Keeping Eyes on the Prize – Engaging all the Moving Parts for Higher Reliability

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Higher Reliability Organizations are those that anticipate things may go wrong and have developed cultures focusing on safety and continuous improvements.
A key element in such industries is strong leadership that sets and sustains the culture, leading by example and valuing the contributions of stakeholders working on the frontlines. Leaders of such organizations understand the risks of failure and keep their eyes on the prize: safety and highest quality outcomes!
The aviation industry is the quintessential example of a high reliability industry, but in my view achieving high reliability in aviation is much easier than in healthcare. Aviation primarily involves the interaction of personnel with continually improving technologies that incorporate numerous fail-safe mechanisms. Healthcare is different because achieving best outcomes requires engagement not just with technologies but most important, with patients, not simply as recipients of healthcare services, like passengers sitting on an airplane receiving the services of the flight crew, but rather as fully-fledged partners in healthcare.
High reliability in healthcare acknowledges patients as co-implementers of healthcare plans and thus considers them as components of the healthcare system. The moving parts – the gears and the clutch that drive healthcare – all need to be fully engaged to achieve highest quality and safety.
Achieving highest quality and safest outcomes in healthcare – the prize – requires intimate patient engagement and this is a responsibility of leadership.
Case Study:
The chief executive of a hospital had become concerned because of a high readmission rate for patients with congestive heart failure. The hospital had an excellent reputation for cardiac care with outstanding rates of early discharge following successful inpatient management of heart failure and after coronary revascularization procedures for cardiac ischemia. The management of these conditions exceeded the national standards for compliance with timing and performance of procedures and administration of medications throughout the course of hospitalization.
This leader’s quandary was that the readmission rate within 30 days of discharge was hovering around 25% and many readmissions were felt to be preventable. Readmissions were increasing utilization of services, increasing inconvenience and expenses for patients and affecting the financial bottom line for the hospital, as several insurers were withholding payment for hospitalizations felt to be avoidable. Several meetings with physicians and nurses had led to a variety of strategies and the use of checklists to assure “appropriate” discharge planning, but no improvements had been realized over a six-month period.
One day while walking through the emergency room, the chief executive noticed an elderly family friend sitting on a gurney breathing heavily through a nasal oxygen cannula. He had not seen this friend in several years and he went over to chat. The patient told the chief executive that he had been discharged recently after a five-day admission for congestive heart failure.
Turns out that this elderly man, in addition to having chronic congestive heart failure, also suffered from obesity, hypertension, type-2 diabetes and peripheral vascular disease substantially impairing his mobility. He lived alone in a third-floor walkup apartment, did not drive and had to walk half a mile to do his shopping. Though he had been provided a written discharge plan, he was unable to implement much of the plan as he could not afford all of the medications, did not fully understand their importance or how to take them, did not have a scale on which to weigh himself, had no dietary plan to follow and, without telephone service, did not have the means to contact anyone if something went wrong. Instead he relied on a kindly neighbor who dropped by every couple of days.
The light bulb moment!
It occurred to the chief executive that the reason this patient had been readmitted was a failure of his healthcare system. The doctors and nurses had focused on providing inpatient services and a discharge plan, but the plan did not include an assessment of this patient’s ability to care for himself at home. In other words, the healthcare system was focused on providing services, but it failed to view the patient as part of the system. The goal of the admission had been to discharge the patient in stable condition, but the more important goal should have included “and prevent his readmission.” Steps could have been taken to perform an in-home assessment, to identify a range of community social services and in-home care interventions that might have been appropriate, and to provide a diet and lifestyle plan that likely would have helped improve his overall health.
The patient’s unique needs and capabilities were not considered part of HIS PLAN.
This chief executive was an authentic leader. He kept his eyes and ears open and valued the contributions of everyone on the frontlines of healthcare, the clinicians AND the patients, and he kept his eyes on the prize.
Grease the gears, push in the clutch, press the accelerator and engage for success!


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