Five Disciplines for Zero Patient Harm: How High Reliability Happens

by Charles Mowll

Overview

Safe care for every patient, in every setting, every time. Is this really an achievable goal for all healthcare organizations?

Yes, it is. The vast majority of occurrences of harm to patients during their care are preventable. But simply aiming for improvement won’t do; healthcare organizations must reset their patient safety goal to zero patient harm.

Five Disciplines for Zero Patient Harm: How High Reliability Happens offers real-world, how-to guidance for driving fundamental change that consistently achieves safe patient care. Drawing on best practices from high-hazard industries such as aviation, nuclear power, and air traffic control, this book details the safety habits and disciplines that are ingrained in such organizations’ cultures and behaviors. Specifically, five disciplines of performance excellence, when consistently applied to healthcare organizations, can save lives and protect patients from harm:
Prepare for excellent performance through simulation, deliberate practice, and training.Apply proven offensive strategies that exhibit consistent, excellent individual and team performance.Minimize both individual and team errors through immediate feedback and coach interventions.Employ strong defensive strategies that effectively block the potential negative effects of errors, latent hazards, and emerging threats.Coach individuals and teams to achieve consistent, excellent performance in the first four disciplines.Zero preventable patient harm can be the norm, not the stretch goal, when the practices and action steps in this comprehensive resource are implemented. Five Disciplines for Zero Patient Harm provides an evidence-based guide for hospitals and healthcare systems to transform unsafe behaviors into safe behaviors and safe behaviors into safe habits. That’s how high reliability happens.

Product Details

ISBN-13:	9781640550681
Publisher:	Health Administration Press
Publication date:	07/01/2019
Series:	ACHE Management
Edition description:	None
Pages:	350
Sales rank:	795,653
Product dimensions:	7.00(w) x 10.00(h) x 0.80(d)

About the Author

Charles A. Mowll, LFACHE, served as executive vice president of The Joint Commission for more than 20 years, acquiring expertise in patient safety, high reliability, and Lean Six Sigma. In this role, Mr. Mowll had the opportunity to interact with and learn from some of the world’s leading experts in these fields. He also understands the financial constraints that healthcare organizations face—he spent the first half of his career as a healthcare financial management executive. Following his retirement from The Joint Commission in 2015, Mr. Mowll formed the Patient Safety Coaches Academy, which focuses on helping hospitals develop patient safety coaching programs, enhance the competence of their patient safety coaches, and spread the consistent use of safe care practices. He earned his master’s degree in public health from the Robert Wood Johnson Medical School at Rutgers University. Mr. Mowll is a Life Fellow of the American College of Healthcare Executives and previously was a fellow of the Healthcare Financial Management Association and an American Society for Quality–certified Six Sigma Black Belt.

Read an Excerpt

CHAPTER 1

Accelerating Change and Changing Behaviors

WHY FOCUS ON CHANGE?

Here is a straightforward reality: A hospital or healthcare system that aspires to transform its patient safety performance from harmful to zero patient harm must change. It must stimulate adjustments in behaviors and practices, and this requires individual caregivers who want to change the way they do things. It must redesign patient care processes and modify embedded defenses, and this requires the active participation of frontline staff in developing and implementing the changes necessary to minimize error traps and improve safety. It must strengthen existing structures and systems to support the consistent delivery of safe care, and this requires active leadership and adequate resources to sustain the benefits derived from the change. Transforming behaviors, processes, and practices and the resultant difference in attitudes, values, and beliefs require a mastery of change facilitation methods and skills. Healthcare leaders must become master change agents if they want to motivate and lead their organization in pursuing transformational improvements in patient safety that will result in zero patient harm.

Which came first — the chicken or the egg? This timeless riddle and folk paradox describes a causality dilemma or the problem of origin and first cause. It raises the question, "What needs to happen first?" Did the chicken come first, or was it necessary to have an egg for the first chicken to hatch? This riddle is a metaphoric expression used when it is not clear which of two factors is the cause and which is the effect. The causality dilemma for hospitals that aspire to ascend to the high-reliability level, in which zero patient harm is the norm, is whether safe practices or safe thoughts come first. Does a change in thoughts (beliefs and attitudes) cause a change in practices and behaviors? Or does a change in practices and behaviors cause a change in thoughts? Does it matter?

