In recent years health care institutions have embraced the High Reliability Organization (HRO) paradigm as a way to enhance outcomes, reduce error, and improve safety. Furthermore, since large health care systems have also been organizing their critical care programs—typically multiple intensive care units across hospitals—into alliances known as Critical Care Organizations (CCOs), the conditions are ripe for CCOs to embrace the HRO methodology. This article is designed to introduce the HRO concepts, relate them into a critical care context, and suggest how a CCO may start and sustain a high reliability venture.
Key points
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The high reliability organization (HRO) paradigm, representing 5 overarching guidelines, has been a many-year mainstay for quality, safety, and culture across many complex, high-risk environments.
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Although in recent years health care has increasingly adopted the HRO paradigm, only recently has there been interest in its implementation in critical care.
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Critical Care Organizations (CCOs), by their nature, are ripe for explicit adoption of the HRO methodology.
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The HRO application for CCOs includes logistical development, communication enhancement, and workflow amelioration, and sustainability necessitates hospital, CCO, and hierarchical ICU leadership commitment.
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HRO sustainability for CCOs necessitates unequivocal commitments from hospital, CCO, and hierarchical leadership.
Abbreviations
| CCO | critical care organization |
| HRO | high reliability organization |
| ICU | intensive care unit |
Introduction and definitions
In the quarter-century since the release of the US Institute of Medicine report To “ Err Is Human,” institutions and government agencies across the health care spectrum have sought ways to enhance outcomes, reduce error, and improve safety. One approach, the High Reliability Organization (HRO) paradigm, offers a compelling framework for improving safety and performance in the complex, high-risk setting of health care ( Table 1 ). Health care organizations that have embraced the HRO philosophy aspire to consistently achieve safe and effective outcomes despite operating under conditions that are inherently hazardous. , They do so by cultivating a culture of mindfulness, continuously anticipating and responding to potential failures, and embedding resilience throughout their systems, particularly in environments where uncertainty and the need for rapid coordination converge.
Table 1
High reliability organization guidelines and relevance to critical care organizations
| High Reliability Organization Guideline | Critical Care Organization Application |
|---|---|
| Preoccupation with preventing failure | Educational, organizational, cultural process and mindset among all providers that ICUs remain openly, persistently, and strategically mindful of failure prevention |
| Reluctance to simplify interpretations | Cultural acceptance that health care abounds with complexity, eschewing the inclination to oversimplify |
| Sensitivity to operations | Optimum, safe patient care best occurs when it takes priority over conflict or other managemental distractions |
| Commitment to resilience | Continual positive reinforcement for real-time problem solving |
| Deference to expertise | Recognition of the importance of seeking opinions from all members of the team, demonstrating the value of experience and expertise from all members of the team |
A Critical Care Organization (CCO)—whether given the moniker department, center, institute, or service line—is typically identified as having administrative governance over the preponderance of intensive care units (ICUs) in a hospital or health care system. Applying high reliability to a CCO may represent a promising strategy to enhance reliability, reduce harm, and promote a culture of safety. This article explores how the key HRO characteristics can be translated into actionable and sustainable practices within the ICUs of a CCO. Examining opportunities for such innovation provides a roadmap for integrating the HRO paradigm into critical care delivery in the United States.
Physicians, nurses, respiratory therapists, and other allied health providers typically coexist in caregiver hierarchies —each group typically has a leader (eg, Medical Director, Nurse Manager) and may have additional subleaders in addition to the other members of each group. The application of the HRO paradigm may occur at the CCO level, the ICU level, or the group level, each of which may be a caregiver hierarchy.
Background
The HRO paradigm originated more than 40 years ago and was initially applied to the complex, high-risk realms of the aviation and nuclear power industries. One highlighting example of how HRO methodologies have made the most impact are in aircraft carrier operations, given that an aircraft carrier represents a microcosm of a multitude of complex, high-risk activities. These activities—including ship functions, nuclear management, and air traffic control—function both independently and interdependently as a high-risk entity within a relatively small, self-contained vessel. That aircraft carriers operate day and night, with thousands of men with varying levels of expertise, continually training and preparing, is in itself creditable. However, the safety records of aircraft carriers are even more remarkable when coupled with the knowledge that it is not the experiential level of the crew that primarily drives success: aircraft carrier crews predictably turn over every 18 to 24 months! Having such continually laudable and emulative performance records given this staffing model suggests that aircraft carriers’ long-standing adoption of high-reliability concepts may be what drives success and is therefore practicable in other areas. ,
Accordingly, in many ways ICUs may be representatively analogous to aircraft carriers: medical, nursing, and respiratory caregivers working—independently and interdependently—24 hours a day, 7 days a week, with personnel of varying levels of education and experience, many of whom turn over frequently, within a relatively small, self-contained environment. However, although the health industry has experimented with the HRO paradigm at hospital and health care organizational levels, , critical care specifically has only seen a nascent interest. This is curious given that the specialty—operating in a high-stakes, high-pressure environment where timely, precise decision making can mean the difference between life and death—would appear to be especially ripe for HRO implementation. In addition, since the dawn of critical care as a practice and specialty, physicians and hospitals have been seeking the best approach to organize, standardize, and benchmark the care of seriously ill patients. Despite advances in technology and clinical protocols, preventable errors, communication breakdowns, and system inefficiencies remain persistent threats to patient safety and care quality. These challenges are particularly notable in ICUs, where complexity, uncertainty, and the need for rapid coordination converge; tying together the organizational aspects of “critical care” with “high reliability” seems congruous. ,
Discussion
Initial Step: Commitment to Critical Care Organization High Reliability
Antecedent to implementation of the HRO paradigm may be the commitment of a CCO to ensure systematization of its operation. Although ICUs in the United States are generally known by their patient populations (eg, medical, surgical, neurosciences), organization on that level does not make for difficulties in systematization. More challenging are the levels of organization that evolve based on local requisites, departmentally siloed leadership, and education-based training necessities. As an example, consider the Accreditation Council for Graduate Medical Education requirement that core faculty members for internal medicine-based critical care training must be exclusive to medically trained intensivists. Thus, ICUs first must agree to transcend these intra-ICU considerations to apply the overarching processes of high reliability.
