Appendix C. High Reliability Organization Learning Network Operational Advice From the Cincinnati Children's Site Visit (continued , 2)
Becoming a High Reliability Organization: Operational Advice for Hospital Leaders
Safety of Handoffs
Identified challenge. A lack of clear communication among staff may have contributed to a child's death during a transfer from a unit to surgery. In response to this event, Cincinnati Children's is in its third year of an effort to improve communication between clinicians when a patient is transferred between departments.
HRO concepts employed. The handoff initiative primarily involves two high reliability concepts:
- Deference to expertise.
- Reluctance to simplify.
Transformation process. A checklist for patient transfers has been created and is used throughout the hospital. In addition to the checklist, Cincinnati Children's requires the anesthesiologist to receive a handoff before the child is transported to surgery. After surgery, the attending surgeon or fellow must accompany the child back to the receiving floor for a handoff. Handoffs are measured on a 200-point scale where 100 points are based on objective measures regarding the completion of the handoff, 20 points are based on physician satisfaction, and 80 points are based on nurse satisfaction. A score of less than 180 is considered a failure. The HRO site visit focused on transfers to and from the cardiac care ICU.
The transformation unfolded over the course of 3 years. Cincinnati Children's rolled out this initiative with cardiac surgeons and otolaryngologists. As the improvement initiative spread, other specialties were included. Gaining the support of one neurosurgeon in particular was the tipping point for gaining the support of the rest of the surgeons.
In addition, when this initiative was initially instituted, the attending physician, fellow, and residents could act as the single physician present during the handoff. It was soon realized that residents did not have enough knowledge to be the sole physician at a handoff, and the rule was changed to attending physicians or fellows. This shows the organization's commitment to defer to expertise, which the residents had yet to develop. However, residents may accompany attending physicians or fellows.
Finally, the patient transfer checklist indicates the names of the physician and nurse present. Although many in the hospital know one another, Cincinnati Children's requires all handoffs to begin with introductions by all present. This reluctance to simplify a process addresses instances where staff do not know one another, which could occur often because of the various schedules both nurses and physicians keep.
Observed improvements. For more information about the observed improvements in improving the safety of handoffs, please feel free to contact a Cincinnati Children's representative. Contact information can be found at the end of this appendix.
Neonatal Intensive Care Unit
Identified challenge. The neonatal ICU (NICU) at Cincinnati Children's faced the challenge of decreasing occurrences of VAP on its unit. In March 2005, the NICU experienced 11.3 VAP infections per 1,000 device days. At that time, Cincinnati Children's believed that the number of occurrences of VAP could be reduced and began working to create a more reliable process for preventing VAP.
HRO concepts employed. In working to reduce the occurrence of VAP, the two primary HRO principles that emerged during the transformation process were:
- Preoccupation with failure.
- Sensitivity to operations.
Transformation process. To address the challenge of the increasing occurrence of VAP, the NICU chartered a VAP team to create a bundle for preventing VAP using evidence-based medicine, as well as an education plan for teaching staff how to use the bundle. By May 2005, a bundle had been created, and education had begun. With the implementation of the bundles, the NICU saw the VAP infection rate drop to 0 per 1,000 device days by July 2005.
During August and September 2005, a small spike in VAP infection rates prompted the team to become more preoccupied with failure. The team put together a couple of job aids, including a ventilator care checklist, to help nursing staff document and remember the important points outlined in the bundle. In addition, the bundles were attached to all ventilators for quick reference.
Being sensitive to operations, the NICU partnered closely with the infection control department to receive information about potential VAP cases earlier. This allowed the ICUs to conduct real-time investigations. Root cause analyses are always conducted for process and practice failures, and changes to the process are made immediately to improve patient care.
Observed improvements. Since the implementation of the new checklist in August 2005 and the addition of a few new heaters in September 2005, the NICU was able to track and post infection rates of 0 per 1,000 device days between October 2005 and May 2006.
The NICU credits sustainability of the reduced VAP infection rate to the following:
- Promoting ownership of work at the staff level.
- Hard wiring the VAP bundle into flowsheets.
- Including improvement work measures in performance evaluations.
- Updating orientation competencies to include the VAP bundle.
- Measuring compliance with the bundle elements as well as patient outcomes continuously.
- Testing the use of real-time notification of VAP from infection control.
Transitional Care Area
Identified challenge. The transitional care area at Cincinnati Children's is a stepdown unit. The challenge this unit, as well as other units in the hospital, faced was figuring out ways to involve families in the discussions about the care being provided in a way that was meaningful and made the families feel like part of the decisionmaking team.
HRO concepts employed. In working to create ways for families to become more involved in the discussion about the care being provided to the patients, the primary HRO principle was:
- Preoccupation with failure.
Transformation process. Involving families in the discussions about the care being provided for the patients in the transitional care area has been done in two ways. The first is to ask families whether they would like to be present and involved during rounds so that they are up to date on the plan of care. Using the HRO principle of preoccupation with failure, staff in the transitional care area use a job aid in the form of a blue note card to cue them to the family's preference. This blue card is taped to the outside of the patient's door and indicates the family's preference to be present during rounds, to be woken up if they are asleep, to decline the opportunity to be present during rounds, and to just receive an update on the patient's condition at a later time. When rounding occurs, the caregivers simply refer to the blue card to determine whether the family would like to be involved.
