Appendix C. High Reliability Organization Learning Network Operational Advice From the Cincinnati Children's Site Visit (continued)

Becoming a High Reliability Organization: Operational Advice for Hospital Leaders

Building a Business Case for Quality and Organizational Transformation

Building a business case for quality is critical to achieving the unified support for organizational transformation on which success depends. If quality, safety, and continuous improvement are not regarded by the CFO and the board as key elements of the business model, the organization will lack the full alignment required to achieve substantial change. When Cincinnati Children's began its transformation, it did not have the CFO's full support. Instead, the CFO asked the leadership team at Cincinnati Children's to help him understand the benefits of investing in quality improvement initiatives so that he could set up a business model based on science and data that would still protect the institution's financial well-being.

Being a pediatric hospital, Cincinnati Children's generates much of its revenue from patients with highly complex conditions who travel distances to receive care at their institution because of the quality of care they believe they can obtain. Pediatric hospitals receive little revenue from Medicare, so their revenue is directly linked to the services they provide as opposed to the diagnosis-related-group (DRG)-based system through which most adult hospitals are paid. Despite the differences between pediatric and adult facilities, the process Cincinnati Children's used to engage its CFO and build its business case is one that, potentially, can be applied to other systems.

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Engaging the Chief Financial Officer

Three themes emerged in the presentation by Scott Hamlin, Senior Vice President, Finance, and Chief Financial Officer of Cincinnati Children's, and subsequent discussion:

  • Getting the CFO on board is critical. To the extent that the CFO influences resource allocation decisions, interacts with the board, and shapes compensation strategies for organizational leaders, organizational transformation is unlikely without the full support of the CFO.
  • Getting the CFO on board is a gradual process. The CFO needs to be tactfully and patiently educated about issues related to quality and safety, as well as how these issues affect the hospital's financial performance. In Mr. Hamlin's case, it took several years for him to evolve from a skeptic about issues related to quality to a champion for quality's role in the hospital's business case. CFOs are trained to be skeptical and focused on financial issues, so it is unrealistic to think that a single presentation, workshop, or set of data will lead to a dramatic change in their outlook. More time and patience will be required.
  • Giving CFOs data and tools that they can use to convince themselves of the business case for quality is essential. Cincinnati Children's helped to train the CFO's staff to perform analyses using matched-case designs (go to Table 2 for definition) that helped convince the CFO of the business case for quality. Analyses performed by quality staff would have been suspect, but once the financial analysts could evaluate data independently to draw financial conclusions, the results were credible to the CFO. The approach used at Cincinnati Children's involved providing the CFO with the data and tools that he and his staff could use to convince themselves of the business case for quality. This self-persuasion worked for them and was consistent with the experiences in other HRO Learning Network systems.

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Building the Business Case

Cincinnati Children's business case grew out of some basic assumptions that leaders made about what the organization must do to attract patients. Over time, these assumptions have been synthesized into three value statements that form the basis of their business case for quality.

Value proposition: Success requires providing things of value to our patients.

  • Patients and their families place value on:
    • Quality (the best opportunity for a positive outcome and an experience with the hospital and its staff that is better than with competitors).
    • Cost (both direct costs of care and indirect costs associated with travel, length of hospitalization, etc.).
  • The goal is to provide the highest possible quality in our target price range (we will earn our price).

Value orientation.

  • Conclusion about value: Improving quality (outcomes and experience) will create value for which customers will pay. More often than not, improved quality can either reduce cost or create opportunities to generate more revenue.

Value commitment.

  • We must continuously prove our current value (which is only possible through the measurement and analyses that are part of improvement initiatives).
  • We must constantly be in a position to improve our future value (which requires ongoing strategic improvement activities).

A key insight to creating this business case was the recognition that better utilization through quality improvements can increase revenue. Most hospitals try to increase revenue by building more buildings and adding more staff. Although such growth was a part of its strategy, Cincinnati Children's leaders also recognized that they could increase revenue by more efficiently using existing resources. For example, preventing infections and other complications through a commitment to quality allowed patients to spend less time in the hospital. Beyond greater levels of patient and family satisfaction associated with shorter hospital stays, reduced infections also made more beds available for sicker patients, who generate more revenue for the hospital in the early days of their hospitalizations. Cincinnati Children's has created demand for these beds and increased its patient population by positioning themselves as a leader in treating rare and complex childhood disorders, which has led to referrals and patients outside the Cincinnati region. These efforts have led to 17 percent annualized revenue growth over the past 5 years, with 50 percent of that revenue coming from outside the region.

