WHO Hand Hygiene Day (May 5) is a good time to remember that one of the most important ways health care systems can improve hand washing — and reduce the spread of infections — is by making it easy for health care workers to comply with best hand hygiene practices. How? By creating reliable systems that ensure hand hygiene products are always available at the right time and right location. Reliability is a key topic in A Framework for Safe, Reliable, and Effective Care, a white paper published by IHI and Safe & Reliable Healthcare.
Reliability is the ability of a system to successfully produce a product to specification repeatedly. In the case of health care, that “product” is safe, efficient, person-centered care. The challenge in achieving reliability in health care is the complexity of the processes, which heavily depend on human beings and their interactions with each other. Vigilance and exhortation are inadequate to counter human foibles, and sometimes good people err and the consequences can be dire. Great organizations design systems that take advantage of people’s intrinsic strengths and support their inherent weaknesses, and in doing so increase the likelihood of reliable performance. Mediocre organizations, by comparison, assume that vigilance and intrinsic strengths overcome human fallibility and inherent personal and organizational weaknesses.
To achieve high levels of reliability across processes and systems, organizations must apply best evidence and minimize non-patient-specific variation, with the goal of failure-free operation over time. This is the science of reliability.
There are four foundational principles for making systems and processes more reliable:
- Standardize: This involves designing processes so that people do the same thing the same way every time. Standardization makes it easier to train people on the processes, and it becomes more apparent if the processes fail and where they fail, enabling the organization to better target improvements.
- Simplify: The more complex something is, the less likely it is to be successful because there are more opportunities for mistakes, and staff may avoid following processes that are too difficult or time consuming. Simplified processes, however, make it easy for people to do the right thing.
- Reduce autonomy: Health care professionals have historically been autonomous, making decisions based on personal preference or an individualized belief in their perspective. However, this can result in care variation and less consistent outcomes. To achieve greater reliability, organizations must set the expectation that care delivery follows evidence-based best practices, unless contraindicated for specific patients.
- Highlight deviation from practice: Clinicians sometimes have good reasons for departing from standardized processes. Smart health care organizations create environments in which clinicians can apply their expertise intelligently and deviate from protocols when necessary, but also relentlessly capture the deviations for analysis. Once analyzed, the new insights can lead to educating clinicians or altering the protocol. Both result in greater reliability.
When contraindications exist, health care professionals need to document the reasons why departing from standard care practice is warranted, so that the organization can learn and determine whether the process should be modified. For example, for patients on a ventilator, there is evidence that the head of the bed should be elevated between 30 and 45 degrees. For most patients, this is the right thing to do. However, there are some individuals who, because of their medical situation or characteristics specific to them, will not benefit from an elevated head of the bed. In these cases it is okay to depart from best practice, provided the patient’s treatment team has duly considered the evidence-based care and documented the reasons why they’re choosing to follow another method.
For most clinical conditions and situations, there is evidence-based care that patients should receive every time, unless contraindicated. When evidence does not dictate a particular care path, clinicians need to work together to identify the simplest and most reliable path and agree to abide by the group’s decisions. In so doing, they simplify the care pathway, enabling organizations to be more efficient and making care more reliable. As new evidence develops, care pathways must be reviewed periodically to ensure that the agreed-upon care practices remain relevant.
Planning for reliability
Reliability does not happen by accident; it has to be planned. This entails applying reliability principles — methods of evaluating, calculating, and improving the overall reliability of a complex system — to each process or system that needs to be improved.
To get started, teams can use high-level flowcharts to visualize the current process or system. Next, target one segment or subset of the patient population and work to improve the reliability of care for this group. Once reliable care can be delivered consistently for this population, then populations with greater complexity can be addressed.
