Identifying High Reliability Practices for Infection Prevention in Long-Term Care, Part I: Literature Review

The foundational work by Wieck and Sutcliffe⁴ describes five core processes for organizing systems, procedures, and responses to advance toward high reliability—also known as high reliability organizing. These processes are: (1) preoccupation with failure; (2) reluctance to simplify; (3) sensitivity to operations; (4) deference to expertise; and (5) commitment to resilience. The first three processes focus on anticipation (ie, detecting an error before it occurs), whereas the last two focus on containment (ie, how the organization responds to an error).⁵ High reliability organizing develops an organization’s strengths through individual actions. Shared attitudes among staff fill the gap between the organization and the individual to promote high reliability.⁶

High reliability processes offer a pragmatic approach for timely response to changing situations that encourages flow of local information from frontline staff toward central authority (leaders), with the migration of authority, when indicated, to the frontline staff. As a situation changes, frontline staff are taught to be vigilant for early heralds of problems or failure (reflecting the first core process of preoccupation with failure). They are reluctant to accept first impressions and are wary that one’s perceptions may not represent what is happening (reflecting the second core process of reluctance to simplify). As events unfold, plans and system structure change in response to these changing operations (reflecting the third core process of sensitivity to operations). Local knowledge and expertise pertaining to specific situations (practical and context-dependent) have greater weight than expert knowledge that is abstract and context-free (reflecting the fourth core process of deference to expertise). Finally, the frontline staff member is supported to continue working through the problem until it resolves or until they are relieved of the responsibility (reflecting the fifth core process of commitment to resilience).

Study Aims

Little is known about the extent to which the core processes of high reliability have been applied to LTC settings and infection prevention practices in particular. To investigate this issue, we undertook a study with the following aims: (1) to identify examples of effective or innovative LTC infection prevention practices from the field and in published literature that are consistent with the processes of high reliability; (2) to convene a roundtable meeting comprised of topic experts and leaders to develop practical recommendations for implementing high reliability practices; and (3) to produce educational materials that describe the concepts of high reliability and present examples of effective practices to share with NHs and ALFs nationwide. 

This article introduces the concept of high reliability in LTC and describes the results of the literature review. The results related to practices from the field and the roundtable meeting will be described in a subsequent article.

In LTC, frontline staff such as certified nursing assistants, dietary assistants, and staff nurses 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 Therefore, applying the model of high reliability to care settings may be an effective strategy to reduce infections in NHs. It is first necessary, though, to understand the applicability of the five high reliability core processes together with LTC, thus further explanation of each core process and examples of its value in nursing and LTC are provided below.

Preoccupation with Failure

According to Henriksen et al⁹ in their description of a state of mindfulness for nurses, “Adverse events are rare in high reliability organizations (HROs), yet these organizations focus incessantly on ways the system can fail them. Rather than letting success breed complacency, they worry about success and know that adverse events will indeed occur. They treat close calls as a sign of danger lurking in the system. Hence, it is a good thing when nurses are preoccupied with the many ways that things can go wrong and when they share that ‘inner voice of concern’ with others.”

The best-designed systems can fail; in an HRO, all members watch for early signs of failure. In LTC, continual focus should be placed on eliminating system failures and human errors that may cause harm to residents, patients, families, and staff. The goal should always be zero harm. For example, infections can be viewed as largely preventable. Strategies may include the use of safety coaches, a “good catch” program in which staff are recognized for reporting near-misses or potential errors, and employing methods to evaluate the thoroughness of cleaning and disinfection.

Reluctance to Simplify

As described by Henriksen et al,⁹ “When things go wrong, less reliable organizations find convenient ways to circumscribe and limit the scope of the problem. They simplify and do not spend much energy on investigating all the contributing factors. Conversely, HROs resist simplified interpretations, do not accept conventional explanations that are readily available, and seek out information that can disconfirm hunches and popular stereotypes. Nurses who develop good interpersonal, teamwork, and critical-thinking skills will enhance their organization’s ability to accept disruptive information that disconfirms preconceived ideas.”

