A Framework for High-Reliability Organizations in Healthcare

A Framework for High-Reliability
Organizations in Healthcare

© 2018 Health Catalyst
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Framework for High-Reliability Organizations in Healthcare
This report is based on a 2018 webinar presentation given by Allan Frankel,
MD, Founding Partner, Safe & Reliable Healthcare and Senior Faculty,
Institute for Healthcare Improvement; and Michael Leonard, MD, Managing
Partner, Safe & Reliable Healthcare and Adjunct Professor of Medicine, Duke
University School of Medicine. entitled, “A Systematic Framework for the
Delivery of Safety, Highly Reliable Care and Habitual Excellence.”
Allan Frankel, MD Michael Leonard, MD

Despite a growing focus on quality improvement in
healthcare, the skills needed to make measurable,
sustainable improvements in care are not inherent.
Even among dedicated, smart healthcare
professionals, those skills were not baked into
their DNA from medical school through residency
through practice as many other skills were.
But as anyone in healthcare knows, quality
improvement is an essential piece of
organizational evolution and development.
Patients and their families are at the center of
everything healthcare providers do. They entrust
their lives and wellbeing with their providers.

To address the need for quality improvement
skills, Drs. Allen Frankel and Michael Leonard,
created a practical, systematic framework that
can be applied in virtually any care setting.
Drs. Frankel and Leonard published a white
paper in 2017 entitled “A Framework for Safe,
Reliable, and Effective Care” with the Institute
for Healthcare Improvement (IHI) that delves
deep into this framework.

In addition to developing the framework, Drs.
Frankel and Leonard put together the key
components of High Reliability Organizations
(HROs).
These include leadership, a safety-focused
culture, and a dedication to continuous learning
and improvement.
They offer practical tools and insights which
enhance the ability to deliver optimal patient
care in an environment focused on learning
and quality improvement.

The necessary pieces for developing
and sustaining a culture and system that
delivers safe, highly reliable care are
strong effective leadership, a culture of
safety, and an accessible learning system.
Figure 1, on the next slide, shows the
components of that framework and how
each aspect fits into three categories:
Leadership
Culture
Learning system
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Based on: https://www.safeandreliablecare.com/blog/2016/11/29/s-r-sociotechnical-framework-ihi-minicourse
Figure 1: Model for the Framework for Safe & Reliable Care

The framework provides a clear roadmap to
move forward and do the work of developing
an organization focused on patient safety.
What Drs. Frankel and Leonard have learned
through their decades in patient safety is that
all aspects of the framework must exist, or
learning won’t be sustainable.
Improvement won’t be sustainable.
The cultural maturity model helps illustrate
the type of culture that is necessary to move
forward toward becoming an HRO.

Cultural Maturity Model
The concept of a cultural maturity model
has been around since around 1975 and
since its development, it has evolved to
help organizations think about how they
can from an unmindful culture to one
that is generative.
Within healthcare, all components of the
framework, from leadership to learning,
can be rated on a cultural maturity scale,
as seen in Figure 2.

Figure 2: Cultural Maturity Model

Historically, nurses and doctors have been trained
and evaluated using the individual expert model.
The idea behind that model is that if expert
healthcare professionals are put in any healthcare
environment, they’ll figure it out.
The problem is – that doesn’t work.
Healthcare today is too complex to do that
successfully across the board.
The best, most effective solution to quality
improvement is to work collaboratively
and proactively.

As Figure 2 showed, the tipping point for
psychological safety is when an organization
goes from a systematic model of managing
hazards to a proactive one where staff
anticipates and prevents problems before
they occur.
The pinnacle of cultural maturity is a
generative culture in which safety is the
culture. It’s how business is done. It’s
constantly vigilant and transparent.

Reactive cultures are like playing defense.
They react to problems rather than trying to foresee them
and get ahead of them before they become catastrophic.
When people within an organization are
simply reacting, they tend to make mistakes.
They’re distracted, they need to multitask,
and they forget things.
Much like distracted driving, distracted
caregiving can have unintended negative
consequences.