Success and sustenance for high reliability within a CCO typically require a leadership triumvirate at system or hospital, individual ICU, and CCO levels. First, the hospital system-level leader must possess the mindset and vision of high reliability and commit to, and be willing to sustain, the necessary components and resources. Second, multidisciplinary intra-ICU leaders should understand and embrace the high reliability ideology. Third, the CCO leader must be willing to operate around (but importantly not insist on eliminating) the existing organizational structures. This leader should have the requisite seniority and multidisciplinary wherewithal to recognize that the high reliability methodology for the CCO transcends the idiosyncrasies of the individual ICUs.
Once such a triumvirate is in place, the CCO can begin to consider implementing the HRO components and ensuring that the physicians, multidisciplinary caregivers, and trainees across the CCO can be engaged in HRO methodology. Weick and Sutcliffe offer a roadmap to the 5 guidelines ( Box 1 ) that are the backbone of the HRO paradigm. However, this publication is not clinically specific but rather describes HRO generalization. What follows is a summarizing interpretation of the HRO guidelines and a tie into a clinical, critical care, context.
Box 1
The high reliability organization paradigm is represented by five overarching guidelines
Data from Weick KE, Sutcliffe KM. The infrastructure of mindful organizing. In Managing the unexpected: sustained performance in a complex world. Hoboken (NJ): John Wiley & Sons Inc; 2015, p. 36–8.
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Preoccupation with failure
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Reluctance to simplify
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Sensitivity to operations
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Commitment to resilience
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Deference to expertise
Guideline 1: Preoccupation with Preventing Failure
Philosophy
An HRO develops a preoccupation with failure prevention by way of a three-fold intent: the first, which can be considered on a macro level, is to explicitly identify mistakes or mishaps that would be considered generally intolerable and to call out if/when they do occur. Second, on a more microlevel, is to observe and monitor for potential small issues that could develop into larger ones. The final component is an additional continual preoccupation with “near misses” as opportunities for improvement, as opposed to satisfaction that the extant system is sufficiently structured to thwart even worse outcomes. There should also be the realization that these 3 levels of preoccupation, once established, should not be considered static, as they need continual reassessment and adjustment. ,,
Application to critical care
As complex, high-hazard environments, ICUs are prime locations within a hospital to which its caregivers should be attuned for potential failures. As such, the physicians, nurses, respiratory therapists, pharmacists, and other allied health personnel should all be explicitly introduced to and mindful of the continual strategic preoccupation with failure prevention. For example, the CCO should consider the requirement of periodic asymmetric training and transparent presentation of mishaps and near misses as they evolve.
Sustainability
The CCO as an HRO should additionally develop, on a higher level, an organized, ongoing process to ensure that the ICUs remain openly and explicitly preoccupied with preventing failure. Thus, in addition to the aforementioned training, the CCO best approach includes periodic (eg, monthly) meetings with the ICU hierarchical leadership and stakeholder groups to review both the macrolevel and microlevel incidents, to include ideas and steps to attenuate future occurrences, as well as frequent improvement updates regarding near misses. These reviews can then be added to asymmetric training opportunities. ,
Guideline 2: Reluctance to Simplify Interpretations
Philosophy
The sentiment to eschew simplification may seem perplexing: it is very common, in medicine generally, and critical care specifically, to make managing concerns, care processes, or challenges easier by developing approaches to reduce their complexity. It turns out that such approaches are considered antithetical to the HRO methodology. One clinical example of a rush to accept a simplistic idea in critical care occurred early in this century when a published study demonstrated a reduction in mortality in critically ill patients when blood glucoses were intensively managed into the (what is considered “normal”) 80- to 110-mg/dL range. The initial response to this study was quick acceptance, and championed in particular by hospital administrators, other nonclinicians, and payers for its straightforward, easy-to-understand—simple—proposition. Within a few years, however, a deeper understanding of the study’s nonconforming protocol as well as independent attempts to reproduce the original finding resulted in the realization that erroneously accepting this perspicuous conclusion may lead to detrimental patient outcomes. Thus, high reliability is more likely ensured with the acceptance of the complexities of the health care realm, and inclination and willingness to consider many possibilities, rather than attempts at simplification. ,
Related posts:
Challenges in Creating a Critical Care Organization at Your Institution
Assessing Workforce Competencies for Physicians and Advanced Practice Providers
Innovation, Technology, and Telemedicine in Critical Care
Pharmacists in Interprofessional Critical Care
Critical Care Billing
ICU Capacity Management and Surge Preparedness
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