Safety

Becoming a High-Reliability Organization Through Shared Learning of Safety Events

Healthcare Life Safety Compliance, March 27, 2020

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Healthcare Life Safety Compliance.

By Jeffery Klenklen

Editor's note: all figures and tables will appear in the March PDF, to be released 3/2/20.

Nearly 20 years after the publication of the Institute of Medicine’s report To Err Is Human, healthcare providers look to methodologies used in other high-reliability organizations for transferrable strategies to reduce error in clinical care processes (Institute of Medicine, 2000). Organizations in industries such as nuclear power anticipate and mitigate errors by focusing on:

  1. Standard work through safe processes
  2. Robust reporting
  3. Simulation training
  4. Establishing a safety culture
  5. Rapid learning from events, and 
  6. Robust process improvement (Birnhack et al., 2013).

Healthcare organizations often struggle to meaningfully translate these methodologies. This is complicated by the growing number of definitions and metrics for quality of care. Leaders struggle from a systematic perspective to define quality and safe care as they ruminate over this expanding plethora of metrics. Today’s successful leader must focus on safety, timely access, effectiveness, efficiency, equity, and patient-centeredness, while still producing enough income each year to finance improvements for the next (Ahluwalia, Damberg, Silverman, Motala, & Shekelle, 2017). Leaders are often forced to prioritize their focus using strategies from reliability science (Chassin & Loeb, 2013). Once focus is shifted away from an area of improvement, under the belief that reliability has been achieved, relapse can occur related to the processes that are no longer receiving focus.

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Healthcare Life Safety Compliance.

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