Being proactive and generative doesn’t come
naturally, and in today’s health systems, it’s
not yet the norm.
Drs. Frankel and Leonard and their team
assessed 30 community hospitals for the
state of Massachusetts to help figure out
how these organizations could sustain high-
quality community care within an ever-
changing environment full of systems
mergers and political changes.
They found that only 4 out of the 30 hospitals
were proactive to generative, and the
overwhelming majority were reactive.

They also found that even within the reactive
cultures there were pockets of proactive units –
departments within the hospitals that were
getting it right some of the time.
And what they learned about those departments
was that they worked collaboratively.
They didn’t do it all the time, but it was a start,
a foundation.

The ability to come together, think ahead, and
play as a team is critical for the ability to deliver
safe care.
Novices on the team can turn to the experts for
valuable information, and thus learn how to
deliver excellent care, eventually becoming
experts themselves.
It creates a huge library of experience for the
entire team to draw from that will create
predictability.
One of the most basic concepts of high reliability
is anything that can be made predictable should
be made predictable.

Key Components of High Reliability Organizations
HROs thrive because their leadership takes
charge of the culture, engages staff, promotes
a culture of safety, and embeds continuous
learning and improvement processes into the
everyday lives of everyone within the
organization.
Effective leadership is the primary component
of an HRO.

Effective Leadership
An organization with a proactive or generative
culture must have effective leadership, both at
the senior and local level, s aligned with the
goals of the organization.
Strong, effective leaders of HROs are engaged
and knowledgeable in several aspects of
organizational and system management, such
as organizational development, whole system
change, and measurement to manage.
They must also have a relentless focus on
process and know that culture is a process,
not a destination.

Cultural Maturity and Senior Leadership
A culture of safety starts at the very top with
senior leadership. An organization is only as
strong as its leaders, so having leaders guiding
the culture is important.
Figure 3 below provides examples of how
leaders are engaged in the different levels of
cultural maturity.
In an unmindful culture, the staff doesn’t know
who the leaders are. The leaders are absent,
and they aren’t engaging with the doctors and
nurses on the ground providing patient care.

Figure 3: Cultural Maturity Model: Senior Leadership

Moving up the scale from unmindful to generative,
the leaders are more and more engaged.
Leaders in proactive and generative cultures are
present. They’re talking with staff. They listen,
support, and learn.
And in the best cultures, they make space for a
cyclic flow of information that encourages
feedback and cross-organizational learning.

Local Leadership
Next in the top-down culture of safety is local leadership.
In unmindful organizations, local leadership is mostly
absent, but in proactive and generative organizations,
local leaders model the behaviors that drive a culture
of safety and create an atmosphere that provides for
psychological safety and accountability.
They play offense, think ahead, and wire the whole
organization for safety and quality improvement.

Local Leadership
Figure 4: Cultural Maturity Model: Local Leadership

Local Leadership
There is plenty of data about the effects of
leadership on overall culture and staff engagement.
One example is a survey of staff at 30
Michigan hospitals.
The data collected shows the importance of
leaders being present and listening to the
frontline staff and how their presence and
engagement can have significant positive
effects on culture, safety, and burnout.

Local Leadership
Drs. Frankel and Leonard published a study in 2017
about cultural data that surveyed and collected data
from 17,000 people across 30 hospitals in Michigan.
The survey looked at seven specific areas:
Learning environment
Local leadership
Teamwork climate
Safety climate
Burnout climate
Personal burnout
Work-life balance
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Local Leadership
At the beginning of the survey, there were two questions.
Do your leaders participate
in walk-arounds in your
organization?
10,000 of 17,000 said “Yes.”
Did you get feedback on
the issues you raised?
4,500 said “Yes” – 5,500 said “No”

Local Leadership
Figure 5 illustrates the effect of leadership not only
asking for feedback, but actually acting on it, closing
the loop, so to speak, of ideas and concerns brought
up by staff on the frontline of patient care.
• The graph in Figure 5 represents the seven
areas surveyed.
• The red bar represents scores when
leadership did not close the loop.
• The green bar represents scores when
leadership did close the loop.
• And the blue bar represents the mean.