Beyond general recognition that quality is a key component to the value proposition of its system, Cincinnati Children's leaders have monitored their investments in quality infrastructure to assess their ability to simultaneously increase quality and reduce costs. Three examples of these efforts are provided to illustrate an approach to building a concrete business case.

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Use of Evidence-Based Care

The organization works in a collaborative effort with community physicians to improve care given at home to children with asthma, bronchiolitis, fever of an uncertain source, and gastroenteritis. Evidence-based medicine (EBM) shows that for many children, these conditions can be effectively treated by community physicians without admission to the hospital. In addition, they are low revenue-generating conditions. As a result of this effort, length of stay and need for hospital admission decreased from 1996 to 2005 for children with the diseases targeted by clinical guidelines and improvement initiatives (go to Table 1).


Table 1. Reduced Inpatient Bed Utilization

ConditionDecrease in Admission
Fever of uncertain source586%

Because Cincinnati Children's has limited capacity, the bed space created by keeping these children out of the hospital created space for patients whose conditions generated more revenue for the hospital. Being able to schedule care more rapidly for these patients with complex needs contributed to greater patient and family satisfaction and probably reduced the number of patients who went elsewhere with shorter waiting times.


Effective Discharge Planning


Cincinnati Children's recognized that an improved discharge planning process would free beds for other patients and cut the number of beds occupied by patients who were generating little revenue for the hospital. The impact of their efforts to improve flow and inpatient capacity is illustrated as follows (go to Figure 1):

Beyond the clear impact that improved discharge planning had on bed capacity, this initiative allowed Cincinnati Children's to better monitor the availability of different types of hospitals beds required for patients of different ages and with different medical issues. These kinds of initiatives make a compelling case for increasing capacity without the expensive capital investments required to expand hospital facilities.

Discussion at the site visit also turned to the impact of improved flow on a range of staffing issues. To the extent that better flow reduces delays and ensures that beds will be available, Cincinnati Children's reduces the need to reschedule surgical procedures that inconvenience both patients and the surgical teams. Moreover, improved ability to manage bed space is key to staffing units, such as assuming full capacity rather than assuming less than full capacity and needing to pay expensive overtime or add staff when a unit is full. Converting to this staffing model helps to reduce staffing costs while providing employees with a more consistent schedule.


Reducing Ventilator-Associated Pneumonia and Surgical Site Infections

Using a bundle of interventions to reduce ventilator-associated pneumonia (VAP), Cincinnati Children's saw an increase in days since the previous VAP move from 7 days in December 2003 to 238 days in May 2005. VAP increases mortality as well as the patient's length of stay and cost of hospitalization.


In addition to VAP, Cincinnati Children's is implementing an Institute for Healthcare Improvement (IHI) bundle of interventions to reduce surgical site infections (SSIs). There has been a decrease from 1.5 infections per 100 procedure days in December 2004 to just over 0.5 in May 2006 (go to Figure 2).

Some hospital administrators might regard these initiatives not as improvements in quality, but as reductions in the amount of revenue generated by the hospital. Cincinnati Children's examined the financial impact of these activities more closely using a matched case–control design study. Their analysis matched patients who did not have SSIs with the same or equivalent surgical procedure, age, procedure date, and comorbidities with patients who had SSIs. Chart reviews were conducted to refine candidates and assess whether the SSI was preventable.


As they expected, the SSIs added on average 10.4 days to the length of stay and $60,480 in additional charges. They also found, however, that the SSIs in their study caused a loss of 208 days of time that beds could have been occupied by higher utilization, sicker patients. Moreover, because many of Cincinnati Children's patients are on Medicaid, which pays only one rate for a stay regardless of an SSI, the costs associated with the SSI for these patients were entirely borne by the hospital (go to Figure 3 and Table 2.)


