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We need a new scientific standard for high reliability | Viewpoint

Opinion
Article

The standard must highlight evidenced-based practice, such as proven treatments to manage diseases.

In 1944, Charles Sidney Burwell, Harvard Medical School’s dean, said in an address to first-year medical students: "Half of what we are going to teach you is wrong, and half of it is right. Our problem is that we don't know which half is which.”

Image submitted by author

K. Scott Griffith (Submitted image)

Today, this applies to the entire spectrum of healthcare delivery in the U.S., not just the practice of medicine.

Healthcare executives face a constantly changing landscape of competing priorities: reduced payer reimbursements, an aging population, pandemic recovery, and labor, supply chain, and capacity shortfalls. These are exacerbated by escalating costs and employee and physician burnout. With so many challenges to optimizing limited resources and delivering the best care possible, it’s no wonder healthcare executives are searching for ways to achieve high reliability.

A healthcare CEO recently shared this ongoing frustration. “We’ve embraced every best practice that comes along – TeamStepps, just culture, huddles, rounding, to name just a few,” she said. “Everyone talks about high reliability, but I’m not sure what that term means, exactly. When I ask people, they give me answers that don’t make sense. Academic models of Swiss cheese and complexity theory don’t help when the patient’s condition is deteriorating right before our eyes. How do we know what we’re doing is working?”

A new standard is needed, one that documents, monitors, and measures ongoing success. The standard must highlight evidenced-based practice, such as proven treatments to manage diseases and data that shows what we’re doing works. But in some cases, such as the evolving threats of microbial infections, our efforts must be evidence-producing, meaning no proven strategies exist but innovations may be on the horizon.

When it comes to high reliability and culture, we must apply the same scientific approach.

Since Edwards Deming's pioneering work in quality management in the mid-20th century, organizations have aspired to higher performance. By balancing the competing priorities of customer expectation, product delivery, and cost, the quality management philosophy revolutionized automobile manufacturing and established a path for other industries to follow.

But hospitals are not manufacturers or nuclear power plants or hotels. In several ways, hospitals are even more complex, with tens of thousands of points of delivery.

For example, hospitals and nurses across the U.S. are still reeling from a patient’s death at Vanderbilt University Medical Center when a nurse incorrectly administered a medication after retrieving the wrong one from a dispensing cabinet, resulting in the patient’s death. After the hospital fired her and the Tennessee board of nursing revoked her license, the Nashville district attorney prosecuted and a jury convicted her, before the judge sentenced her to probation. The continuing tragedy of this event is the chilling effect on nurses who fear reporting risk into an unreliable health system where punishment is the most likely response when things go wrong.

An integrated science has emerged to answer these questions and challenges, producing a new high-reliability standard. Collaborative High Reliability® and its first component, the Collaborative Just Culture® program, have been developed over decades of work in high-consequence industries – including aviation, healthcare, railroads, emergency medical services, firefighting, law enforcement, and energy.

The main building blocks of this evidence-based approach are:

  • A voluntary reporting program comprising management, employees, unions and regulators that encourages reporting risks without fear of losing your job or accreditation. This collaborative approach to finding solutions rather than assigning blame is exemplified by the U.S. airline industry's highly successful Aviation Safety Action Program, which has been a dominant contributor to the 95% reduction in the fatal accident rate over the past three decades.
  • Combining engineering and behavioral sciences with legal and ethical systems of justice to guide human resources departments and professional boards to a more consistent response to human behaviors.
  • Following ISO 9001 and quality management principles that require organizations to “document, monitor, and measure” what works.
  • Most important, aligning all activities into a reliability management system, eliminating what doesn’t work and developing processes, programs, and systems into an integrated whole.

A key component of this success is independent assessment by a third-party accreditation body required to achieve qualification standards on a two-year, periodic schedule.

The time for guessing what works and what doesn’t should be over. The healthcare industry should represent the best that we have to offer, from medicine to engineering to behavioral science, along with the ethical attributes of diversity, equity, and inclusion.

It’s time to adopt a scientific approach that works and discard activities that don’t. It’s time for a new standard.

K. Scott Griffith is the founder and managing partner of SG Collaborative Solutions.

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