LTC organizations that are reluctant to simplify understand that things are not always as they seem. For example, exploring the less obvious underlying causes of a resident’s change in condition can often lead to unexpected insights. Communication strategies among staff that promote openness and coordination are critical. The SBAR (situation, background, assessment, and recommendation) tool¹⁰ can be an effective mechanism for framing conversations that require immediate attention. Use of a structured root cause analysis review process for catheter-related infections often uncovers occult contributions to the infection and demonstrates the interconnectedness of care. 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 serious resident crises often start as mundane problems.

Sensitivity to Operations

Henriksen et al⁹ states, “Workers in HROs do an excellent job of maintaining a big picture of current and projected operations. Jet fighter pilots call it ‘situational awareness’; surface Navy personnel call it ‘maintaining the bubble.’ By integrating information about operations and the actions of others into a coherent picture, they are able to stay ahead of the action and can respond appropriately to minor deviations before they result in major threats to safety and quality. Nurses also demonstrate excellent sensitivity to operations when they process information regarding clinical procedures beyond their own jobs and stay ahead of the action rather than trying to catch up to it.”

LTC organizations are complex environments that require staff and leaders to work together to eliminate complacency and promote teamwork. Staff can prevent harm by remaining focused on finding hazardous conditions or close calls at early stages before harm occurs. By maintaining this high level of awareness, staff create a learning environment. Safety rounds and huddles provide opportunities for information exchange, promoting real-time situation awareness among staff. Other examples include monitoring daily resident temperatures during influenza season, in order to proactively identify variations from baseline that could indicate infection, and frequent rounding by nursing leadership, to identify impediments to compliance with isolation precautions.

Deference to Expertise

“In managing the unexpected, HROs allow decisions to migrate to those with the expertise to make them,” Henriksen et al goes on to say, “Decisions that have to be made quickly are made by knowledgeable frontline personnel who are closest to the problem. Less reliable organizations show misplaced deference to authority figures. While nurses, no doubt, can cite many examples of misplaced deference to physicians, there are instances where physicians have assumed that nurses have the authority to make decisions and act, resulting in a diffusion of responsibility. When it comes to decisions that need to be made quickly, implicit assumptions need to be made explicit; rules of engagement need to be clearly established; and deference must be given to those with the expertise, resources, and availability to help the patient.”

LTC organizations can achieve the best outcomes by actively engaging residents in decisions about their care. A person-centered approach enables those working closest with the resident to know them as unique individuals. Helpful insights on how to improve care processes are often best sought from the certified nursing assistant with first-hand knowledge of resident’s lifelong routines and preferences. Examples include engaging frontline staff as “hand hygiene champions” to oversee hand hygiene practice among residents at meal times, and asking staff caring for residents in isolation to complete observation sheets with suggestions for improvement. Frontline staff often know how to individualize infection-related precautions to their residents. They can detect problems early when interventions are less costly and more effective. Deference to expertise is particularly important in LTC, in part because physicians and other clinicians are less accessible to frontline staff than in hospitals.

Commitment to Resilience

Finally, Henriksen et al⁹ explains commitment to resilience as follows, “Given that errors are always going to occur, HROs commit equal resources to being mindful about errors that have already occurred and to correct them before they worsen. Here, the idea is to reduce or mitigate the adverse consequences of untoward events. Nursing already shows resilience by putting supplies and recovery equipment in places that can be quickly accessed when patient conditions go awry. Since foresight always lags hindsight, nursing resilience can be honed by creating simulations of care processes that start to unravel (eg, failure to rescue).”