Based on the high-reliability organization research of Karl Weick and Kathleen Sutcliffe (2007) and the study of human factors and safety culture by James Reason (Reason and Hobbs 2003), the following discussion suggests that changing practices and behaviors is a far more direct and effective way to achieve the zero harm goal than first trying to modify attitudes, beliefs, and values throughout the organization. A change in behaviors and practices comes first, resulting in improved attitudes, beliefs, and values that, in turn, cause a transformation in the organizational culture.

Hospitals and healthcare systems that aspire to put in place a consistently safe, highly reliable patient care environment must have a competency in effecting change in practices and behaviors. Facilitating this change and adopting the safe practices of high-reliability organizations is the most effective and direct route to eliminating preventable patient harm. Visioning is important; as Douglas Smith (1996, 230) has said, "Visionless people do not change." But visioning or thinking about and believing in a goal alone is not sufficient for goal realization. Changing practices and behaviors is the critical delta necessary to achieve and sustain zero patient harm (see exhibit 1.1).

This is why chapter 1 is devoted to change. Change facilitates the achievement of zero patient harm, which requires the acquisition of knowledge, skills, and abilities (KSAs) necessary for becoming an excellent agent of change. Job number one for leaders of organizational efforts to eliminate all patient harm is to learn how to create a sense of urgency for change, clearly communicate the vision of a more successful future, gain staff's commitment to and engagement in the change effort, reduce complacency and resistance to change, and provide ongoing support and resources to ensure the successful implementation of the change.

WHY IS CHANGING PRACTICES AND BEHAVIORS CRITICAL TO ACHIEVING A CULTURE OF SAFETY AND CONSISTENTLY SAFE PATIENT CARE?

How often do we think about doing something, create a mental plan for accomplishing it, and dream about the potential results, but then procrastinate and fail to take the action necessary to realize the goal? Getting from A (the current state) to B (the desired future state) requires change. Most people are fearful of change and the uncertainty it represents. But as our experience with making changes in either our personal or professional life grows, we learn that change often provides new opportunities for both personal and professional success. It is an unassailable fact that people need to take action to actualize their thoughts and aspirations. To change the outcomes of something, people need to change their practices and behaviors.

The same is true for an organizational change effort. Actualizing the aspiration of zero patient harm can only occur through action or doing — specifically, following the Five Disciplines of Performance Excellence: (1) preparing (through simulation, practice, and training) to deliver safe care, (2) applying proven safe care or offensive strategies, (3) minimizing errors and mistakes, (4) maximizing the controls or defensive strategies, and (5) routinely receiving guidance and feedback from patient safety coaches.

In the pursuit of a culture of safety, organizations may find it harder to change attitudes and beliefs than practices and behaviors. "Effective practices ... will eventually bring attitudes and beliefs into line with them" (Reason and Hobbs 2003, 156). Although action is the key determinant of goal achievement, action is only possible if the people affected are convinced of its merits and are motivated to take or support it. In other words, action is dependent on effective change facilitation and competent agents of change. "No matter how well a system or solution is conceived, designed, and executed, if people do not like it, it will fail. The goal of the change leader is to ... create well-designed solutions that will gain wide acceptance" (Bulger and Weber 2005, 372). In addition to being a visionary and charismatic champion for patient safety, today's healthcare leaders must have a mastery of the KSAs of change facilitation to be able to define, reward, and expect the practice of safe behaviors by all staff. According to John Kotter (1996, 151):

Culture changes only after you have successfully altered people's actions, after the new behavior produces some group benefit for a period of time, and after people see the connection between the new actions and the performance improvement. Changing the culture should never be the first step in a major change effort.

According to Jeffrey Hiatt and Timothy Creasey (2012, 1), change management provides the bridge between solutions and results: "The bridge between a quality solution and benefit realization is individuals embracing and adopting change." Organizational transformation occurs because the people in the organization are convinced that, after the change, they will be better off and the organization will be in a better position to meet its objectives. People change the organization, what it does, and what it is able to accomplish. Healthcare leaders must become competent agents of change to facilitate the changes in staff practices and behaviors and the adoption of safe care practices.

Change involves patient care teams doing their jobs differently. "A perfectly designed process that no one follows produces no improvement in performance" (Hiatt and Creasey 2012, 1). Therefore, leaders who want to achieve a level of performance excellence must use effective change facilitation tools, including being a champion for change; creating a shared need for change; explaining how the change will benefit both staff and the organization; building a coalition of support for the change; mobilizing the commitment for change; and motivating, monitoring, and rewarding action.

