Harris Health is the safety-net provider serving residents of Harris County, Texas, and is the country’s fourth-largest safety-net health system. It comprises Ben Taub Hospital (level I trauma center), Lyndon B. Johnson Hospital (level III trauma center), 37 ambulatory community clinics, and care for 10,000 detainees of Harris County Jail.
In 2020, the health system embarked on a transformative journey by formulating its five-year strategic plan, with a central focus on “Quality and Patient Safety” as the foundational strategic pillar. Central to this pillar was the ambitious goal of evolving into a high-reliability organization (HRO), a vision wholeheartedly embraced by the organization’s leadership and board of trustees. This goal necessitated a comprehensive approach underpinned by specific objectives and measurable metrics to operationalize the vision. Thus, developing an HRO dashboard became necessary to gauge progress and steer initiatives toward high reliability.
Upon initiating the journey to HRO, it soon became evident that there is no standard way to become an HRO, nor are there clearly accepted metrics to document the progress toward the goal of becoming an HRO. Initial evaluation included a comprehensive review of pertinent medical literature regarding established best practices, including white papers from the American College of Healthcare Executives, The Joint Commission, and esteemed industry leaders and consultants.(1–4)
As we started our HRO journey, it became evident that we needed to tackle the implementation of HRO from multiple angles. These inputs were leveraged to develop a comprehensive HRO strategy, framework, and tactics, as well as process and outcome metrics, allowing the organization to monitor vital deliverables and performance indicators that measure progress toward HRO. Measuring progress provides the motivation, transparency, communication, and accountability to drive the changes necessary to become an HRO.
This article delves into this strategic endeavor’s genesis, implementation, and outcomes. Measuring the progress toward becoming an HRO has become one of the most critical components of the journey, as we all know from Harvard Management Professor Peter Drucker: “What gets measured gets managed.”(5)
FRAMEWORK, STRATEGY, AND TACTICS
Five principles that guide HROs were reviewed in detail as part of an iterative process for developing strategies and tactics to implement HRO in the organization:
Preoccupation with Failure: Constantly identify and mitigate potential failure.
Reluctance to Simplify: Recognize the complexity of operations and do not simplify problems.
Sensitivity to Operations: Closely monitor day-to-day operations.
Commitment to Resilience: Build resilience by encouraging flexibility and learning from failures.
Deference to Expertise: Respect the expertise of individuals at all levels of the organization (see Figure 1).
Figure 1. The Guiding Principles of High Reliability
We studied the framework proposed by The Joint Commission to provide expertise for our strategic framework. The Joint Commission is an independent, nonprofit organization that accredits and certifies thousands of healthcare organizations and programs in the United States. According to the commission, the critical framework to becoming an HRO is based on a triad (see Figure 2):
Leadership Commitment: Demonstrate a commitment to high reliability, establishing it as a core value and priority for the organization.
Safety Culture: Create a culture of safety where all staff feel empowered to report errors or near misses without fear of retribution and where learning from events is prioritized.
Robust Process Improvement: Implement robust process improvement methodologies, such as Lean Six Sigma, to continually improve processes and reduce variability in care.
Figure 2. Joint Commission Framework for HRO
Several strategic initiatives and their respective tactics have been implemented to enhance safety and reliability within our organization (see Table 1).
ESTABLISHING HRO MEASUREMENTS AND PROGRESS
Setting metrics is crucial for guiding organizations and individuals toward becoming an HRO. Metrics provide a quantitative way to measure progress and success. They allow the organization to track performance against established benchmarks and adjust strategies to achieve goals.(6)
Setting metrics and goals creates accountability within the organization for performance and can transparently communicate progress to stakeholders.(7) By regularly reviewing performance data, the organization can identify areas for improvement and implement changes to enhance effectiveness.(8) The organization can optimize its impact by focusing resources on activities that contribute most to achieving goals.(7)
Following best practices in goal setting and performance measurement can lead the organization to success. The SMART framework helps set clear goals for improving reliability and safety by making them Specific, Measurable, Achievable, Relevant, and Time-bound. This ensures that metrics are well-defined, feasible, aligned with organizational goals, and can be tracked within a set timeframe (see Figure 3).
Figure 3. SMART Metrics are Specific, Measurable, Achievable, Relevant, and Time-bound
In selecting metrics, an organization should understand the SMART principle for choosing goals (see Figure 4), the five principles of HRO, and The Joint Commission framework to become highly reliable (see Figure 4).
The following are the critical categories of metrics selected to reflect HRO alignment that we have focused on:
Leadership Commitment to Safety: Gauge leadership involvement through the frequency of safety messages, participation in safety rounds, and establishing safety goals.
Safety Culture Assessment: Conduct regular surveys to assess staff perceptions of safety, communication, openness, and feedback processes.
Staff Training and Competency: Track completion of safety training and assess competency in applying safety protocols.
Patient Safety Indicators (PSIs): Monitor rates of hospital-acquired infections, pressure ulcers, and adverse drug events to ensure patient safety.
Error Reporting and Analysis: Track reported severe safety events and near misses to analyze root causes and implement corrective actions.
Patient and Family Engagement: To enhance safety, assess patients’ and families’ involvement and understanding in care decisions.
Specific metrics were meticulously selected to align with evidence-based criteria for HROs (see Tables 2 and 3 for a complete list of metrics). For instance, the electronic incident reporting system’s number of reports/utilization rate ensures prompt incident reporting and resolution. Tracking the frequency of the Patient Safety Huddle provides insights into risk identification and mitigation.
