EXECUTIVE SUMMARY

High reliability training can lead surgery centers and other healthcare organizations to better safety outcomes.

• For one health system, the process resulted in a significant reduction in serious safety events.

• Holding structured time-outs can help prevent errors related to wrong site surgery.

• Ambulatory surgery centers (ASCs) tend to operate with strong safety profiles. A high reliability program’s challenge is to find additional ways to make ASCs even safer.


Healthcare organizations can reduce serious safety events through a focus on high reliability training and education.

This process resulted in an overall 75% reduction in serious safety events over a four-year period at Hartford (CT) HealthCare, according to Rocco Orlando III, MD, chief medical officer.

When Hartford began its high reliability work in 2013, the health system educated all aspects of its organization on improving safety. The message was spread throughout the acute care setting of seven hospitals as well as ambulatory settings, including a large medical group, home care, skilled nursing facilities, and ambulatory surgery centers (ASCs), Orlando reports.

“We paid a great deal of attention to the language of high reliability, and made sure it was language that everyone used,” he notes. “We didn’t want it to be perceived as wisdom that arrives on an airplane; we wanted it to be part of our culture and part of our operating model.”

The high reliability model focuses on leadership, staff interactions, and daily management. It takes time to create a culture in which every leader and employee makes safety a priority. “It’s been a long journey,” Orlando acknowledges. “We began to expand the high reliability education into all aspects of our system.”

The definition of high reliability varies according to the employee’s workplace setting. For example, the definition of a harm event in an ASC is different than a harm event in a mental health facility, Orlando explains. Formal training into high reliability was possible only after each area defined harm events for their setting.

Another challenge involves ASCs and their governance and structure, Orlando adds. The health system could secure buy-in from most Hartford departments and organizations, but it took additional steps with ASCs. “We had to have conversations with the boards of ASCs and ask them if this made sense and what they thought,” Orlando recalls. “Once we had this conversation, there was broad recognition that it was a reasonable thing to do and that kind of training was appropriate.”

Another challenge with ASCs involved defining the baseline of serious safety events. “They tend to be a safer environment than the acute space. How do you drive the serious safety events numbers still lower?” Orlando asks. “What is that rate if you are not monitoring it? What are the reportable adverse events that occurred?”

Some states require ASCs and other healthcare organizations to report all serious safety events to the department of public health. This reportable information could be used to determine the baseline number of serious safety events. “ASCs are dependent on a physician partnership for that kind of reporting,” Orlando says. “One of our assets is we’ve linked this program to our risk management program, and our risk management director is a driver of decreasing harm.”

A high reliability safety organization creates a psychologically safe environment for its employees, says Stephanie Calcasola, MSN, RN-BC, CPHQ, vice president, quality and safety, Hartford HealthCare. “The underlying principle is having employees feeling psychologically safe to report events,” Calcasola says. “We work to create an environment for self-reporting of adverse events and near misses.”

Collecting data on near misses can be vital to an organization because this information reveals problematic areas before a crisis develops. But it takes work and trust to convince staff to report these incidents.

“Helping employees to feel empowered to report is the foundation of any healthcare organization,” Calcasola offers. “Hartford is quite mature in that journey of using the principle of transparency as a way to drive change.”

Hartford employees consistently report harm events as well as worrisome incidents they prevented from becoming a harm event, Calcasola adds. Data and trends involving near misses can help an organization redesign care or processes. “We can always do better, and make staff psychologically ready to report,” Calcasola says.

One tactic surgery centers can employ to improve this culture is to measure self-reporting through surveys to employees, Calcasola suggests. “There are 19 questions in the culture of safety survey,” she says. “Our data has shown us that our staff feel very comfortable raising concerns and reporting errors.”

Another step in creating a high reliability organization is to perform a root cause analysis of serious safety events. “We look at the way people can improve and how to create an environment of learning,” Calcasola says. “Also, every year, we look at what are the risk points in our system of care.”

Understanding the risk points helps an organization anticipate future adverse events and prevent serious safety events from occurring. “We can redesign and re-engineer workflows,” Calcasola says.

Leaders meet with the people involved in a safety error or near-miss and ask for information that will help everyone understand what occurred. Then, the group can discuss possible solutions and follow the PDSA (Plan, Do, Study, Act) process. “You can test a change and see how it impacts the process,” Calcasola says. “You can redesign and measure for the desired outcome.”

This process of analyzing problems and improving processes is embedded in Hartford HealthCare’s operating model, which also relies on other quality improvement and best practices principles, she notes. “This creates the best foundation to drive out error and create a safety reliability healthcare design,” Calcasola says.

For example, suppose an eye surgery center experienced a serious safety event in which the wrong lens was implanted in a patient’s eye. The center conducts a root cause analysis and finds a series of communication issues related to the preoperative assessment by the ophthalmologist. When the root cause analysis and PDSA process suggest a solution that could prevent this serious safety event from recurring, the suggested changes are disseminated to all the surgery centers that perform eye procedures.

“When we share these events across the whole organization, there’s no reason to fix it at [only] one site, but at all sites simultaneously,” Orlando explains.

In an operating room, the high reliability path means directing all staff to be attentive to each step of the surgical process. This is important to preventing wrong-site errors.

“There should be a mindfulness of rigor of doing standard work for evaluating a time-out for surgery,” Calcasola says. “This means having the team intentionally present, making sure patients are receiving the right procedure on the right site.”

When there are mistakes, they often are the result of inadequate focus and mindfulness, she adds. “Mistakes result in human error, an inability to cross-check and peer check, every time and every day,” Calcasola explains. “It doesn’t matter what surgery or procedure, that is a basic safety rule — to ensure a complete and accurate time-out every time in surgery.”

Surgery centers can create a structured time-out process by confirming the right patient is at the right surgery site, and ensuring the operating room contains all the proper equipment to perform the procedure. It also is important to cross-check the patient list to match the recipient to the correct implant. Further, be sure to address the facility’s performance quality all along the way.

Training staff on the high reliability journey is a significant commitment, Orlando cautions. “It’s not just one hour of training; it is three to four hours of training for all clinical staff,” he says. “It is something that can be done with internal resources, if there is someone with the expertise to master the data. But it is more commonly done with experts.”

ASCs often work with experts in-house, Orlando notes. “In most ASCs, the good thing is that physicians are likely to be familiar with high reliability,” he adds.