Creating a high-reliability patient care organization inevitably involves great complexity—and an unending amount of work. That reality was made very clear in the opening keynote presentation, entitled “Safety and Unintended Consequences of Interoperability,” that was presented by Luis Saldaña, M.D., and Mary Beth Mitchell, R.N., of the Arlington, Tex.-based Texas Health Resources, on Thursday morning, at the Health IT Summit in Dallas, sponsored by Healthcare informatics. Dr. Saldaña, the chief medical information officer of the 29-hospital THR, and Mitchell, the chief nursing informatics officer of the system, shared with the audience gathered at the Hilton Anatole Dallas, the challenges and advances involved in their high-reliability care initiative, at the Dallas-Fort Worth-area integrated health system.
“We’ve been on a journey towards high reliability,” Dr. Saldaña told the Health IT Summit audience. “Probably a lot of you may be on this journey. We started this journey a few years ago; it would have helped me to know these things as a practicing emergency physician. Interoperability may seem like a technology problem, but it’s really a people, process, and technology problem.”
Saldaña made several references to the book Managing the Unexpected: Sustained Performance in a Complex World, by Karl E. Weick and Kathleen M. Sutcliffe, first published in 2001 and revised in 2015. As an online description of the 2015 edition of the book states, “Since the first edition of Managing the Unexpected was published in 2001, the unexpected has become a growing part of our everyday lives. The unexpected is often dramatic, as with hurricanes or terrorist attacks. But the unexpected can also come in more subtle forms, such as a small organizational lapse that leads to a major blunder, or an unexamined assumption that costs lives in a crisis. Why are some organizations better able than others to maintain function and structure in the face of unanticipated change? Authors Karl Weick and Kathleen Sutcliffe answer this question by pointing to high reliability organizations (HROs), such as emergency rooms in hospitals, flight operations of aircraft carriers, and firefighting units as models to follow. These organizations have developed ways of acting and styles of learning that enable them to manage the unexpected better than other organizations.”
Mary Beth Mitchell, M.D. and Luis Saldaña, M.D.
In addition, an organization called High Reliability Organizing, states on its website that, “In the world today we deal with uncertainty and threat. This can be on the personal level of family or job, on the business level of the economy, or in geopolitics. High Reliability, evolved for optimal performance in an environment of uncertainty and threat, can strengthen a person’s performance, improve the function of a team, and move an organization forward through uncertainty…. The High Reliability Organization is commonly described as an organization that performs high risk work but without rare, catastrophic events.”
In that context, Dr. Saldaña told the audience at the Health IT Summit, “Part of becoming a high-reliability organization is be preoccupied with failure. Years ago, while traveling,” he said, “I met an engineer from Exxon. He was retired, but told me that he continued to carry the same habits of the culture of safety with him, in his personal life, in retirement. He used checklists; he wore compression socks when traveling, to prevent VTE”—venous thromboembolism.
A key point about the Managing the Unexpected book, Saldaña said, was this—a quote from the book: “High-reliability organizations operate under very trying conditions all the time and yet manage to have fewer than their fair share of accidents.”
And, per the book, Saldaña noted that “Risk is a function of probability and consequence. By decreasing the probability of an accident, high-reliability organizations operation to make systems ultra-safe. In that context, he referenced the following principles that patient care leaders need to follow when developing high-reliability initiatives. They need to: “be preoccupied with failure; be reluctant to simplify; be sensitive to operations; commit to resilience; and defer to the experts.” The key in that, he said, is to find a balance between the meeting the need for reliability and “managing the cadence of where the system is moving operationally.”
Saldaña also referenced Nassim Nicholas Taleb, for his concept of “anti-fragility,” as articulated in his 2012 book, Antifragile: Things That Gain From Disorder. “In some cases,” he emphasized, “challenges and failures can actually make you stronger.”
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