Key Acronyms: Catheter-associated Urinary Tract Infections (CAUTI), Central Line-associated Bloodstream Infections (CLABSI), Surgical Site Infections (SSI) Colon, SSI Hysterectomy, Patient Safety Indicator (PSI) 90, Serious Safety Events (SSE Type 1 & 2), and Healthcare Effectiveness Data and Information Set (HEDIS)
The HRO dashboard also incorporates quality and patient safety metrics validated by third-party agencies and tailored to address organization-specific issues, such as infection rates and serious safety events (SSEs). Metrics related to the ambulatory care settings and cultural aspects, like the internal culture of safety surveys and HRO education training rates, further reinforce safety culture and continuous improvement.
Metrics related to patient safety focus on proactive identification and resolution of potential issues, while reliability metrics ensure processes’ adaptability and effectiveness in overcoming failures. A culture of safety metrics values frontline input, and learning metrics prioritize organizational improvement from failures. Process metrics recognize process complexities, and resilience metrics assess the organization’s ability to anticipate and recover from disruptions.
Leadership engagement is also crucial in developing and implementing HRO and accepting the HRO dashboard to document progress. Once the HRO dashboard is created, the organization must communicate progress toward becoming an HRO to leadership at all levels. This communication is essential in securing the “buy-in” of the entire board, CEO, physician leadership, and the executive team.
One key strategy to engage leadership is clearly defining goals that rely on healthcare industry-accepted metrics. This approach helps align leadership with the organization’s objectives and fosters a sense of accountability. Additionally, all leadership members should be included in mandatory HRO education and training to provide leadership with the necessary knowledge and skills and demonstrate the organization’s commitment to transparency and accountability.
MILESTONES ON OUR JOURNEY
The following are important milestones in our journey to becoming an HRO.
Serious Safety Event Rate Approaching Zero
We closely monitored our electronic incident reporting systems and severe safety events as one of our proxy HRO progress metrics. Usually, electronic incident reporting systems and serious safety event reporting rates increase when transitioning to a high-reliability organization because people are more willing to report incidents. Initially, our serious safety event rates increased as expected. Still, they have since dropped significantly by year 3, nearing zero, thanks to the practical safety program and rapid process improvements we have put in place (see Figures 5 and 6).
Figure 5. Typical Improvement Curve (Example contains proxy data to ensure confidentiality.)
Figure 6. Serious Safety Event 1-2 Rate Chart (Example contains proxy data to ensure confidentiality.)
HRO Education Rollout
In the first year, 100% of our hospital leaders, including directors and higher medical executive committee members, participated in in-person HRO education. In the second year, 99% of all high-risk areas underwent in-person HRO education and training in our health system, including the emergency department, obstetrical unit, perioperative area, pharmacy, laboratory, interventional radiology, intensive care unit, correctional health, ambulatory division, and psychiatry.
For year three, we rolled out HRO education to all remaining healthcare employees and physicians by partnering with human resources to ensure HRO education and training were incorporated into the onboarding process for new employees and the mandatory annual refresher courses.
Utilization of HRO Communication Tools
We have encouraged the use of HRO communication tools like daily safety huddles at all levels of the organization and the situation-background-assessment-recommendation (SBAR) framework for memos, which helps us communicate about critical events. For example, we send out weekly safety alerts using the SBAR method.
By modeling HRO tools at the corporate office, we have improved communication, transparency, and teamwork. This has helped create a culture that values standardized communication practices and recognizes the importance of all HRO tools (see Figure 7 for the HRO sharing alert template).
Figure 7. HRO Safety Sharing Alert Template
Recognition Initiatives
Recognizing our employees’ outstanding contributions and celebrating early wins is vital to our journey. To support high-reliability principles, our health system now offers more formal awards for staff, mainly through “Good Catch” and “Zero Harm” awards.
We celebrate Good Catch award winners at our health system board meetings, where they receive certificates and jackets and are recognized alongside board members for reporting and correcting potential safety issues (see Figure 8 for images of award jackets). Additionally, we present Zero Harm awards to nursing units with no falls or pressure injuries for 12 straight months, celebrating their achievements on-site.
Figure 8. Good Catch Award Jackets
External Validation
Since implementing HRO practices, we have seen measurable improvements in quality and patient safety metrics. Our Leapfrog Hospital Safety Grades rose from a grade D to a B across both hospitals, showing our commitment to building a culture of safety. Strong leadership engagement has created a psychologically safe environment where staff can openly discuss safety concerns, and the daily focus on quality metrics has significantly impacted driving improvement.
We have reduced many hospital-acquired complications, including infections, by following strict protocols and hand hygiene practices. Regularly sharing quality outcome metrics publicly allows us to find areas for improvement and turn them into actionable quality improvement programs.
CONCLUSION
Harris Health’s journey toward becoming a high-reliability organization (HRO) has been an iterative process that has yielded significant improvements in patient safety and quality of care. The organization has made measurable strides in reducing adverse events by focusing on HRO principles such as leadership commitment, a safety-focused culture, and robust process improvement. It has also fostered an environment of continuous learning and accountability.
The daily focus on standard work and HRO metrics has played a pivotal role in tracking progress, ensuring transparency, and aligning efforts across all levels of the organization. We were able to set a catalyst for change by engaging leadership and frontline staff in HRO and ensuring education, training, recognition, modeling, and reinforcement.
Harris Health has demonstrated that a systematic, data-driven approach to reliability can lead to sustained improvements in healthcare delivery. As we continue to evolve on this HRO journey, the lessons learned from our experience will serve as a foundation for further enhancements in patient care and a model for other healthcare organizations striving for HRO.
References
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