Table 2: SSI Overall Results

 Aggregate 16 PatientsAverage per Case (n = 16)
 Hospital DaysGross ChargesAverage Length of StayGross Charges
Total SSI240$1,740,00015.0$108,730
Total match70$793,0004.4$49,563

This example illustrates how a matched-case design can help assess and document the business case for many quality improvement initiatives. By considering costs resulting from complications, the extent to which those costs are (and are not) passed on to payers, and the opportunity costs associated with those complications, Cincinnati Children's was able to provide compelling financial reasons for supporting a key quality improvement initiative.

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Summary of Business Case Issues

Building a business case for quality is a slow process that requires the ability to measure quality, assess costs accurately, and engage the CFO and financial analysts in developing analyses to assess financial impact accurately.

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Specific Improvements Toward Organization Change

How has the broad commitment to organizational change been translated into specific improvements that make patient care and the patient experience better than it used to be?

More often than not, more improvement opportunities exist than an organization has time to tackle at any given time. Given the excess projects and the competing demands for time and resources, how can improvement priorities be set?

At Cincinnati Children's, several factors influence improvement priorities, including the significance of the clinical outcome, national imperatives for improving patient safety, and national benchmarking. Leaders at Cincinnati Children's have also developed a system for setting improvement priorities based on managing internal demands, which is described below.

All new initiatives at Cincinnati Children's are classified as a system-level, department-level, or unit-level project. An upfront determination about the project level will help to determine the scope and resources needed to complete the project. A unit-level project, for example, may require a greater time commitment from the nursing staff on a specific unit and less time from a senior executive. By recognizing the difference, the hospital can plan additional staffing resources for the unit to compensate for time invested in the project.

Once initiatives are classified by level, how are they prioritized at each level? Cincinnati Children's prioritizes initiatives with what it calls the DICE methodology, which is an acronym for a set of guiding questions to help with the prioritization process. The DICE guiding questions are:

  • Duration: How long will this initiative take to complete?
  • Integrity: Will this initiative break down if manipulated?
  • Capability: Do we have the skill set within our staff to successfully complete this initiative?
  • Effort: How much effort is required for this initiative?

Initiatives that score high on the DICE scale receive highest priority and access to resources.

After improvement priorities are set, the work of implementing the initiatives begins. The following are examples of improvement initiatives from Cincinnati Children's that helped to make processes and systems more reliable. These specific examples were highlighted during walkabouts on the first morning of the site visit. The information reported below is a reflection of the information reported by the groups who participated in those walkabouts.

To make this section easier to navigate, each example is structured to answer the following questions:

  • What is the challenge being addressed in this initiative?
  • What are some of the HRO concepts taken into account during this initiative?
  • What was the transformation process for this initiative?
  • How did Cincinnati Children's know whether the process changes represented improvements for this initiative?

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Emergency Department

Identified challenge. The Cincinnati Children's emergency department recently underwent physical plant renovations. As a result of the renovations, the emergency department had an opportunity to change the existing processes for admissions, triage, and electronic registration to be more reliable and efficient. To date, the emergency department has not shown significant improvement in the flow measures, yet the team is continuing to look for and test factors in trying to find that breakthrough.

HRO concepts employed. The emergency department process redesigns primarily involved two high reliability concepts:

  • Preoccupation with failure.
  • Deference to expertise.

Transformation process. The new admissions process in the emergency department employs clerks at the front desk who greet and admit the patient, asking only for the patient's name, age, and chief complaint. The patients are directed to the newly designed waiting area and are called back by pager to the desk when a nurse is ready for triage. Sensitivity to patient privacy has ruled out the old method of calling the patient's name to the group. Using the HRO principle of deference to expertise, the new admissions process requires a clear understanding that admitting clerks are not assessing patients beyond the "first look" method in which they have been trained. If they, or the family, believe that there may be reason for concern, a nurse is made available immediately to asses the patient's condition.

During triage, a nurse assesses the patient in an individual room located in a separate triage area. A process change based on preoccupation with failure has made it more reliable for nurses to document and monitor each patient's condition by having access to a computer terminal in each triage room. This changed from entering and referencing information with the electronic medical record (EMR) system at a central terminal after the triage examination. Similarly, as in the example above, deference to expertise is practiced during the nurse triage process. The nurses do not give any medication beyond Tylenol or fever reducers. If they or the family believe that immediate medication or treatment is needed, an emergency department physician is made available.

