Identifying High Reliability Practices for Infection Prevention in Long-Term Care, Part 2: Practices From the Field

High reliability organizations (HROs) have been described as “systems operating in hazardous conditions that have fewer than their fair share of adverse events.”¹ Outside of health care, examples of industries considered to be highly reliable include nuclear power, aircraft carriers, and air traffic control. At its core, high reliability is characterized by nearly defect-free operations. Engaged leadership and strong safety culture, together with standardization, simplification, and error-proofing of routine practices, are common elements of HROs.² With the constant problem of infections in long-term care facilities (LTCFs), the principles of high reliability organizing may be an effective strategy to improve current infection prevention practices or to create new infection prevention models.

HROs employ five core processes in their organizations in order to become highly reliable and effective in daily operations. HROs aim to ensure the following processes are ever-present in the minds and actions of individuals managing and working within organizations: (1) preoccupation with failure, (2) reluctance to simplify, (3) sensitivity to operations, (4) deference to expertise, and (5) commitment to resilience.³ These core processes develop an organization’s strengths through individual actions. In other words, shared attitudes among staff fill the gap between the organization and the individual to promote high reliability.⁴ 

Essentially, organizing for high reliability is a pragmatic approach to encourage flow of local information from frontline staff toward central authority (leaders), with the migration of authority, when indicated, to the frontline staff for timely response to changing situations. Frontline staff should be taught to be watchful or vigilant for early heralds of problems (ie, preoccupation with failure). They should also be taught to be reluctant to accept first impressions and wary that one’s perceptions may not represent what is happening (ie, reluctance to simplify). As events unfold and situations become complex, procedures and operations should be altered accordingly (ie, sensitivity to operations). Moreover, local knowledge and expertise of specific situations are considered to have greater weight than expert knowledge that is generalized, abstract, and context-free (ie, deference to expertise). Finally, frontline staff members should be supported to continue working through a problem until it resolves or until they are relieved of the responsibility (commitment to resilience). An extended explanation and discussion of high reliability core processes can be read in our previous work.⁵ 

Current regulations, aiming to improve infection prevention practices, highlight the need for more effective prevention strategies in LTCFs. According to the US Department of Health and Human Services, healthcare-associated infections range from 765,000 to 2.8 million infections among 1.5 million Americans in over 16,000 LTCFs annually.⁶ In LTC, applying high reliability concepts would involve the main leadership figures, such as medical directors (MDs), nursing home (NH) administrators, etc, and frontline staff such as certified nursing assistants (CNAs), dietary assistants, and staff nurses, who are often the persons most familiar with the needs and changing conditions of residents and families. In acute care, staff empowerment, standardization of practices, and adoption of a safety culture has been shown to successfully reduce infections over time.^7,8  

This article builds upon our past article,⁵ which explained the applicability of high reliability concepts to LTC and investigated the prevalence of these concepts in current LTC literature. In that article, we found that instances of core processes are already directly or indirectly being applied in facilities and incorporated into national initiatives. 

This article presents the second part of our project, wherein we sought to identify examples of high reliability practices used in existing facilities for the prevention of infections that could eventually be adapted for the development of online education materials. Our ultimate aim of the project was to identify how high reliability practices can be applied in facility-based LTC settings to reduce transmission of infection. To achieve these aims, we sent out a call for examples to facilities in the field regarding their current infection prevention practices, convened an expert panel to assess facility responses, and then described practical examples consistent with high reliability processes. The results of our research produced education materials to share with LTCFs nationwide for application in their facilities.

Methods

Call for Practices

This project was funded through a conference grant and not considered to be human subjects research.

A brief questionnaire to identify effective, successful, or high reliability practice examples was developed using Qualtrics^© software (version 2012, Provo, UT). The survey included 14 questions, asking respondents to describe their facility’s effective or successful infection prevention-related practices or improvements, how leadership is involved in preventing infections, what actions frontline staff take to prevent infections, how the organization staffs infection prevention services, and their facility demographic characteristics, in addition to other questions. Supplemental Figure 1 includes the full questionnaire used.

The settings of interest were NHs, skilled nursing facilities (SNFs) and assisted living facilities (ALFs) in the United States. The questionnaire was first pilot-tested at 3 sites; pilot test sites were asked to respond to questions that included the time to complete the survey, clarity of survey questions, concerns about sharing information, and questions that should be included that would better elicit examples of innovative or effective practices. Pilot testing identified potential obstacles including the challenge to staff of trying to judge whether their own practices might be considered innovative or effective and the tendency to ignore nonessential emails due to time and staffing constraints. One suggestion was to be more specific and include some examples in the questions. Another suggestion was to keep the survey “quick and easy” with yes/no response options when possible. We also identified the need to rephrase a question about frontline staff actions to exclude hand hygiene. Revisions were made to several items including adding examples and deleting one question.  

