High Reliability Organization

Our journey toward becoming a High Reliability Organization (HRO) requires a collaborative mindfulness and acute awareness that even small failures in safety processes or behaviors can lead to serious adverse outcomes for our patients. We are committed to constantly search for even the smallest system issues that might lead to failure, and ultimately a safety event.

We embrace and adhere to a “safety culture”, described by James Reason and Alan Hobbs, who suggest that this culture involves Trust, Reporting, & Improvement.

We are improving our safety culture through some of the following programs:

Daily Check-In (DCI) for Patient Safety:

• We huddle at the start of the day to maintain awareness of operations and immediate problems impacting the front line. Our top executives lead a daily meeting (7 days/week) individually calling on leaders from 70+ different departments, nursing units, and service lines to report out the safety status of their front line operations. We Look Back for significant safety or quality issues from the last 24 hours and Look Ahead to anticipate safety or quality issues in the next 24 hours.
• Leaders huddle following the meeting to further discuss issues that were raised, assign ownership for issue resolution, and ensure common understanding of focus and priorities for the day.

Nursing Unit Safety Huddles:

• A focused Daily Check-In is conducted on individual nursing units to identify risks (patient at risk for falls, high risk medications, etc.) This exercise in situational awareness pulls the patient care team together by focusing priorities and teamwork to keep our patients safe.

Root Cause Analysis:

• Our Patient Safety Specialists investigate safety issues reported via Daily Check-In, our online Improvement Reporting System, or our Physician Safety Line. If appropriate, a Root Cause Analysis is performed to determine the “root” cause(s) of system failures which led to a safety event. Variations in practice are identified and action plans developed to improve consistency and reliability of systems and processes.

Process Improvement:

• Our multi-disciplinary Process Improvement Teams focus on removing barriers and implementing consistent, reliable, and industry “Best Practice” methods in delivery of our services. Teams are initiated as a result of identified variations in practice from safety events or as a result of our quest to constantly improve outcomes.