Achieving 95+% reliability – how will you do it?

Cognitive Institute Associate Medical Director, Dr Stephen Walker, highlights the critical role of people and their environment in further improving reliability in health care. Stephen discusses the rationale behind Cognitive Institute’s AlwaysChecking™ approach and its function in creating a cultural shift towards improved reliability.

One of the most pressing challenges facing healthcare organisations is to improve patient safety and maintain high-quality care in an environment where we need to contain, or indeed reduce, costs. Despite technological advances and considerable effort and investment to address process and system deficiencies, these systems commonly struggle to deliver non-controversial care much beyond 80% reliability1-2 (eg, hand hygiene, venous thromboembolism risk assessment, medication prescribing, appropriate antibiotic use and others).

Investments in technology, equipment, skills training and clinical knowledge have provided the capability to deliver complex care of remarkably high standard yet we still find room for improvement when it comes to reliably achieving high quality care. There is also a persistent, strongly held belief that error and poor reliability are best tackled with more training on technical skills and more clinical sciences knowledge. The truth is quite different.

Improving reliability with science

To achieve high reliability we must find a balance between standardising those aspects of health care that must be performed consistently and universally (eg, hand hygiene, venous thromboembolism risk assessment, right drug to the right person etc) and enabling clinicians to deliver the nuanced, patient-specific care an individual needs. We must eliminate unwanted and unwarranted variability, while building skills, processes and systems to ensure the individualised care we want delivered to our patients is, in fact, reliably delivered.

Reliability science alerts us to the fact that moving beyond low levels of reliability requires more than the same strategies of memory, diligence, vigilance and self-regulation, while imploring clinicians to try harder. We need to apply insights from human factors science. In its simplest terms, human factors are anything within people, or the systems and environment in which they work, that improve or impede their performance. The diverse disciplines that contribute to human factors science include the study of individual competencies, human limitations, attitudes and behaviours as well as study of process, environmental and equipment design excellence that enhance the way clinicians work and support high reliability.

Health care has had a strong history and culture of celebrating and privileging the ‘doing’ of care delivery. However, human factors science highlights the equally critical role of ‘checking’ and the ‘checker’ if higher levels of reliability are to be attained and sustained.

Health care has had a strong history and culture of celebrating and privileging the ‘doing’ of care delivery. However, human factors science highlights the equally critical role of ‘checking’ and the ‘checker’ if higher levels of reliability are to be attained and sustained.

Increasing reliability using the AlwaysChecking™ approach

Cognitive Institute’s AlwaysChecking™ philosophy underpins a programme of education and the development of a healthcare checking culture that promotes quality and safety. The AlwaysChecking™ philosophy advocates for the value and role of ‘checking’, and works to change culture by increasing the knowledge, skills and attitudes of leaders and clinicians.

The AlwaysChecking™ approach identifies important principles for safe and reliable care including:

  • collegiate checking of agreed approaches to clinical care and adherence to them
  • clarity in communications
  • training as teams
  • methods of managing clinician variance.

To achieve increases in reliability past the currently accepted 80% towards 99%, healthcare organisations need to embrace a number of reliability principles that apply both personal and systems checking strategies. Healthcare organisations also benefit from developing a process to embed these principles not only within services and units, but between services and units. The principles are not the only commitments required to drive improvements in health care reliability, but they do represent an achievable and pragmatic response to enhance quality of care.

To achieve increases in reliability past the currently accepted 80% towards 99%, healthcare organisations need to embrace a number of reliability principles that apply both personal and systems checking strategies. 

Cognitive Institute has developed programmes in reliability and safety for leaders and frontline clinicians in health care. The programmes explore the AlwaysChecking™ elements in detail and provide a strong foundation for understanding human factors science and its application to health care. Further programmes on Colleague Interaction, Speaking up for Safety™ and Promoting Professional Accountability complement the Safety and Reliability learnings, and are being used by several organisations and individual clinicians to help them take the next step.

Cognitive Institute’s Safety and Reliability Improvement Programme is an education programme developed for organisations. All aspects of the program, including involvement from the board to frontline clinicians, references the AlwaysChecking™ philosophy to advocate and develop a cultural shift for reliability.

Four parameters frame the design and delivery of training in the Safety and Reliability Improvement Programme:

  1. Needs Analysis. We work with the board, executive and leadership to resolve a commitment to safety and reliability directions and goals.
  2. Leadership Development. Training and support is provided to advance leaders’ knowledge and skills in reliability science, inter-colleague communication and safety advocacy.
  3. Improvement Projects. We focus on creating capability to achieve quality and safety goals by applying reliability science. This includes developing non-technical skills for improved colleague interactions, open disclosure and mechanisms to support ‘speaking up for safety’.
  4. Accountability. To support high performance work practices, frameworks and skills are delivered to ensure ‘always means always’.

Our healthcare systems are steadily improving the way we deliver care through a scientific approach to knowledge and skills development. Yet, when it comes to ensuring the care we have decided our patients’ need is actually reliably delivered, opportunities for further improvement remain. Applying reliability science and an understanding of human factors will allow us to apply the scientific process to ‘improve improvement’.

References
1    Resar RK, Making noncatastrophic health care processes reliable: Learning to walk before running in creating high‐reliability organizations, Health Serv Res 41(4):1677-89 (2006)
2    Panesar S, Carson-Stevens A, Salvilla S, Sheikh A, Patient safety and healthcare improvement at a glance, Chichester: John Wiley & Sons (2014)

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