“The best way for any company- and its people- to respond to unpredictable challenges is by building an effective organization that expertly spots the unexpected when it crops up and then quickly adapts to meet the changed environment.” -Dr. Karl E. Weick, Industrial Psychologist, (for more)
The mandate for healthcare organizations is clear…IMPROVED VALUE! Many healthcare leaders have responded by embracing the new mandate as an ideal. Some are making incremental refinements to existing operations towards increasing quality at lower cost, critics say that is simply not enough. The time it would take to ‘right the ship’ through incremental progress is not acceptable at the current national cost for our healthcare infrastructure. The debate that will play out over the next 5+ years. Regardless of where you land on this spectrum of thought, if you are a healthcare leader what is undeniable is that you need to be building a better healthcare organization (a report brief issued by the Institute of Medicine). I believe that a better organization is one that is always learning, adapts to new understanding, and is above all accountable. The Highly Reliable Organization (HRO) paradigm provides a framework for highly complex systems to operate effectively, when the results of not doing so would be catastrophic.
Five characteristics of a Highly Reliable Organization (HRO):
Appreciation for Operational Literacy-
When I was in Business Development, everything that my team talked about was sexy. Acquisitions, service-line development, marketing, and community outreach…this is the sexy side of business. Finance was the same way. Everything the finance division did at our hospital was critical to mission, after all ‘no margin, no mission’. Operations often go the unsung heroes in healthcare. Nurses are often viewed as a cost to be contained, physician’s clinics a necessary loss leader and ancillary support constantly has to defend their mere existence. Almost nothing is glamorous about operations, but yet that is where healthcare value is possible. To become an HRO, adherence must be given to practices that breed true operational excellence. Resources have to be allocated appropriately in our organizations because it is what the patients are coming to us for. Strong operational leadership needs to be cultivated and celebrated in healthcare, because the days of cost-shifting and growing out of our organizational problems are over.
Embraces Complexity of Systems-
In business we tend to strive for simple answers. We love when we can distil a complex process into an acronym and many healthcare organizations are living on the 80/20 rule. The problem is that some systems demand the whole of the system is understood, and not acknowledging essential complexities can lead to unsafe results. While striving to understand a system in its most elegant form is always desired, we must resist oversimplifying in a way that doesn’t honor the entirety of understanding.
Commitment to Resilience-
Healthcare has experienced eras when honest mistakes led to clinicians being exiled from the industry in hopes of making the system stronger. The results were under-reporting of events and near-misses for fear. Healthcare didn’t get any safer as a result. Then the pendulum swung the other way and the prevailing belief was to have a ‘blame free’ approach to healthcare errors. That was equally as undesirable due to the lack of accountability. A commitment to resilience is about learning from every event or near-miss that is discovered and getting to why it occurred. If it is due to willful disregard for good policy and procedure, than accountability must occur. However, if the event or near event occurred due to system flaw (which is most likely the case), then the process needs to be refined. A resilient organization is constantly learning and refining itself.
Deference to Expertise-
A system is most fit when decisions are made at the point of best understanding. True understanding cannot occur if the frontlines are not engaged in problem identification, innovation, and solution. Conversely an organization is doomed to fail by abdicating all decision power to the frontlines due to poor leadership. Organizational leaders, when hired correctly, have training and experience in understanding why systems yield the results they do. Making top-level decisions at the frontline levels of the organization is just as dangerous, as making organization design decisions without understanding of frontline realities.
Preoccupation with Failure-
Safe cultures are always on the lookout for ways to get better and prevent poor outcomes. As a proactive extension of learning from adverse events, an HRO doesn’t wait for mistakes to happen to refine processes. Monitoring for safety and a culture of preventing harm should be the top priority in all healthcare organizations.
Shawna Beese-Bjurstrom, RN, MBA lives in Spokane, WA with her family where she is an Executive/Business Coach. She writes on issues such as healthcare strategy, operational excellence, communication, and leadership, read her blog.
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