A convenience sampling approach was used to distribute the questionnaire as widely as possible between April and July in 2013 via 4 mechanisms: (1) a general announcement sent to approximately 30,000 subscribers using a Joint Commission email list, (2) targeted messages to Joint Commission accredited nursing homes and surveyors, (3) dissemination by 14 organizations associated with participants invited to sit on the expert panel, and (4) personal handouts at a local conference. 

The 14 organizations included: AMDA—The Society for Post-Actue and Long-Term Care Medicine, LeadingAge, the National Association of Directors of Nursing Administration, Assisted Living Federation of America, Life Care Centers of America, American College of Health Care Administrators, Veterans Health Administration Community Living Centers, Association for Professionals in Infection Control (APIC), APIC LTC subgroup in Pennsylvania area, Society for Healthcare Epidemiology of America (LTC subgroup), Illinois Department of Public Health LTC collaborative, California Department of Public Health, Maryland Department of Health and Mental Hygiene, and the Pediatric Complex Care Association. The local conference chosen was the APIC conference titled “Continuing the Care: Infection Prevention in the Long-Term Care Setting,” because one of the leadership team members was a member of APIC and a conference organizer.

This approach allowed us to reach a broad range of NHs and ALFs but was not designed to be representative of the population or to allow calculation of response rates.

We then categorized the responses based on themes identified from our initial literature review process.⁵ When reviewing the literature, the project team created a running list of infection prevention-related topics and high reliability/improvement-related themes that emerged from the literature reviewed. The refined list of themes was then used by the expert panel to categorize the responses from the field.

Expert Panel and Roundtable Discussion

Sixteen people with expertise in the delivery of facility-based LTC, infection prevention and health care epidemiology, high reliability and quality improvement science, LTC consumer perspective, and LTC quality oversight were invited to a roundtable meeting to contribute to the assessment of the responses. These experts were found through existing relationsips with The Joint Commission or through published literature and chosen based on scientific expertise, provider experience, or both.

At the roundtable meeting held on July 26, 2013 in Oakbrook Terrace, IL, the expert panel evaluated the responses. We created a worksheet for roundtable meeting participants to use that included prefilled information using the refined list of themes. 

Participants were divided into five predefined groups for reviewing the facility responses; each group comprised persons with different backgrounds or roles in LTC. Participants were free to engage in group discussions, but each was asked to complete their own rating form. Reviewers were asked to rate each submission on the extent to which they considered the practice to be (a) innovative, (b) effective, and (c) systematic, using a 5-point Likert scale from strongly disagree to strongly agree. Reviewers also advised on corrections to the pre-categorized topic areas and high reliability themes. Numerical weights were assigned to levels of agreement and submissions were rank-ordered within each criterion to identify the highest ratings.

Results

Responses

The call for practices from the field yielded 65 submissions, four of which were deemed ineligible (from vendors or those missing contact information). Supplemental Table 1 describes the characteristics of submitting organizations.

Table 1 (N = 61) outlines and categorizes the facilities’ responses based on the refined list of infection-prevention topic areas and improvement-related themes. Submitted infection-prevention topics focused on clinical care practices and procedures such as isolation precautions (n = 10), hand hygiene (n = 10), and outbreaks (n = 10). Improvement-related themes focused on enhancing communication (n = 14), structured quality improvement and training (n = 13), and using systematic processes (n = 12). 

Roundtable Discussion Results

The expert panel identified eight facility submissions that
included promising practices to highlight in the educational module. Because most practices were not unique
to organizations, and submissions often incorporated multiple practices, we do not ascribe specific practices to
organizations. Instead, we acknowledged contributors within the module, which is freely available online at https://www.jointcommission.org/HRipcLTC.aspx (CD version available upon request).⁹

Excerpts from facility responses are provided in the Case Vignettes, which include short facility descriptions.

Discussion

In this second part of our project, we sought to identify NH and ALF infection prevention-related practices from the field that were consistent with the core processes of high reliability, to evaluate them against criteria together with an expert panel, and to develop an educational product for widespread use. We found that there was a great deal of consistency between the core processes of high reliability and examples of effective practices submitted from the field. Although high reliability per se was rarely mentioned by submitting organizations, the practice examples given in responses did demonstrate high reliability concepts. Similar to the findings from the literature in Part 1,⁵ differences found related more to terminology and semantics than substance. 

