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During the COVID pandemic, we have seen that highly reliable organizations were adaptable and could rapidly standardize their work with innovative solutions. They converted pre- and post-operative spaces into additional intensive care unit beds or turned GI endoscopy labs into emergency department overflow. Health systems rapidly innovated new processes, developed ways to communicate new information efficiently and effectively (e.g., Incident Command Systems), and then managed to those new standards. The subject matter changed, but in many ways the system of care and its processes did not.
Managing rapid change can be challenging, but it can be streamlined if you have critical tools, job aids, checklists, and formalized processes captured in written guidance to avoid overreliance on passing information person-to-person. But all those tools and resources are not enough to ensure that a highly reliable organization maintains its level of excellence. Here are some lessons on high reliability that do not get enough discussion:
- Be wary of change for the sake of change. When it comes to sustaining high reliability, consistency of the workforce, processes, and guidance are big challenges. The natural human tendency to change things over time can drive us to “refresh” perfectly effective models and instructions. Maybe a checklist feels like it is getting stale. Maybe a process seems like it is degrading, but it may not be the process that is breaking down. Has the staff turned over? Is new staff being trained differently? Do staff lack a strong connection to the purpose of the process, so they are not executing it as consistently? Consider these kinds of factors and address the true source of the concern before making a change that may not be necessary.
- Look beyond traditional risks, even when things appear to be going well. When it looks like we have a well-oiled machine running, it can be harder to say we need to invest upfront in things like orientation and onboarding. The COVID-19 pandemic has exposed vulnerabilities in our orientation and onboarding processes through the increased numbers of temporary clinical staff and providers. Turnover requires additional orientation and onboarding to achieve the same consistency of results. The challenge is to invest in thorough preparation of the workforce, including addressing pandemic-related gaps in training of newer graduates, so we do not lose ground in quality and patient safety. Current realities in turnover require new approaches to ensure temporary staff are ready to meet the challenges of providing high-quality care in new and unfamiliar environments.
- Recognize equity, joy in work, and well-being as part of the high-reliability journey. When we think about what makes for an equitable work environment, it is consistency of process, accountability, relationships, and communication. All of this must be in service of fostering trust, respect, and dignity for all. One of the most important lessons the pandemic has taught us is that we have to take better care of our entire workforce. We have to support their safety and well-being, and that includes work environments free of threats, ranging from incivility to physical assaults on clinicians, staff, and employees. No one should accept threats to personal safety and security — that erode and dehumanize the experience of working in health care — as a condition of employment. Creating reliable processes to ensure all facets of safety in our healing workplaces is vital to the stability and sense of belonging that promotes stronger performance and outcomes.
High reliability is driven by the climate created by leaders. It requires visibly present leadership to model high-reliability behaviors. It requires consistency of effort. Ultimately, it is the well-being, belonging and safety of our workforce, as well as the reliability of our processes and resilience of our systems, that ensure patients get the healing care they expect and deserve.
Jeff Salvon-Harman, MD, CPPS, CPE, is the Institute for Healthcare Improvement's Vice President of Safety.
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