The EMR process further helps staff to be more preoccupied with failure by using a color-coding system that alerts all staff to the progress of a patient's care, monitoring levels of acuity and sending alerts to staff based on certain preset parameters about the patient's condition. All staff have received training on the EMR system.

Observed improvements. For more information about the observed improvements in the emergency department, please feel free to contact a Cincinnati Children's representative. Contact information can be found at the end of this appendix.

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Pharmacy Redesign

Identified challenge. The pharmacy department at Cincinnati Children's faced three challenges: alleviate inefficient use of workspace in the pharmacy; decrease the number of missing, wasted, or returned medications from patient rooms; and reduce the processing time for medication orders.

HRO concepts employed. The high reliability principles used to address the pharmacy challenges were:

  • Sensitivity to operations.
  • Preoccupation with failure.

Transformation process. One way in which the pharmacy addressed some of the challenges was by using a real-time observation and implementation plan. A team was formed and asked to observe the process and workflow of pharmacists and pharmacy technicians during a regular workday. In one example, the observation team noted an inefficient use of lab workspace and asked the technicians for improvement suggestions. The technicians suggested that the addition of extra shelves would create a less cramped and more reliable workspace. A member of the observation team phoned the maintenance staff in the moment, and temporary shelves were installed so that the team could determine whether the additional shelves had a positive impact on the workspace. Following subsequent observations of that space, it was determined that the shelves had made a positive impact on the reliability of the technicians' work, and permanent shelves were installed.

The second way in which the pharmacy addressed some of the challenges was to adopt the Lean methodology coupled with physical plant renovations to remove waste in existing processes. A Lean consultant was hired to train staff on how to look for waste in processes. Physical plant renovations also reduced the distance that pharmacy staff had to walk to process and deliver medication orders.

Observed improvements. Results have shown a 50 percent reduction in the number of returned medications from patient rooms. Process efficiency measures also show a 58 percent reduction in pharmacy technicians' walking distance, a 43 percent increase in workspace, and a 75 percent reduction in processing time, shortening the lengthy full-day process to just 5 hours.

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Preventing Codes Outside the Intensive Care Unit

Identified challenge. Cincinnati Children's staff on unit A6S noticed that there was a higher than expected rate of codes occurring outside the ICU. To address this problem, a decision was made to focus on prevention in their unit, which had already begun adopting high reliability concepts to improve quality and patient safety. The unit developed the Pediatric Early Warning Score (PEWS) as an improvement initiative aimed at reducing codes.

HRO concepts employed. The PEWS initiative primarily involves two high reliability concepts:

  • Preoccupation with failure.
  • Sensitivity to operations.

Transformation process. While A6S tried to find solutions to help prevent codes in the unit, the clinical director found an early warning score system for adults in the United Kingdom. Adapting that to children, the unit developed PEWS, which is an objective assessment of every patient to determine their clinical deterioration and how likely they may be to code. Depending on the score (ranging from 0 to 10), staff must take certain actions to ensure proper treatment and decrease the likeliness of a code.

When the unit first began implementing the initiative, it discussed PEWS with unit staff. Because staff were already doing the different clinical assessments, they just needed to change how they were reporting and using this information. The PEWS chart has specific instructions for what to do depending on a patient's score. This is sensitive to the fact that sometimes nurses are reluctant or hesitant to call interns and residents if they are unsure of the necessity. Instead, the PEWS algorithm makes this decision for the nurses, so no debate or questioning is necessary. In addition, the unit discussed the initiative with patient families and got family buy-in for the display of a large PEWS chart in the hallway, which shows each patient's PEWS and allows the staff to review it regularly as they walk by.

Observed improvements. There are two major ways that Cincinnati Children's knows that the PEWS initiative has made a difference. First, at the time of the site visit, it had been 164 days since the last code in the unit, which is an improvement. The unit has a goal of reaching one full year since the last code. Second, the staff has incorporated PEWS review as part of their daily activities. After reviewing the PEWS chart, they are immediately aware of the overall status of each patient and where and how to devote their attention.

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Computerized Work Orders

Identified challenge. Another area where Cincinnati Children's wanted to focus its improvement efforts and become more reliable was with physician order entry. The challenge was to reduce errors in orders and transcriptions.

