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Next Steps

• Consider using these audits on your unit,
  department
• Walk the walk
• Increase the number of mindful moments in your
  unit
• Identify a modest problem, look at failures,
  assume nothing, develop a solution and focus on
  the expert in handling the problem rather than
  blaming the person responsible

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Thank You