What are the essential elements when it comes to organizing for high reliability in NHs and ALFs? How can LTC leaders apply these findings to their daily practices? As described by Chassin and Loeb,² there are three interdependent and essential changes that health care organizations must undergo to become highly reliable: (1) leadership must commit to the goal of high reliability, (2) an organizational culture that supports high reliability must be fully implemented, and (3) the tools of robust process improvement must be adopted. A common thread found in the practice examples is facility leadership’s commitment to infection prevention. Case Vignette 1 and Supplemental Case Vignette 1 both have core groups of leaders; in Case Vignette 1, this group is primarily concerned with ensuring that the facility procedures and staff protocols are up-to-date with new regulations and making sure that any needed resources are obtained. 

In addition to handling these items, the leadership group in Supplemental Case Vignette 1 also serves as enthusiastic “tone-setters” for staff. For instance, they initiate pre-outbreak-season group think sessions, send out email updates during outbreaks, and routinely reiterate to staff the importance of consistently lowering infection risks. They also conduct regular in-services to remind clinical staff of daily measures such as hand-washing and glove-wearing. Similar to Case Vignette 1 and Supplemental Case Vignette 2, leaders in Case Vignettes 2, 4, and Supplemental Case Vignette 2 review new tools, research, and guidelines for implementation consideration. Case Vignette 4 facility leaders serve as members of an outbreak rapid response team that integrates all staff, whereas leaders in Case Vignettes 2 and 6 serve in more supportive capacities in terms of infection control, performing standard tasks like reviewing new guidelines, performing infection control rounds, and promoting infection prevention education. As found in the research² and in the practice examples mentioned above, ensuring that organization leadership is fully engaged in optimizing operations seems to be an essential part of organizing for high reliability.

Along with leadership, the rest of an organization’s staff must also commit to the core processes of high reliability for these concepts to succeed. Fei and Vlasses suggest organizing for high reliability can serve as a framework for development and maintenance of a safety culture.¹⁰ This typically requires that leaders adopt a system-level approach to identifying, analyzing, managing, and preventing errors rather than placing blame through traditional hierarchical structures. Castle and colleagues identified effective teamwork, communication, nonpunitive response to errors, and collaborative learning as the key characteristics of a safety culture in NHs.^11,12 In what follows, we highlight examples from the call for practices that we thought aligned with the research above and that seemed demonstrative of the high reliability core processes: (1) preoccupation with failure, (2) reluctance to simplify, (3) sensitivity to operations, (4) deference to expertise, and (5) commitment to resilience.³ Many of these examples were subsequently integrated into the education module and could readily be integrated into current organizational cultures.

Preoccupation With Failure

As mentioned previously, the core process of preoccupation with failure reflects staff vigilance for vulnerabilities of the facility, system, and patient care. The best-designed systems can fail; in an HRO, all members of the staff watch for early signs of failure. An example from the facility responses includes the use of invisible markers and black light technology to audit the completeness of environmental cleaning to prevent transmission of organisms such as Clostridium difficile (C diff). Examples of these tools can be seen in practices from Supplemental Case Vignette 2 and Case Vignettes 5 and 6. Environmental cleaning is often less effective than planned, thus employing methods to evaluate the thoroughness of cleaning and disinfection (eg, the use of fluorescent markers, agar slides, or bioluminescence) to monitor effectiveness is another layer of protection for residents.¹³ These technologies can be used collaboratively among the frontline staff and housekeeping departments to enhance the effectiveness of environmental cleaning. Practice examples from Case Vignettes 1 and 3 also contain evidence of preoccupation with failure, as Case Vignette 1 notes that the residents themselves are proactively educated on hand hygiene, and Case Vignette 3 explains that staff are encouraged to remind each other of potential infection-related risks.

Reluctance to Simplify

Evidence of a reluctance to simplify, wherein staff are reluctant to accept first impressions and perceptions of situations, was also found in the call for practices. The use of a structured root case analysis review process for catheter-related infections involving urinary, central and peripheral lines is one example from Case Vignette 1. This type of analysis not only uncovers occult contributions to the failure (infection) but also demonstrates the interconnectedness of care in the LTC environment. Even though someone or some action did not contribute to the failure, the person or action may prevent it. Staff learn that simple actions can have major contributions to care and that the most serious of resident crises often start as mundane problems.

