Becoming a High Reliability Organization: Army Medicine Foundation for Patient Safety

By Mr. Ronald W Wolf (Army Medicine)January 14, 2015

HRO Summit
Lt. Gen. Patricia Horoho, The Surgeon General, leads discussion on becoming a high-reliability organization (HRO). The HRO summit at Fort Belvoir invited more than 160 officer and enlisted leaders to discuss leadership issues, patient safety, and ro... (Photo Credit: U.S. Army) VIEW ORIGINAL

The healthcare industry across the United States faces daunting challenges during the next few years. One significant factor demanding the need for change in healthcare is that costs continue to skyrocket.

The Army Medical Department also faces the challenges of high-costs; however, chief in the mind of Lt. Gen Patricia Horoho, The Surgeon General of the Army, is keeping the confidence of Soldiers, families, and all of America that Army Medicine is the safest and most reliable healthcare organization in the world. "We will not be satisfied until we have zero preventable harm," she said.

More than 160 Army Medicine officer and enlisted leaders from the Northern Regional Medical Command held a summit at Fort Belvoir on Jan. 12-13 to discuss exactly how to become a "high reliability organization" or HRO. HROs, in general, are organizations that set zero preventable harm events as a goal, yet operate in environments where human errors occur and risk for adverse events is high.

Well-known examples of HROs are the airline and the nuclear power industries. These industries could not operate for long without the full confidence of their customers or if they had accidents on a regular basis. In fact, commercial airline crashes and nuclear power incidents in the United States are rare.

The health care industry cannot make a similar claim. One estimate in the Journal of Patient Safety from 2013 is that as many as 400,000 preventable deaths occur every year in the United States in civilian hospitals. Patient safety has to be at the heart of a healthcare HRO. Confidence by patients in their medical safety is critical to the future of Army Medicine as with all healthcare organizations.

Horoho pointed out that there is a sense of urgency. Within the next three years, Horoho said, a significant amount of progress needs to be made toward becoming an HRO healthcare system that aims to reduce or eliminate preventable harm to the maximum extent possible.

Healthcare HROs have five key factors that are critical for success:

First, HROs are proactive to prevent errors from occurring with a constant focus on noting risks and preventing them.

Second, HROs are reluctant to simplify. Often failure is caused by a number of factors (e.g., human error, inadequate training, poor communication, failure to use checklists, and so on) rather than just one; these factors often combine to increase risk. Oversimplifying potential causes to an incident might mask the ability to understand why patients are at risk at a healthcare HRO.

Third, HROs are sensitive to operations. There is attention to where physicians, nurses, and technicians interact with the patient. Sometimes near-misses that might cause harm occur; these near-misses should be identified and viewed, not as proof that the system has effective safeguards, but as areas that need improvement.

Fourth, HROs respect expertise. Leaders and supervisors need to be willing to listen to the insights and respect the experience of staff who have the everyday experience to know how processes work and the risks that patients face.

Finally, HROs have a commitment to resilience. Leaders and staff need to recognize errors early to reduce the potential for harm and be trained to respond when system failures do occur. In short, accountability needs to be considered a positive rather than a negative event.

The attendees at Fort Belvoir discussed three imperatives for HRO in healthcare: commitment of leadership, a culture of safety, and robust process improvements.

The attendees tackled that challenge and listed topics to address. The group agreed on the need to eliminate variance in patient care, establish how to measure progress to becoming an HRO, evaluate and improve training of staff; in short, a road map to success needed to be created.

Horoho pointed out that Army Medicine already has "been on a journey to becoming an HRO for at least the past three years."

Becoming an HRO is the next critical step in Army Medicine's goal of becoming a System for Health. While the road to becoming an HRO faces many planning and implementation decisions, improving patient safety remains the highest priority and the most important goal of becoming an HRO.

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