Over the summer, as I move to a new residence, I plan to update my ezines. With this ezine, I introduce you to Ellen Guarnieri, who participated in my ACHE seminar, Practical Strategies for Engaging Physicians.
If you want to learn more about how her hospital improved reliability in the area of cardiac medications, please read on.
Applying High-Reliability Principles to Improve Cardiac Outcomes
Case Presentation
After discussing quality outcome scores for their institution, leaders at a community hospital system decided to take action. Physicians were not routinely following protocol for ordering aspirin (ASA), beta blockers, and angiotensin-converting enzyme inhibitors (ACEI) on admission and discharge. The doctors claimed the data were wrong. Was it a performance issue or a data integrity problem?
A review of the institution’s cardiac medication outcome data showed that the issues were multi-factorial. The organization had set a benchmark for performance on cardiac medication administration at 90% compliance, but composite performance scores were 76%. The Vice President of Quality voiced concern that despite improvement methods, no movement in scores occurred.
The hospital assembled a team of cardiologists, primary care doctors, nurses, pharmacists, information technology experts, a project leader, and a finance approver. The team set a goal to achieve 95% compliance by the end of the 9-month project cycle. They applied the following five principles of high reliability organizations to their new approach. High reliability organizations* (HRO) are those that can perform relatively error-free, complex operations consistently over long periods of time:
Sensitivity to operations – Hospital leaders assumed that poor compliance with cardiac medication standards was the result of poor ordering practices by the physicians. However, chart reviewers only agreed on abstraction of charted data 42% of the time. They developed standard review procedures for chart abstracters. Physician experts at each system hospital reviewed data and coached individual physicians on documentation accuracy of admission diagnoses to improve data integrity.
Deference to expertise – The team engaged experts at all levels of the cardiac medication delivery system to standardize protocols. Physicians peer-reviewed charts for diagnosis, intervention, documentation accuracy, and protocol compliance. Individual physicians received information regarding their performance and reviewed aggregate data at monthly medical staff meetings. Their focus on correcting care and process issues resulted in improved compliance with evidence-based protocols for cardiac medication administration and improvement in care outcomes.
Reluctance to simplify- The project team employed the Six Sigma process: Define, Measure Analyze, Improve, Control (DMAIC) to solve complex problems. They analyzed data to make fact-based decisions, identified errors and roadblocks, and made changes by piloting solutions. When the team encountered process problems, such as lack of standardization of the patient discharge process, they used a technique known as Work-Out to solve complex problems where the causes are evident. The streamlined discharge process, which included protocols for cardiac medication ordering, was piloted on one nursing unit then implemented hospital-wide.
Resilience – The project manager was responsible for ongoing analysis and reporting of outcome data. A physician council appointed by the Board of Trustees was entrusted with oversight of the process. A monthly dashboard tracked compliance with medication ordering, administration to patients, and chart reviews. The cardiac medication dashboard was incorporated in the quarterly quality report to the Board. Reviews conducted over the next 18 months showed that the process was capable of accurately capturing data, and ongoing focus on the process of ordering and administering cardiac medication showed continued improvement in performance.
Preoccupation with failure: Before the project began, caregivers and hospital leadership accepted defects in the system as physician error. At the conclusion of the 9-month project cycle, the steps of the medication delivery system were streamlined, which led to better information, greater understanding of the care needs of cardiac patients, improved cardiac medication administration, and better relationships between hospital leadership, physicians, and the rest of the care team. The institution exceeded its goal by achieving an overall cardiac medication compliance score of 97.3% by the end of the project cycle, an improvement that they have sustained over time.
Addendum
Although comparisons with other industries have their limitations, the progress that commercial airlines have made in safety over the past 30 years has been remarkable, averaging one fatality per million flights. HRO’s differ from other organizations in that they are able to demonstrate safe outcomes consistently over time. This time-based performance has been attributed to a culture shift present within an HRO. It is the creation of this culture that HRO’s aim to explicitly foster.
HRO’s are organized to acknowledge certain fundamental realities. Chief among these are that teamwork does not come naturally to people and that errors, no matter how much planning is invested for prevention, will happen and that an organization must therefore be prepared for recovery after such events.
Given the key position occupied by physicians in the medical super-structure, if healthcare is to become an HRO, doctors must be a major presence in any culture of reliability. As this case showed, finger-pointing on both sides needs to give way to a data-driven climate of inquiry.
The enabling features of organizations that foster highly reliable teams include:
- a culture of trust, shared values, safety, and risk-mitigating communication processes
- communication that provides opportunities for discussion and improvement
- distributed decision-making, in which all team members share accountability
- communication that is frequent, specific, accurate, problem-solving, and based on mutual respect
Rather than have safety imposed upon us, let’s start now to incorporate the principles that high-reliability organizations embody.
Ellen Guarnieri has over twenty five years of comprehensive healthcare experience in roles that ranged from staff nurse to CEO of a leading New Jersey Hospital. She is currently the President and CEO of Comprehensive Healthcare Strategies, focusing on organizational planning and redevelopment. Ellen can be reached at Eguarnie@comcast.net.
*Reference
Weick KE, Sutcliffe, KM. Managing the Unexpected: Assuring High Performance in an Age of Complexity. San Francisco: Jossey-Bass; 2001.