Local Leadership Based on: https://qualitysafety.bmj.com/content/27/4/261
Figure 5: Michigan SCORE Survey Data
For statistical
significance, there
must be a five to
seven-point
difference in scores.
In this survey, the
difference is more
than 30 points in
some cases, and in
all cases, it’s at least
nine points.

Culture of Safety
Another component of HROs is a culture of safety.
Patient safety is an important part of that culture,
but it’s more of a result and a goal than a defining
part of the culture.
A culture of safety must address burnout and
encourage different aspects of safety.
Burnout in healthcare can lead to many negative
effects, including errors, infections, higher
mortality, and decreased patient satisfaction.
It can also lead to high turnover, which can
have a significant effect on the bottom line.

Culture of Safety
Burnout Versus Resilience–The opposite of
burnout is resilience.
A culture of safety tends to have low burnout
rates and encourage resilience.
Going back to the cultural maturity model,
resilience goes up and burnout goes down
as the culture becomes more proactive
and generative.

Culture of Safety
Psychological Safety–Safe, optimal care
requires psychological safety and feeling safe
and empowered to speak up.
When frontline care providers don’t feel safe
and empowered, they may not feel
comfortable speaking up if they notice
something that isn’t quite right.
Wrong site surgeries and retained foreign
bodies are very preventable medical errors.
When OR staff feels safe and empowered,
there are fewer surgical events like these.

Culture of Safety
Accountability–another significant aspect in a
culture of safety.
The framework stresses differentiating between
individual issues and systems issues when
holding individuals accountable.
It’s also important to create a work environment
that is perceived to be both just and fair.

Culture of Safety
Teamwork and Communication – a culture of safety
requires teamwork and effective communication.
Much like psychological safety, successful teamwork
is correlated with improved patient safety.
Going back to the cultural maturity scale, a
generative culture values teamwork and
continuous learning.
These things are deeply embedded in the culture,
and teamwork is taught and modeled across the
organization.

Culture of Safety
Teamwork and Communication
There are four tenets of effective teamwork:
Plan forward.
Reflect back.
Communicate clearly.
Resolve conflict.
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Culture of Safety
Negotiation – Conflict is unavoidable.
Whenever there are more than two people
involved in an organization, there will be conflict.
But conflict does not have to be negative or
degenerative.
With collaboration and negotiation, conflict can
be addressed effectively, thus encouraging a
more robust culture of safety.
The process should involve collaborative forms
of negotiation.

Culture of Safety
The four concepts that must be addressed to
develop and nurture a culture of safety,
psychological safety, accountability, teamwork
and communication, and negotiation, all work
together to create teams that work – for each
other and for the patients.
Healthcare organizations must also
address burnout. If leadership focuses
on these things and makes them central
parts of the culture, they are well on their
way to becoming an HRO.

Learning System
Another vital component of an HRO is
continuous learning.
HROs have one thing in common when it
comes to learning: a visible and
transparent learning system.
An effective learning system must be
transparent. It must be reliable. It must
focus on continuous learning.
And it must provide for improvement and
measurement in order to learn and grow.

Learning System
A learning system, when well developed and
rolled out, can have measurable positive
effects throughout the organization.
For example, Drs. Frankel and Leonard have
spent about 25 years running interventions at
hospitals and health systems.
One of their significant interventions started at
Mayo Clinic.

Learning System
After working to integrate the framework into
their organization, including a transparent
learning system, Mayo now has local leadership,
local managers, and power workers who give
staff a voice and make them feel cared about.
From there, they can successfully layer on the
improvement process.