Sensitivity to Operations

Several of the submitted practices exemplified the core process of sensitivity to operations. This is the ability to adapt plans in real time to local activity. Examples from responses include use of infection control “huddles” to improve communication by identifying discrepancies between real-time resident activity and facility-developed plans for care (Case Vignette 1); monitoring daily resident temperatures during influenza season to proactively identify variations from baseline that could indicate infection (Supplemental Case Vignette 1 and Case Vignette 2); and frequent rounding by nursing leadership to identify impediments to compliance with isolation precautions and other aspects of infection prevention and control (Case Vignettes 5 and 6). These practices utilized the strategy of robust monitoring, reporting, and analysis of errors or unsafe conditions, which is integral to many established infection-prevention initiatives as well.

Deference to Expertise

Practice examples of deference to expertise—staff recognition of local knowledge and skill—were found in responses as well. This included engaging frontline staff volunteers as “hand hygiene champions” (Case Vignette 1 and Supplemental Case Vignette 2). Another example of deference to expertise included a practice wherein some staff would specifically oversee hand-washing among residents prior to meal times, as in Supplemental Case Vignette 1. Deferring to frontline staff can have practical benefits. Many times it is frontline staff who know how to individualize infection-related precautions to their residents. Also, they can be the persons who notice early development of problems when interventions are less costly and more effective. 

Indeed, one could make the argument that the core process of deference to expertise can translate into valuing and appreciating one’s workforce. A few of the practice examples contained instances of work-related management practices, such as using incentives and positive reinforcement to promote a culture that focuses on safety (Case Vignettes 3 and 5); maintaining an “open door policy” (Case Vignette 5) so that everyone is comfortable communicating their questions and concerns; and nonpunitive “stay-home-if-sick” policies (Supplemental Case Vignette 1 and Case Vignette 4). In either sense, deference to expertise is particularly important in LTC, in part because physicians and other clinicians are less accessible to frontline staff than in the hospital. As resident severity of illness has increased, LTC has adapted, with increased authority migration and better communication between frontline staff, management, and physicians.  

Commitment to Resilience

Finally, the core process of commitment to resilience was exemplified by practices like the use of infection-prevention teams. These multidisciplinary, rapid-response, decision-making teams are made up of leadership and staff who share their expertise to manage infection-related outbreaks, such as in Case Vignettes 1 and 4 and Supplemental Case Vignette 1. Practice examples from these responses note the creation of “core groups” of leaders or appointed “driver” leaders for the purpose of preventing and controlling infection (noted previously). For example, these teams reviewed and adapted the most recent regulations and guidelines for facility implementation, standardized procedures, and established strategy timetables and assignments for staff. Other practices exemplifying this core process include working collaboratively with local hospitals, health departments, and/or NHs to employ consistent, multifaceted approaches to staff training for environmental cleaning (Supplementeal Case Vignettes 1 and 2 and Case Vignette 6).

Challenges to HRO

There are likely to be challenges to organizing for high reliability in LTC. For instance, the ability to defer to the expertise of frontline staff can be hindered by high staff turnover rates. Moreover, in a home-like, social model where group meals and activities are promoted, it can be difficult to restrict movement and activities among ill or colonized residents who are mobile yet may be confused.¹⁴ Modifying infection control practices to accommodate individual residents can also interfere with the effectiveness of practices intended to protect others, such as contact isolation. This speaks to the need to develop adaptive solutions with frontline staff input that carefully balance the psychosocial consequences of such measures against infection control benefits. 

One lesson learned from this project is that it can be difficult for LTC staff to judge what practices might be considered innovative or effective. While the expert panel was pleasantly surprised by some submitted practices—such as the ones discussed above that were later integrated into the education module—it was not impressed by others (eg, hand hygiene monitoring, which was considered basic). This suggests that LTC staff might benefit from more sharing of examples of effective practices, a key component of the collaborative model¹⁵ for improvement. The use of interdisciplinary communication from Case Vignette 1 and collaboration efforts from Supplemental Case Vignettes 1 and 2 and Case Vignette 6 are practical examples of how this may be applied in facilities. 

One obstacle that our team encountered during analysis was that some high reliability core processes are difficult to distinguish from the mechanisms or strategies that are used to achieve them (eg, robust monitoring and analysis of errors). In fact, it seems that the effectiveness of organizing for high reliability results not only from application of the individual processes (independent of one another) but also from the interaction and/or interdependence of these processes. For example, employing infection preventionists in facilities in an isolated manner or for a short period, without consistent communication with frontline staff, would likely prove less effective compared with the strategies in Supplemental Case Vignettes 1 and 2 wherein preventionists are integrated into a wide range of facility procedures. It is more likely that a combination of multiple high reliability processes and implementation strategies are needed to progress toward becoming an HRO. 

