Introduction

Patient safety and quality are of increasing importance to consumers, payers, providers, and organizations. As a large majority of the workforce, nurses are on the front lines of the delivery and provision of safe and effective care. Although there is an abundance of new theory and research on the topics, the practical application of these concepts is challenging for the clinical nurse in practice. Furthermore, the current hospital environment of complexity, interdependent processes, and unpredictable conditions demands that new models and theories be applied to achieve outcomes. There is a need to bridge the gap between theory and practice to improve quality outcomes and patient safety in our current healthcare climate.

High reliability is not a new concept. These days, the term is used contagiously in healthcare organizations. Although high reliability is often discussed, and excitement and support grow, high reliability methods and science have still not been totally implemented into our healthcare culture. For example, although numerous efforts have been undertaken to improve safety, we still have adverse events in hospitals and are not as reliable and safe as we desire to be (James, 2013). It seems that as soon as we begin to see improvement, another issue arises. Emergent issues and unintended consequences of well-intentioned improvements seem to characterize healthcare today. It has been said that complexity leads to error, and the best way to prevent error is to acknowledge complexity and to adapt or cope with it (Woods, Dekker, Cook, Johannesen, & Sarter, 2012). Acknowledgment of complexity entails accepting that perhaps we cannot control all factors and emergent situations that lead to outcomes. This is difficult for those in healthcare delivery systems to accept, as the linear cause-and-effect model is still the prevailing method for process improvement.

Although high reliability thinking has drastically increased, the deployment of high reliability still has been in the traditional model of healthcare change management and quality improvement. We have added many new protocols, expectations, and structures but have not really delved into how the human beings on the front lines make successful outcomes occur in complex environments. We focus on the absence of negative events to tell the story of our quality and safety while not focusing on the abundance of small things that happen every day to ensure that negative events do not happen. It is sometimes not the protocols and processes that lead to success but the ability for people to adapt and critically think through unexpected events. We have focused on compliance but perhaps not as much on adaptability and resilience in the face of the unexpected.

Weick and Sutcliffe (2015) state that “managing the unexpected is not simply an exercise in going down a checklist” (p. vii). In their most recent work, Managing the Unexpected: Sustained Performance in a Complex World (3rd ed.), they assert that we need to focus on the human factor and how human beings adapt with resilience to make things go right.

This gap in the advancement of healthcare high reliability might be explained by Thomas Kuhn’s view of normal science and revolutionary paradigm shifts (1962). Kuhn argued that large shifts in thinking occur when current thinking and approaches become unacceptable because they do not solve current problems. Within hospitals, traditional thinking focusing on prediction, production, and control is common practice, although there is evidence that patient safety exists in a complex system that is dynamic, unpredictable, and emergent (Dekker, Cilliers, & Hofmyer, 2011; Effken, 2002). The thinking, however, is beginning to change. Many are realizing that solving patient safety and quality problems requires a new approach. High reliability concepts provide the antidote to the traditional method, which is not effective in a highly complex environment.

So, what is a highly reliable organization? High reliability organizations (HROs) are those organizations that are high-risk, dynamic, turbulent, and potentially hazardous, yet operate nearly error-free (Weick & Sutcliffe, 2015). Examples include aviation, nuclear engineering, defense operations, and acute care hospitals. HROs stay error-free by doing the following:

• Recognizing that small things that go wrong are often early warning signs of trouble

• Recognizing that these warning signs are red flags that provide insight into the health of the whole system

• Valuing near misses as indicators of early trouble and acting on them to prevent future failure

• Being innovative and creative and valuing input from all corners of the organization

• Recognizing the value of preparing for the unexpected and the unknown, as failures rarely occur if they are expected

This book elaborates on and gives practical examples of the following principles of HROs, as described by Weick and Sutcliffe (2015):

• Preoccupation with failure: HROs are preoccupied with all failures, especially small ones. Small things that go wrong are often early warning signals of deepening trouble and give insight into the health of the whole system. However, we tend to ignore or overlook our failures (which suggests we are not competent) and focus on our successes (which suggests we are competent).

• Reluctance to simplify: HROs restrain their temptation to simplify through diverse checks and balances, adversarial reviews, and the cultivation of multiple perspectives.

• Sensitivity to operations: HROs make strong responses to weak signals (indications that something might be amiss). Everyone values organizing to maintain situational awareness.

• Deference to expertise: HROs shift decisions away from formal authority toward expertise and experience. Decision-making migrates to experts at all levels of the hierarchy during high-tempo times.

• Commitment to resilience: HROs pay close attention to their capability to improvise and act—without knowing in advance what will happen.

The current message in patient safety and quality literature is that we, in healthcare, need to strive to be highly reliable, meaning that we should be a system that detects and prevents errors from happening even though we operate in high-risk, emergent conditions. Most often, the conversation goes in the direction that healthcare should be similar to aviation. This message is not helpful to healthcare providers as they strive to understand what high reliability is and looks like in the healthcare field. This book addresses that gap by providing an understanding of HRO and the application of its concepts to clinical practice. Practical examples are provided that support each of the five concepts of HRO along with useful tools, measurements, and design strategies.

This book is meant to change current thinking by highlighting challenges in our healthcare system and our current process of addressing safety and quality and then suggesting HRO principles as an overarching framework for promoting a better model. This organizing framework expands reader knowledge and understanding by providing concrete examples that illustrate principles of HRO.

