Health care systems such as RWJBarnabas Health, Virtua Health and Hackensack Meridian Health are seeking to become High Reliability Organizations, a designation once reserved for airlines and nuclear power plants, and enforced by the federal government’s Joint Commission on Accreditation’s Center for Transforming Healthcare Leaders.
For a hospital to call itself an HRO, it must train all of its employees in rigorous safety standards with the goal of eliminating all preventable harm, including accidental deaths. Those safety standards are enforced through visits and inspections several times per year from members of the Joint Commission.
For health systems, the benefits of becoming an HRO are numerous. From a clinical standpoint, it means zero preventable harm was done to patients and zero deaths due to medical errors. From a business standpoint, a health care organization gains the reputational benefit of being an HRO and may be looked upon more favorably by insurance companies that are seeking to partner with health systems.
“Becoming high reliability has a definite tie to our business model,” said Robert Garrett, co-CEO of Hackensack Meridian. “Our model is all about providing value to the people and the communities we serve, and the insurers are looking for organizations that they want to partner. So by becoming high reliability, we’re not only getting better quality results, we’re also reducing variation, reducing costs and therefore ultimately making health care more affordable.”
The HRO model began in the 1980s, when the Joint Commission recommended safety standards for both the airline and nuclear power plant industries to increase passenger and employer safety and reduce or eliminate accidental deaths.
In 2000, the CTHCL’s Institute of Medicine published a paper, “To Err is Human,” in which it is estimated that 44,000 to 98,000 people die every year due to medical errors in hospitals. The paper suggested hospitals institute specific safety measures to cut down that number and become HROs themselves.
In 2013, an updated version of the paper came out claiming that the number of people who die due to medical error is actually about 440,000 per year. The paper identified four areas in which hospitals make the most common errors: diagnostics, treatment, inadequate follow-up treatment and lack of communication between health care workers.
“More commonly, errors are caused by faulty systems, processes and conditions that lead people to make mistakes or fail to prevent them,” the institute found. “For example, stocking patient-care units in hospitals with certain full-strength drugs, even though they are toxic unless diluted, has resulted in deadly mistakes.”
Since then, national health care groups such as MedStar Health have implemented tight safety protocols to achieve HRO status, and New Jersey hospital systems are following suit. RWJBarnabas and Virtua Health will offer employee training this summer, while HMH already has trained 25,000 employees in high reliability standards.
“High reliability is the way you perform your business and approach your work,” said Dr. John Bonamo, chief medical and quality officer at RWJBarnabas. “We have been at this for more than a year now. We’ve already been using a lot of the safety techniques to become high reliability leading up to this year. Now, we have decided to do a full-fledged, organizational-wide high reliability journey bringing everybody in.”
Bonamo said one of the keys to becoming an HRO is teaching open communication between employees.
“In health care, there’s a huge power distance between doctors and other workers. What I mean by that is that there are many times people on the health care team see things that they think are a problem but don’t say anything because the doctor doesn’t see it. In an HRO, that doesn’t exist. We’re teaching our physicians to have accepting attitudes instead of shutting down subordinates.”
Ultimately, said Bonamo, becoming an HRO means putting safety first and thereby eliminating deaths due to medical error.
“In the original Institute of Medicine report, it talked about 99,000 people per year dying in American hospitals that don’t have to, and so that was a frightening number,” he said. “You take the high side of that it’s the equivalent of a 747 crashing every day.”
Bonamo said that RWJBarnabas’ goal is to have its employees receive four hours of safety training in high reliability training by the end of the year, as well as update its systems and technologies.
“The high reliability system is ongoing; the journey never really stops,” he said.
Garrett said that HMH began its HRO training in 2016, shortly after the Institute of Medicine updated its data. The health care system aims to have all 33,000 of its workers fully trained by the end of the year.
“The Joint Commission does identify high reliability as the gold standard of health care, so when they come around and survey hospitals, they want to see evidence of high reliability practices in three key areas: leadership support, commitment to patient safety and robust process improvements,” said Garrett. “We’re always trying to practice these three principals.”
Robbie Brown, HMH’s vice president of process improvement, said HRO training and practices implemented thus far have resulted in major improvements.
“We’ve had success in our program,” Brown said. “Southern Ocean Medical Center, for example, has made strides in reducing hospital-born infections. Bayshore Community Hospital has gone well over a year with no urinary tract infections, for example.”
Said Garrett: “There is a definite correlation between increasing high reliability training and improved outcomes. Once a week, we have a network-wide call with all of our hospitals to discuss any safety events that were reported. If there’s a serious event, the safety board on our board of directors may determine if we need to do a root cause analysis of it.”
Laura Hayes, vice president of clinical safety and performance at Virtua Health, said all 9,000 of the system’s employees will begin undergoing the four hours of HRO training next month. The system’s goal is to have all of its employees trained by the end of the year, and 56 employees have been trained to educate others in HRO guidelines.
Virtua’s acute care facilities are implementing “safety huddles,” in which senior leaders and department managers meet every 24 hours to speak about safety situations that occurred that day while anticipating ones that may happen in the future.
“The HRO journey is one that we are just beginning,” Hayes said. “It is an ongoing process that will eventually trickle down to outcomes. Our payers will see that and it could benefit us. But the end goal is to really have zero preventable harm and to prevent any harm that we can.”