Additional resources for implementation of high reliability processes can be found at the following websites: https://www.centerfortransforminghealthcare.org/hro_portal_main.aspx and https://high-reliability.org.^16,17

There are several limitations to the findings. Our convenience sampling approach likely did not reach all types of facilities, particularly staff in ALFs who were not notified of the call for practices through project partners. Facilities without a preexisting relationship with Joint Commission may have been less likely to respond, although accreditation status was irrelevant to this project and not assessed. Responses to electronic surveys are limited by the extent to which the target audience has the time and interest needed to respond. Thus, responses are not likely to be representative of the population, and we may have missed innovative practice examples. Because of the design, we cannot draw definitive conclusions about the prevalence or effectiveness of specific practices. Additionally, submitted practices were based on self-report with limited evidence of effectiveness and not validated by the research team. 

Further research is needed to determine if the practices identified from the field are associated with improved outcomes, such as lower infection rates and higher satisfaction among residents in the facilities. Studies linking processes to outcomes are particularly challenging in resident populations whose physical and functional health status is often declining due to multiple comorbidities.

Conclusion

Although high reliability is generally an unfamiliar term in LTC infection prevention, many of the core processes are relevant, appropriate, and being applied in several instances. Therefore, practices that support high reliability should be relatively straightforward to incorporate into infection-prevention initiatives within facilities. When introducing new terminology associated with high reliability processes, it may be helpful to highlight the extent to which there is overlap in strategies and focus areas with current initiatives. Education and engagement of both leaders and staff, using resources such as the educational module developed in this project, can assist NHs and ALFs in their efforts to reduce infections through the application of high reliability concepts. 

1. Reason J. Human error: models and management. BMJ. 2000;320(7237):768-770.

2. Chassin MR, Loeb JM. The ongoing quality improvement journey: next stop, high reliability. Health Aff (Millwood). 2011;30(4):559-568.

3. Weick KE, Sutcliffe KM, Obstfeld D. Organizing for high reliability: processes of collective mindfulness. Res Organ Behav. 1999;21:81-123.

4. van Stralen D. Weick/Sutcliffe social psychology: managing the unexpected through mindfulness. High Reliability Organizing website. http://www.high-reliability.org/Weick-Sutcliffe#weick1988. Accessed March 7, 2017.  

5. Braun BI, Longo BA, Chitavi A, et al. Identifying high reliability practices for infection prevention in long-term care, part I: literature review. Annals of Long-Term Care: Clinical Care and Aging. 2017;25(1):29-35.

6. Department of Health and Human Services. National Action Plan to Prevent Healthcare-Associated Infections: Road Map to Elimination; Chapter 8: Long-Term Care Facilities. https://health.gov/hcq/pdfs/hai-action-plan-ltcf.pdf. Published April 2013. Accessed March 31, 2017.

7. Pronovost PJ, Goeschel CA, Colantuoni E, et al. Sustaining reduction in catheter related bloodstream infections in Michigan intensive care units: observational study. BMJ. 2010;340:c309. doi:10.1136/bmj.c309

8. Fakih MG, Watson SR, Greene T, et al. Reducing inappropriate urinary catheter use: a statewide effort. Arch Intern Med. 2012;172(3):255-260. doi:10.1001/archinternmed.2011.627. 

9. The Joint Commission. Applying high reliability principles to infection prevention and control in long term care. The Joint Commission website. http://www.jointcommission.org/HRipcLTC.aspx. Accessed March 7, 2017.  

10. Fei K, Vlasses F. Creating a safety culture through the application of reliability science. J Healthc Qual. 2008;30(6):37-43.

11. Castle NG, Wagner LM, Perera S, Handler SM. Assessing resident safety culture in nursing homes: using the nursing home survey on resident safety. J Patient Saf. 2010;6(2):59-67.

12. Castle NG, Wagner LM, Ferguson JC, Handler SM. Safety culture of nursing homes: opinions of top managers. Health Care Manage Rev. 2011;36(2):175-187.

13. Centers for Disease Control and Prevention. Healthcare-associated infections: Options for evaluating environmental cleaning. http://www.cdc.gov/HAI/toolkits/Evaluating-Environmental-Cleaning.html. Accessed March 25, 2017.

14. Mody LM, Bradley SF, Huang SS. Keeping the “home” in nursing home: implications for infection prevention. JAMA Intern Med. 2013;173(10):853-854. doi:10.1001/jamainternmed.2013.330.

15. Institute for Healthcare Improvement. The Breakthrough Series: IHI‚Äôs Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2003. 

16. Joint Commission Center for Transforming Healthcare. High reliability in health care. http://www.centerfortransforminghealthcare.org/hro_portal_main.aspx. Accessed March 7, 2017.

17. van Stralen D. High reliability organizing. http://high-reliability.org/. Accessed March 7, 2017.