Learning System
About 18 months into the work with Mayo, one senior
surgeon talked to Dr. Frankel about the transformation
he saw throughout the organization. He said,
Before we started this program, my biggest concern when
I went home in the evening was that I didn’t know what I
didn’t know. In other words, nurses weren’t comfortable
coming and talking to me about the issues they were
running into with the patients on the unit. Now that nurses
and staff are comfortable about speaking up about their
concerns, I know what I need to know to help the services
run smoothly and safely. I go home in the evening with
great assurance that we are on track.”

Learning System
What’s notable and important about this comment is
that it’s illustrative of the idea that when people are
comfortable speaking to each other, it can be an
essential piece of creating operational excellence
and delivering safe, reliable care.

Learning System
Similar results can be seen at other
organizations when the three components
of the framework are in place: culture,
leadership, and a learning system.
Leadership is the key component.
Without effective, engaged leadership
that supports a generative culture, it
becomes difficult to have holistic change.

Learning System
Local leadership must work hand in hand
with senior leadership to create a culture
where psychological safety is manifest,
where people feel like they’ll be held
accountable fairly, and where the team
behaviors, like briefings and debriefings,
are robust regardless of care setting.

Ultimately, Drs. Frankel and Leonard have
seen true change is possible.
Cultural maturity can happen if teams and
units and organizations are both self-reflecting
and improvement-capable.
The culture must be robust enough that self-
reflection becomes part of that culture, and
they must have enough improvement capacity
that they can look at weaknesses and cracks
and act on them in an effective, cultural
healthy way that focuses on overall safety.

Practical Tools and Insights
In addition to the framework, Drs. Frankel and
Leonard have developed practical tools that enhance
the ability to deliver optimal patient care in an
environment of continuous learning.
The most effective tool is a real-time learning board.

These learning boards have several benefits.
They tend to increase efficiency. (Nurse managers report
spending about 75% less time on non-clinical work.)
They lead to two to three times more engagement and
completed projects.
They offer an avenue for more consistent communication
and transfer of information between shifts.
They help facilitate conversations aimed at improving
psychological safety.

A well-designed learning board encourages a culture of safety in key ways:
They lead to better huddles and help staff connect about
important issues between huddles and shifts.
They increase self-reflection.
They give management more effective, real-time tools.
They help leaders understand issues across care types.

Putting it All Together
Through their years of experience, Drs. Frankel
and Leonard have found that doing this work
and creating a culture of safety is critical.
It provides a framework to integrate all
initiatives and a foundation to successfully
carry them out.
It also gives a clear focus on culture, and
a proactive, generative culture is essential
to creating sustainable value and providing
world class care.

Culture is the social glue. It reflects the attitudes
and behaviors of the people delivering care.
So, a generative culture enhances patient
care – and care for the caregivers, the frontline
personnel–which can go a long way to
addressing burnout and increasing
psychological safety.
Figure 6 shows how the components of HROs
all come together into the Framework for Clinical
and Operational Excellence.

Figure 6: The Framework for Clinical and Operational Excellence

With this framework in place, and patients and
their family always at the center of care, it is
possible to become an organization that delivers
safe, highly reliable care across the board.
But to do this successfully and sustain
improvement, all pieces of the puzzle must
be in place.
A culture change starts at the top with strong,
engaged, system-wide leadership that
encourages a culture of safety and pursues
continuous improvement by implementing a
transparent, robust learning system.

Drs. Frankel and Leonard, along with their team
at Safe & Reliable Healthcare, have been
working on this process at more than 1,300
hospitals for more than two decades.
Much like cultures at HROs, their process has
evolved and matured.
It’s a process that works – that leads to
significant changes that can have real, positive,
measurable effects on patient care and safety.
When organizations follow the framework for the
delivery of safe, reliable care, benefits are felt
from top to bottom, staff and patients. That’s
worth the investment every time.

For more information:
“This book is a fantastic piece of work”
– Robert Lindeman MD, FAAP, Chief Physician Quality Officer

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Other Clinical Quality Improvement Resources
Click to read additional information at www.healthcatalyst.com
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