CHANGE TO IMPROVE PERFORMANCE

The four major targets and resulting benefits of organizational change initiatives are as follows:

1. Structural. These changes are focused on reorganizing the organization's operating units or parts to improve efficiency and performance. Such change efforts might include acquiring new parts through acquisition or shedding some operating units through divestiture.

2. Efficiency. These changes are focused on cost reduction, elimination of nonessential activities, and identification and elimination of waste.

3. Process. These changes alter how things get done in the organization. The objective is to make processes more reliable, safer, less costly, more effective, and faster.

4. Cultural. These changes focus on modifying the norms, attitudes, beliefs, and behaviors of the organization to support a new vision.

All four of these targets facilitate the organizational changes necessary for a hospital to become highly reliable, to eliminate all preventable patient harm, and to achieve a level of consistent performance excellence. Given that changes in staff behaviors (setting clear behavior-based expectations) and the adoption and consistent application of safe care practices are a top priority in delivering safe care, making process changes should be the first order of change in the organization. Along the way, hospitals should make efficiency changes, applying Lean Six Sigma tools and techniques to root out waste and inefficiencies in care processes and design, to ensure that only the critical and high-quality characteristics remain.

Effective change management requires leaders to introduce structural changes to structures and systems that will support the hospital's evolution to an environment of high reliability and zero patient harm. Visioning, revising or creating policies, providing training, and providing positive reinforcement are examples of the type of structures needed to support the practical changes in patient care practices and behaviors. Leaders must avoid the appearance of change for change's sake and clearly and regularly communicate the desired harm-free healthcare objective. As a result of the changes in priorities, processes, and practices, cultural changes occur in the form of new norms, attitudes, and beliefs. As Smith (1996, 98) says, "A performance focus forces everyone to consider the consequences and benefits of changing or not changing." Managing and facilitating change in the hospital setting is "the ultimate human challenge" in that the leaders, functioning as change agents, transform organizational performance and practices of a large group of people by learning new skills, behaviors, and working relationships.

ASPIRING TO CHANGE

The management of organizational change — change that is meaningful and enduring — will be carried out in three stages. Phase 1 establishes the shared aspiration for improvement through change. Phase 2 involves making the change happen through those most affected by the change. Phase 3 entails assimilating the change and related new behaviors and habits throughout the affected parts of the organization.

An aspiration is an ardent desire to accomplish something new. The safety-related aspiration for hospitals is a culture in which every patient receives harm-free healthcare. Leading change, creating a shared need, and shaping the vision for change are the first three pillars of the Change Acceleration Process model (Six Sigma Institute 2019). In this model, the leader's role is to articulate the reason for change as well as explain why the change is important, how it will help them, and how it will benefit the organization. The CEO and senior leadership must be champions for the change initiative and, as such, must demonstrate public commitment to and support for the change. Visioning spotlights the desired outcomes of the intended change and defines the adjustments in behaviors needed to realize the benefits of the change. Creating a shared need for the change happens when the perceived need for change exceeds the resistance to change.

Following are the five determinants of the rate of change adoption that leaders must proactively address to enable the change initiative to succeed (Bulger and Weber 2005):

1. Relative advantage. If those affected by the change perceive it as relatively better than the current situation, the change is more rapidly adopted.

2. Compatibility. Change adoption is faster when staff perceive the change to be consistent with their values, past experiences, and needs.

3. Complexity. The simpler the change, the more likely it is to be adopted.

4. Trialability. The perception of risk is lowered if the change can first be implemented on a trial basis before it is adopted.

5. Observability. The adoption of the change is enhanced if the affected staff can observe others who are trying the change first.

Facilitating the change initiative will require leaders to create a sense of urgency about the need for change, to overcome the organizational tendency toward homeostasis. Homeostasis is the ability to maintain a relatively stable internal state through feedback mechanisms despite the influence of external changes. As Esther Cameron and Mike Green (2012, 140) note, "The forces of homeostasis act to preserve the status quo in any organization." Leaders have to assess the organization's propensity for change before announcing a change initiative. This assessment should include a review of the following (Cameron and Green 2012):

• Nature of the change. Five types of change can each provoke a different response from those potentially affected by the change: evolutionary or revolutionary, externally driven or internally motivated, one time or routine, minor or transformative, and contraction or expansion.