HRO concepts employed. The implementation of computerized physician order entry (CPOE) was successful because of its focus on:

  • Deference to expertise.
  • Reluctance to simplify.

Transformation process. Cincinnati Children's began using a Siemens Web product for its CPOE, although the system has been greatly customized to meet the organization's specific needs. Cincinnati Children's first began implementing the CPOE in a few of its inpatient units and then expanded the implementation to almost all its inpatient units within 18 months. In most of these units, two mobile laptops now are used on clinical rounds. One of these computers is devoted to computerized work orders so that staff can enter work orders during rounds. In addition, there are workstations in the hall where work orders are entered. During the initial implementation, residents found the order sets too complicated, and they actually got actively involved in the redesign.

One of the unique aspects of Cincinnati Children's CPOE system is that the help desk support team is composed of clinical staff as well as technical staff. Therefore, the help desk staff fully understand clinicians' language, needs, and processes.

Observed improvements. Immediately upon implementing the CPOE system, Cincinnati Children's found fewer clarification calls about orders, an elimination of transcription errors, and a 52 percent decrease in medication delivery time to the unit. The intermediate results included a decrease in unsigned verbal orders from 40 percent to 8 percent. The system itself has built-in improvements, such as automatic hard stops and automatic links for certain drugs. If a clinician ignores a system recommendation, he or she must give a reason in the comment box. Therefore, the work order system is designed to be comprehensive and to improve care, not to be the quickest to navigate and put in entries.

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Surgical Site Infections

Identified challenge. Cincinnati Children's recognized the need to address the challenge of SSIs in both inpatients and outpatients. Evidence-based studies demonstrate that patients receiving prophylactic antibiotics before surgical incision have lower SSI rates. Cincinnati Children's same-day surgery and inpatient surgery units are implementing evidence-based practices to reduce Class I and II nosocomial SSIs to 0.75 and 0.25 per 100 procedure days, respectively, by July 2006. The outcome measure is: nosocomial SSI rate/100 procedure days for Class I and II procedures. Process measures include timely antibiotic administration (percent given within 0 to 60 minutes before incision) and complete preoperative antibiotic orders received before 10 a.m. the day before surgery for same-day surgery patients and timely antibiotic administration (percent given within 0 to 60 minutes before incision) for inpatients. The site visit focused on same-day surgery.

HRO concepts employed. The SSI initiative primarily involves two high reliability concepts:

  • Preoccupation with failure.
  • Sensitivity to operations.

Transformation process. Cincinnati Children's used a bundle of interventions in this initiative. The transformation process included the following phases: define opportunities, measure performance, analyze opportunity, PDSA (plan, do, study, act), improve and sustain performance, and spread improvement. Two examples of how it implemented the bundle follow:

  • Cincinnati Children's recognized the need to ensure that all patients wear a proper indicator identifying whether they received a preoperative antibiotic. A patient wristband is placed over the patient identification band on the same wrist to remind the clinician to check whether the patient received preoperative antibiotics when he or she checks the patient identification wristband. In addition, other preoperative antibiotic reminders, such as stickers, all use the same color: orange. Cincinnati Children's engraved this into the minds of its staff through a marketing campaign: ABC—Antibiotics Before Cutting. These methods of preoccupation with failure work to minimize errors.
  • As an example of sensitivity to operations, Cincinnati Children's recognized the need for one form for surgical prophylaxis antibiotic orders for all physicians to use. In addition, the department realized the need for a nurse to check all orders the day before the scheduled surgery. The nurse checks the next day's schedule, the antibiotic list, and the physician order form, paying particular attention to missing information. Because of the time it takes for the nurse to perform this function (2 hours), the role of "antibiotic nurse" was created. Some nurses on the floor are trained, and the 2 hours of time is built into their schedule to be used for this function only.

Observed improvements. Efforts led to a decrease in Class I infections from an average of 1.57 per 100 procedure days in 2004 to 1.15 in April 2006. Class II infections decreased from an average of 0.76 per 100 procedure days in 2004 to 0.30 in April 2006.

Page last reviewed April 2008
Internet Citation: Appendix C. High Reliability Organization Learning Network Operational Advice From the Cincinnati Children's Site Visit (continued): Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. April 2008. Agency for Healthcare Research and Quality, Rockville, MD.