Organizations should strive for the highest level of reliability possible for each process. In some circumstances, 100 percent is necessary — for example, preventing wrong-site surgery and correct administration of blood. However, in certain situations which we refer to as non-catastrophic processes (that is, the patient will not experience harm within the next few hours), 95 percent reliability is perfectly acceptable because reaching that last 5 percent necessitates a big investment in time and resources, and the cost-benefit is not feasible. In such cases, ensure that other processes are in place to identify and correct these defects.
As work progresses, the team should continuously monitor the process, checking if it yields the expected outcomes. At this point, the team needs to make sure that the reliability extends to all aspects of the process — not just whether the process occurs reliably, but also whether the desired outcomes are in line with goals. If the process is not generating the desired outcomes or performance begins to slip over time, then the team needs to revisit the process and identify and address any root causes.
Consider the transfer of patients from an emergency department (ED) to an inpatient setting. The ED may do a great job evaluating the patient and identifying that he or she needs to be admitted to the hospital. The staff on the unit might do an equally great job of caring for the patient once he or she is admitted. However, if the transfer time is prolonged and the patient languishes in a hallway for hours without delineation of whether the ED or the unit is responsible for his or her care, then the system is not as reliable as it should be.
Just as reliability must be planned, it also has to be encouraged and nurtured. Leadership needs to be supportive in giving staff the time, space, and training to apply improvement methods and tools to build reliable processes. Providing more clinical training and education, or asking staff to work harder or be more vigilant without also creating the environment that makes this feasible, won’t lead to improved results. Staff also need to build improvement capability and skills, and get coaching on applying these skills in their daily work to deliver safer, more reliable care. Leaders must also ensure there is psychological safety, so staff feel comfortable offering ideas about making processes more reliable.
Consider the example of a hospital where a staff member suggests during a leadership team huddle that medication reconciliation is not at a high level of reliability because the current process is not successful for all patients. When people arrive in the emergency department, for instance, doctors and nurses are busy and may begin treatment before they have a complete medication list. By contrast, patients scheduled for elective surgery almost always have a complete list. In the elective surgery setting, the care team has time to discuss the medications with the patient prior to the procedure and there is a back-up plan that involves the anesthesiologist reviewing the patient’s medication list just before surgery. If the list is not complete or available, the anesthesiologist and preoperative nurses take action to remedy this. In the ED, there is little time to employ a back-up plan.
The team analyzes the two situations and determines that the process for patients scheduled for elective surgery does not work for ED patients; however, some aspects of the preoperative evaluation are amenable to testing in the ED. A back-up plan is put into place for staff to review the patient’s medication list on the inpatient unit, utilizing some of the techniques applied by anesthesiologists in the elective surgery environment. Reliability is improved, made possible by the psychological safety that allows a team member to speak up, and because there is opportunity to reflect on current activities and spread a best practice.
Similarly, consider the example in which, during leadership rounds, staff members report that they are having difficulty ensuring that all eligible patients receive their pneumococcal pneumonia vaccine before discharge. The leader asks what processes are in place. Staff members respond that they have tested and implemented a standardized process where, on the day before discharge, all patients are assessed to determine if they meet criteria for the vaccine. The medical staff has agreed to a standard protocol for nurses to administer the vaccine if a patient meets criteria. According to the standardized process, this responsibility falls to the nurse caring for the patient on the day before discharge. However, due to staffing changes, early discharge, or lack of available vaccine on the ward, sometimes patients are sent home without receiving the vaccine.
The leader asks the staff for suggestions about how to improve the process. Since the initial process was standardized and works well about 80 percent of the time, the staff suggest implementing a back-up plan to identify all eligible patients who don’t receive the vaccine prior to discharge. They suggest that, as part of post-discharge communication, the nurse who reaches out to the patient asks if he or she received the vaccine. If the patient answers “yes,” then the matter is closed. If the patient answers “no” or “I don’t know,” the nurse notifies the patient that the nurse will contact the primary care provider to inform the practice that the patient will need the vaccine.
To learn more about other essential components of a system of safety, consult the IHI white paper, A Framework for Safe, Reliable, and Effective Care.