Executive Summary

This document is written for hospital leaders at all levels who are interested in providing patients safer and higher quality care. It does not contain the views of researchers or theorists on how you can do better. Instead, it presents the thoughts, successes, and failures of hospital leaders who have used concepts of high reliability to make patient care better. It is a guidebook for leaders who want to do the same.

High reliability concepts are tools that a growing number of hospitals are using to help achieve their safety, quality, and efficiency goals. These concepts are not an improvement methodology such as Six Sigma® or Lean. Instead, they are insights into how to think about and change the vexing quality and safety issues you face. Hospitals do most things right, much of the time. But even very infrequent failures in critical processes can have terrible consequences for a patient. Creating a culture and processes that radically reduce system failures, and effectively respond when failures do occur is the goal of high reliability thinking.

At the core of high reliability organizations (HROs) are five key concepts, which we believe are essential for any improvement initiative to succeed:

• Sensitivity to operations. Preserving constant awareness by leaders and staff of the state of the systems and processes that affect patient care. This awareness is key to noting risks and preventing them.
• Reluctance to simplify. Simple processes are good, but simplistic explanations for why things work or fail are risky. Avoiding overly simple explanations of failure (unqualified staff, inadequate training, communication failure, etc.) is essential in order to understand the true reasons patients are placed at risk.
• Preoccupation with failure. When near-misses occur, these are viewed as evidence of systems that should be improved to reduce potential harm to patients. Rather than viewing near-misses as proof that the system has effective safeguards, they are viewed as symptomatic of areas in need of more attention.
• Deference to expertise. If leaders and supervisors are not willing to listen and respond to the insights of staff who know how processes really work and the risks patients really face, you will not have a culture in which high reliability is possible.
• Resilience. Leaders and staff need to be trained and prepared to know how to respond when system failures do occur.

This document shows how hospital leaders have taken these basic concepts and used them to develop and implement initiatives that are key to enhanced reliability. The document shows how the concepts have been used to:

• Change and respond to the external and internal environment.
• Plan and implement improvement initiatives.
• Adjust how staff members do their work.
• Implement improvement initiatives across a range of service types and clinical areas.
• Spread improvements to other units and facilities.

Summaries of applications in each of these areas are followed by more extended discussions of them drawn from a series of site visits and case studies of systems that participated in AHRQ's High Reliability Organization (HRO) Learning Network. Beyond the table of contents, there are two ways to easily locate the issues of most interest to you. One index allows you to locate particular clinical issues to which high reliability concepts have been applied while a second index allows you to locate discussions of particular high reliability concepts.

Applying high reliability concepts in your organization does not require a huge campaign or a major resource investment. It begins with leaders at all levels beginning to think about how the care they provide could become better. We hope this document will help you see what is possible, and that it will help you begin the process of transforming your organization into one where safe, high-quality, and efficient care is received by each of your patients.

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