Aim for high reliability

Abstract

M ic h a e l Tr in s e y Standardizing processes within your organization will affect the quality of care on your unit because doing so meets the principles of high reliability: sensitivity to operations, reluctance to accept “simple” explanations for problems, preoccupation with failure, deference to expertise, and resiliency.1 These principles fall into two categories: anticipation and containment. First, let’s address the principles in the anticipation category. Sensitivity to operations means that operations are complex and dynamic. Consistent rounding on your unit gives you firsthand knowledge of challenges, opportunities, and best practices. Being transparent increases attention to patient care processes. For instance, you’re observing medication administration using a recently added bar code reader and you notice the nurse pulling the device’s cord due to its short length and dropping it as a result. You share the information with other leaders and it’s determined that this is a common issue; as a result, the bar code reader cords are replaced with longer ones. Reluctance to accept “simple” explanations for problems means to dig deep into answers by performing a root cause analysis. Continuing with our bar code reader example, you discover that a nurse makes a medication error. On your organization’s reporting tool, you document the “simple” explanation for the error: the unit was short staffed that shift. However, upon further review, the root cause was that the nurse overrode a process due to bar code reader failure, which contributed to the error. There was no record of the device being reported as defective or any attempt to obtain another bar code reader before administering the medication. Preoccupation with failure means that leaders are looking at how processes may break. Evaluating the good catches in your environment may lead to preventing future failures. Also, being thoughtful and observant of what’s working well assists in error prevention. Replicating what’s working well in other areas is essential for high-reliability organizations. Now, let’s review the principles in the containment category: deference to expertise and resiliency. A common misconception regarding deferring to an expert is that it’s based on seniority or positional hierarchy. In some cases, the process expert is the clinical nurse who performs the task daily. That’s why it’s important when changing products that we ask staff members to evaluate them. Another example is that employees who are new to your organization may communicate best practices from previous employers. As a leader, refrain from saying “I know” because this deters employees from sharing ideas that may lead to improvements. Resiliency is the ability to recover quickly in times of high stress, adapt well to change, keep focused, and learn from adversity. A clinical example of nursing resilience is during a code. Nurses stay focused in what may be a rapidly changing situation and rebound quickly afterward to care for the next patient. After the code, the team gathers to debrief and discuss what went well and what didn’t. The team learns from the situation and takes the new knowledge to future events. We can communicate the lessons from this event to others so that practice changes can be made. Resilience also indicates that your organization can find swift fixes to prevent errors. Enabling rapid cycle change assists with being highly reliable. As a leader, consider process standardization to be a positive step toward keeping your patients and staff safe. Your organization has observed failures or errors, which increases attention to processes (sensitivity of operations). In developing standardized processes, your organization has looked to data and root causes for future prevention (reluctance to accept “simple” explanations for problems). As a result, it has sought out best practices (deference to expertise) and examined good catches to implement changes to decrease the chance of future errors (preoccupation with failure). And learning the skills associated with the standardization will allow your staff members to grow and provide consistent care (resiliency). NM