Mark Kestner, MD is Chief Innovation Officer of MediGuru. He has extensive executive leadership experience in the military, university systems, integrated delivery systems and particularly in community-based healthcare systems.

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In 1998, the Institute of Medicine established the Committee on the Quality of HealthCare in America. The goal was to develop a strategy that substantially improved the quality of healthcare. The committee’s first report, titled 

To Err is Human: Building a Safer Health System

, concluded the majority of medical errors result from inefficient and variable processes such as varying provider education and experience, and fluctuating patient case mix. The list went on, as did the complexity of the issues.

The committee’s second report addressed innovation in healthcare delivery. Both reports called for processes and care that were more effective, safe, patient-centered, timely, efficient, and equitable. In response to these reports, industry leaders began trying to make care delivery processes more predictable. In the late 1990s, for example, healthcare organizations were required to initiate public reporting of quality measures. Despite some quality improvements over the past two decades, leaders haven’t made the desired progress.

Most concerning, the incidence of preventable adverse events remains disturbingly high. Medical error remains the third leading cause of death in the US., and is estimated to cost the U.S. economy about $20.8 billion per year.

These shortcomings have financial ramifications that the advent of value-based medicine have only emphasized. With reimbursement now closely tied to clinical outcomes, demonstrating measurable improvements in care is more critical than ever.

Physicians are an essential component of any solution. They will need to lead the reinvention of healthcare and its delivery, measurement, and improvement. Unfortunately, too many of them are disengaged to the point of burnout. Indeed, about four in 10 physicians reported feeling dissatisfied in their medical practice (42%), according to 

It should come as no surprise, then, that unhappy physicians are much less likely to be champions for quality improvement, which has knock-on effects to patient care. One way to re-engage them is to adopt the philosophical approach employed by high reliability organizations (HROs).

HROs are organizations that successfully avoid catastrophe, despite a high level of risk and complexity. 

Typically, even minor errors in these organizations can result in disastrous consequences. (Think nuclear power plants, or air traffic control systems.) So what do HROs do that the healthcare system does not? And how can their solutions be applied in the healthcare arena? Here’s a shortlist:


Front line medical staff are in the best position to spot potential failures and identify areas for improvement. Focusing on clinical processes leads to observations that guide decision-making and operational improvements. HRO leaders actively encourage communication, take employees’ concerns seriously, and visit the unit to ask questions. The lesson: every voice needs to matter.



HROs rely on experts, not authority figures, for decision-making. Physicians and other clinical experts, more than hospital administrators, must assess and respond to patient safety issues. In other words, expertise should trump authority.


Recognizing that any deviation from the expected result can quickly escalate into disaster, HROs immediately and completely address any human, technical or process failure—no matter how small. Similarly, hospital staff need to identify and troubleshoot potential process breakdowns, finding trouble before it finds the patient.



HROs reject simple diagnoses of problems, instead conducting root cause analyses. To challenge long-standing beliefs about why problems occur, HRO leaders examine benchmarks and other performance data. The net-net: healthcare providers must stop trying to keep it simple and use technology to pay attention to all the data at our disposal.



In an HRO, the work is never done. HROs recover quickly by anticipating trouble spots and improvising when the unexpected occurs. They prepare for emergencies, identify errors that need to be corrected, and develop innovative solutions, enabling a rapid operational response to each crisis. So should we.

Of course, there is no “one size fits all” approach to quality improvement. What is obvious is that, in order to promote movement towards zero patient harm, quality initiatives should focus on meeting patient needs. This requires measurement, transparency, and accountability. Quality improvement metrics and KPIs must be identified, tracked, and, when appropriate, made publicly available. This is more than just “best practices.” Quality measurement and reporting are also essential, as well as increasingly required for reimbursement.

Articles

Despite advances in medical science and technology, our healthcare system doesn’t always translate knowledge into practice. All too often, this leaves healthcare providers questioning the key business decisions that impact patient care. What caregivers need is a model for applying new technology safely and appropriately. Thankfully, such a model exists: the High Reliability Organization (HRO) model. 

Mark Kestner

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Look to HROs to Sustain Healthcare Innovation