• Consequences of the change. Those affected by the change will want to know who the potential winners and losers will be; who will benefit; who will be "hurt"; and what the specific consequences will be for employees, customers, and the organization.

• Past experience with change. How the organization has handled change initiatives in the past, how it has resourced changes, and what its capacity is to support change should be considered when launching a new change initiative.

• Individual change factors. Change is accomplished through the individuals in the organization; therefore, it is important to understand what values motivate them (e.g., money, power, status, inclusion), what personality types may be affected by the change, and what their past experience has been with organizational change initiatives and their adaptive resilience to handle change.

"We aspire to be a hospital that consistently provides excellent patient care that is safe and free from harm" is an example of a patient safety vision. Setting such a vision must be based on a clearly defined business problem (eliminating preventable patient harm), must describe an altered and improved future (delivering harm-free healthcare), and must inspire the commitment and energy of all of the staff affected by the change (adopting the safe care practices of high-reliability organizations) (Luecke 2003). Turning the aspirational change objective into action requires change in behavior or practice; leaders need to decide and announce what they specifically want people in the organization to become continually better at doing. Then, they need to provide the support and facilitation that will enable people to learn and adopt the expected and desired change (Smith 1996, 261–67).

In preparing to implement a change initiative, the organization should determine its readiness with the following tasks (Smith 1996, 259):

1. Identify the people who will be affected by the change, and determine how their behaviors and activities will need to shift.

2. Articulate the from/to aspect of the changes in job functions (e.g., ensure peer checking for high-alert medication administration) and individual behaviors (e.g., consistently ensure that all aspects of the fall prevention policy are enforced, including installing bed alarms for at-risk patients and answering the call for ambulation assistance quickly).

3. Assess the sources of readiness.

4. Assess the sources of reluctance.

5. Create the inspirational vision and purpose of the change and effectively communicate them.

6. Describe the "how" of making the change happen.

7. Describe the expected or desired behavior or practice during the change initiative.

ACTUALIZING THE CHANGE

The goal of this book, which should be the principal goal of every hospital or healthcare system, is to facilitate the adoption of best practices, including the Five Disciplines of Performance Excellence (each of which is discussed in its own chapter), that if consistently followed or incorporated into day-to-day performance will lead to excellence and the elimination of preventable patient harm. These practices demand a commitment to changing behaviors and adopting new safe care practices. This commitment, in turn, requires leaders to be smart about initiating and executing change as well as convincing the staff that change is critical to protecting patients from harm. This commitment enables the gains in improved patient safety to be sustained for a long time.

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Excerpted from "Five Disciplines for Zero Patient Harm"
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Copyright © 2019 Foundation of the American College of Healthcare Executives.
Excerpted by permission of Health Administration Press.
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Table of Contents

Introduction,
Part I Mastering Change to Enable Safe Care,
Chapter 1 Accelerating Change and Changing Behaviors,
Part II Preparing to Deliver Safe Care,
Chapter 2 Enhancing Individual Competence, Behavior, and Performance,
Chapter 3 Training Individuals to Effectively Participate on Teams,
Chapter 4 Preparing Through Deliberate Practice and Simulation,
Part III Performing Safe Care Practices: The "Offensive" Strategy,
Chapter 5 Preventing Harm Through Safe Care Practices,
Chapter 6 Cultivating Resilience and Adaptability,
Chapter 7 Using Technology to Improve Patient Safety,
Part IV Minimizing Errors and Event Precursors,
Chapter 8 Understanding the Specific Causes of Serious Safety Events,
Chapter 9 Influencing Human Performance and System Performance,
Chapter 10 Influencing the Human Factors That Impact Human Performance and System Performance,
Part V Maximizing Defenses and Barriers: The "Defensive" Strategy,
Chapter 11 Strengthening Defenses to Prevent Harm,
Chapter 12 Designing Safer Systems,
Part VI Coaching to Facilitate Safe Care,
Chapter 13 Developing Effective Patient Safety Coaching Skills,
Chapter 14 Coaching Teams to Consistently Demonstrate Safe Behaviors,
Part VII Creating a Safety Culture and Climate,
Chapter 15 Leading the Cultural Transformation to Harm-Free Healthcare,
Index,
About the Author,