Families of children awaiting or who have had liver transplants are provided with a portal that allows them to see important information, such as the medication list, dosages, improvements in condition, and physician names. Families also can use the portal to send messages to the patients' caregivers and to track the patients' progress over time.
Observed improvements. For more information about the observed improvements in the transitional care area, please feel free to contact a Cincinnati Children's representative. Contact information can be found at the end of this appendix.
High Fidelity Simulation Center
Identified challenge. High fidelity simulation is widely regarded as an important way to train staff to work as teams on patients experiencing the range of conditions observed in a busy emergency department. The simulation center at Cincinnati Children's wanted to maximize the value of the training for participants and demonstrate its value to other hospital departments and healthcare providers so that the costs of its operations could be spread as broadly as possible.
HRO concepts employed. The simulation center emphasizes the creation of a realistic experience that will require teams to work together to successfully treat multiple patients at the same time and to respond to family members' concerns about their child's welfare. Effective teamwork presumes all of the aspects of a high reliability system, including:
- Preoccupation with failure.
- Deference to expertise.
- Sensitivity to operations.
- Reluctance to inappropriately simplify the care of a patient.
Transformation process. Several innovations make the simulation experience at Cincinnati Children's one of high perceived value for physicians, nurses, and other staff:
- Staffs are trained as multidisciplinary teams, which allow them to practice principles of effective teamwork and to receive feedback on what could allow their team to function more successfully.
- Patients experience complications that challenge participants to monitor and adapt to changes in the patient's condition, as reflected in real-time monitors of heart rate, pulse, and other vital signs. Beyond the clinical care of the patient, the teams also must address the concerns of parents and others in the room so that the experience matches the norm in many emergency departments.
- Participants receive immediate feedback on their performance as a team. Performances are scored so that progress can be trended over time and so that future training sessions can avoid duplicating experiences that the team handled effectively. The center has found that the impact of training tends to lessen after about 6 months, so continuous retraining is regarded as critical.
Observed improvements. The center retains scores and videotapes for all simulation sessions. It uses multiple strategies for assessing the impact of this training. Evidence of impact includes:
- Improvements in simulation scores for teams that have more training.
- Observation of videotapes to establish improvements in team performance following additional training and practice.
- High levels of repeat and new business from departments other than the emergency department, from the nursing school, and from other health care providers outside Cincinnati Children's.
At present, the center gets some funding from the emergency department; some comes from the training budgets of other departments; and some support comes through an AHRQ grant. A major ongoing challenge of the center is the creation of a sustainable business model. Key to this model will be the ability to support not only the equipment required for high fidelity simulation, but also the staff who program the simulators to exhibit complications and medical conditions that meet the needs of the center's constituencies.
What can be learned about how process redesign efforts can drive organizational transformation?
Many insights were shared at the site visit about organizational transformation. Following are a few key lessons that consistently emerged as critical knowledge for effective transformation:
- Reducing resource investment in quality improvement initiatives during lean times is a mistake. Optimally, dedicating resources to quality improvement initiatives should be a priority before an organization faces lean times. But if lean times are upon the organization, continuing to invest resources in quality improvement initiatives is imperative, especially if there is waste in the system. Additional savings and resources can be realized over time by eliminating wasteful practices and implementing more reliable, safer practices. Consider how efficiencies can be realized in all departments, not just in clinical areas. To determine which initiatives will make the best investments, one may use the DICE methodology and assess the initiatives on duration, integrity, capability, and effort.
- Beware of bucketing errors into preventable and unpreventable categories. Once errors fall into the unpreventable category, they often fall prey to the "out of sight, out of mind" phenomenon. Subscribe to the philosophy that all errors are preventable, but recognize that knowledge has yet to be created to prevent some errors. Invest research dollars and time in understanding how to make errors preventable.
- Transformation requires ambitious targets and setting transformational versus incremental goals. Pursuing perfection goals can help one to quickly identify serious system-level barriers that need to be addressed. Cincinnati Children's focuses on designing systems that will achieve 100 percent effectiveness and 0 percent defects and believes that it is not that much harder to strive for 100 percent effectiveness versus small incremental goals.
- Start before you are ready. Don't be paralyzed by the pursuit and creation of a perfect implementation plan. Much can be learned during the process of actually doing the work. If one is careful to prioritize initiatives ahead of time, then it is easier to strike a balance between working on what can be done now and slowly "peeling the onion."
- Involving leadership at every level is critical. Without engaged leadership, transformation is difficult to start and even more difficult to maintain. Leaders must take ownership for setting the climate and focusing the work. Cincinnati Children's believes that the role of leaders is to make the job easier for those at the department level.
- Create a culture of accountability and responsibility. Helping staff to recognize that quality is everyone's responsibility will help to create a platform for making systems more reliable.
A special thank you goes out to the leadership team at Cincinnati Children's for the time and energy they invested in hosting such a valuable site visit for the HRO Learning Network. Their commitment to excellence and remarkable transparency provided a forum for a more open, honest, and robust discussion among Network members at the site visit.
If you are interested in acquiring more details about any of the information provided in this appendix, please go to the contact information below for representatives from Cincinnati Children's Hospital Medical Center.
Uma Kotagal, MBBS, MSc
Vice President, Quality and Transformation
Steve Muething, MD
Associate Director, Clinical Services
Quality Improvement Consultant