The first edition of this book described why HRO is needed and how it can be applied. Material included:

• High reliability science as an organizing framework for quality and patient safety

• Practical applications of high reliability science, focusing on quality and patient safety

• Knowledge and tools that can be applied to current quality and safety practices

• Real-world examples of high reliability principles employed in a variety of patient care areas

The second edition builds on the foundation created in the first by updating previous material, adding relevant exemplars, and providing a more in-depth discussion of cultural aspects essential to sustainability. Organizational culture is key to success of an HRO and is reflective of leadership. It is imperative that leaders, both formal and informal, skillfully build a culture of safety and shape a work environment conducive to psychological safety to make zero harm a reality (Edmondson, 2019). Second edition new material includes:

• Zero harm and the role of leadership in achieving it

• Creating a culture supporting HRO along with discussion of cultural barriers that hinder progress

• Just Culture focusing on healing, resilience, and second victim syndrome

• Human factors and the emerging field of human factors engineering within healthcare

• Psychological safety

• Organization learning and tiered safety huddles

• High reliability in infection prevention and ambulatory care

• Designing a resilient work environment and clinician well-being

Nurses represent the majority of healthcare workers and are on the front lines of delivery and provision of safe and effective care. As a result, nurses are ideally situated to drive the mission to achieve high reliability in healthcare. We expect the primary audience of this text to be frontline nursing staff, nurses in administration, quality and patient safety professionals, advanced practice nurses, and nurse educators. The healthcare professional who purchases this book will do so with the desire to learn more about the application of HRO principles to patient safety and quality problems. This book is unique in that it uses HRO principles as an organizing framework for practical application. The intent of the editors is to provide a quality and patient safety book that is useful to professionals doing the work of healthcare. Although we do not intend this as a textbook, it could be used in graduate courses focused on patient safety or quality management in nursing, health services administration, or clinical programs.

The book is divided into eight parts:

• Part 1: This part provides background for the current safety and quality climate. Chapter 1 provides the rationale for a paradigm shift to a new model and the current challenges internal and external to safety and quality. Chapter 2 and Chapter 3 review the current patient safety and quality drivers within our healthcare environment. Chapter 4 describes how the journey to high reliability is connected to organizational culture and presents tools for this culture change. Chapter 5 discusses the vital role of leadership in creating an HRO.

• Parts 2–6: These parts offer HRO concepts as a framework for the new model with examples. The first of these HRO concepts is that HROs have a preoccupation with failure. Chapter 6 discusses how to use failure mode and effects analysis to predict failures. Chapter 7 provides the reader with a review of close calls and near misses along with associated myths. The second of these HRO concepts is that HROs restrain the impulse to view events through a single lens and are reluctant to simplify. Chapter 8 discusses human factors science and the practice of designing work systems to better fit the needs, limitations, and capabilities of humans. Chapter 9 presents how to use root cause analysis as a high reliability tool in a complex environment. Chapter 10 offers a discussion of how Just Culture affects high reliability. The third HRO concept is that HROs demonstrate sensitivity to operations by making strong responses to weak signs. Chapter 11 provides a discussion of working solutions for alarm safety. Chapter 12 explains how innovative technology and standardization affect high reliability. Chapter 13 provides a discussion on how learning on safety can occur throughout a large organization. The fourth HRO concept is that HROs shift decisionmaking away from formal authority and apply deference to expertise. Chapter 14 provides a discussion for interprofessional collaborative care and teamwork. Chapter 15 presents a discussion of nurses creating highly reliable care through patient engagement. Chapter 16 describes how high reliability can be achieved in pediatric care through safety coaching. The final HRO concept is that HROs have a commitment to resilience. Chapter 17 presents resilience as the path to high reliability. Chapter 18 discusses opportunities for designing a resilient work environment with clinician well-being. Chapter 19 describes building high reliability through simulation. Chapter 20 expands on resilience and teamwork through the lens of emergency response teams. Chapter 21 communicates strategies to sustain and maintain the gains in a resilient organization.

• Part 7: This part puts it all together and provides the reader with examples of how HRO concepts are assimilated into practice across the care continuum. Chapter 22 describes how a clinical nurse specialist uses HRO concepts to improve pain management effectiveness and patient safety. Chapter 23 describes how high reliability principles can be used to address the unique challenges to quality and patient safety in the ambulatory care setting. Chapter 24 explains how a leader working with staff nurses applied HRO principles to reduce patient falls across a large healthcare system. Chapter 25 describes the synergy between high reliability and the Magnet Recognition Program^®. Chapter 26 illustrates the role of the bedside scientist in achieving high reliability.

• Part 8: This part provides the reader with real-world examples of HRO principles employed in a variety of patient care areas. Chapter 27 describes using the principles of high reliability and a target of zero preventable harm to identify and prevent the spread of infectious diseases. Chapter 28 describes one operating room team’s journey to becoming a highly reliable surgical team. Chapter 29 describes how a team of nurses in an intensive care and step-down unit used high reliability principles to reduce catheter-associated urinary tract infections. Chapter 30 describes how one hospital designed a highly reliable process to achieve timely reperfusion of myocardial infarction patients to achieve better patient outcomes. Chapter 31 describes how telehealth processes can reliably prevent hospital readmissions. Chapter 32 explains how a committee was intentionally formed to foster an environment of high reliability and promote growth in a culture of safety through the creation of a virtual resource toolkit.

Healthcare professionals are constantly seeking practical tools and descriptions of practices that will improve and enhance patient safety and quality outcomes. High reliability is a current goal for hospitals, and the principles are sound. However, there is little in the literature that discusses how to apply the principles at the front lines of care to improve outcomes. This text hopefully addresses this gap by placing the need for high reliability concepts into our current climate in healthcare through illustrative discussion (theory and research) of each of the five concepts of HRO, along with a description of a current best practice and/or tool that applies to the model. The goal of this book is to stimulate organizations to embrace high reliability concepts while striving to improve the quality and safety of care delivered to patients and families. We all benefit from a safer healthcare environment.