LTC staff demonstrate a commitment to resilience by anticipating situations in which safety to residents, families, and staff could be compromised and proactively putting safeguards in place. Examples including putting personal protective equipment in places that can be quickly accessed, having appropriate levels of backup supplies on hand, and providing sufficient training and education can help minimize the negative effects of an influenza outbreak. Other strategies include use of a multidisciplinary rapid response team comprising leadership and staff to manage infection-related outbreaks, and working collaboratively with local hospitals and NHs to employ consistent, multifaceted approaches to staff training for environmental cleaning.

 A scoping review of published literature (Figure 1) was conducted of peer-reviewed publications, clinical practice guidelines, and guidance documents or toolkits.^11-13 With assistance from medical librarians, we searched PubMed and Cumulative Index to Nursing and Allied Health (CINAHL) databases for English-language abstracts published between 1983 and 2013 in which the setting was LTC, and article focus was related to infection control and/or quality improvement (including safety culture and high reliability). Although high reliability and quality improvement are conceptually distinct (ie, the former focuses on a safety-oriented mode of operation while the latter is a targeted effort to improve a particular process or outcome), we used the broader term of quality improvement to capture articles that addressed high-reliability-related concepts. The following medical subject headings and free text search terms were used: [“long term care” or “nursing home” or “assisted living facility”] AND [“infection control” or “cross-infection” or “communicable disease control” or “infection/infection prevention and control”] OR [“quality improvement” or “quality of health care” or “quality” or “leadership” or “organizational culture” or “safety culture” or “safety management” or “accreditation” or “high reliability” or “reliability” or “HRO].”

Abstracts and full articles were screened against the inclusion criteria: (1) the setting was clearly either a NH or ALF, and (2) the article addressed either infection prevention or high reliability, safety culture, and/or learning culture. All included articles were independently abstracted by two team members to ensure accuracy. The literature review identified 403 potentially relevant abstracts to review; after screening and abstraction, 88 articles, 28 guidelines, and 50 guidance documents were included.

Themes From the Literature

Table 1 outlines the key themes we found in the reviewed literature. We categorized the literature according to 16 infection prevention topic areas and 9 quality improvement themes. Key aspects of the articles are available in an online, searchable database.¹⁴ Only two articles specifically used the term high reliability in the context of LTC.^15,16

Most improvement-related articles addressed efforts related to safety culture, structured quality improvement and training, and leadership engagement.  Articles related to safety culture included organizational transformation toward person-centered care and associations between culture and other measures of care processes and resident outcomes. Articles related to structured quality improvement and training targeted interventions to improve care processes. Articles related to leadership engagement included associations between effective leadership, staff satisfaction, and organizational performance. 

In general, many articles addressed strategies and focus areas considered integral to high reliability health care such as leadership engagement,¹⁷ frontline worker empowerment,¹⁸ and a culture that prioritizes safety.³ However, only one of the two articles that mentioned LTC high reliability described the core processes.¹⁵ This finding is consistent with a study of patient safety-oriented hospital leaders that found the term high reliability was rarely used, but the processes were being adopted.¹⁸

High Reliability Concepts in National Initiatives

Table 2 presents examples of the strategies and focus areas addressed either directly or indirectly in prominent national quality improvement initiatives and in organizing for high reliability. 

Two large initiatives, the Center for Medicare and Medicaid Services Quality Assurance and Performance Improvement (QAPI)¹⁹ and the Advancing Excellence in Long-Term Care Collaborative,²⁰ directly or indirectly utilized the strategies and focus areas of (1) robust monitoring, reporting, and analysis of errors or unsafe conditions, (2) structured quality improvement processes, (3) leader engagement and commitment to needed resources, (4) the prioritization of organizational safety, (5) having a valued and appreciated workforce, and (6) having care tailored to needs and preferences. These strategies are also used in organizing for high reliability. All the initiatives directly or indirectly utilized the strategies of leadership engagement, valuing the workforce, and resident-centered care. The Advancing Excellence Collaborative specifically addressed infection prevention in the areas of Clostridium difficile, environmental cleaning, antibiotic stewardship, and hand hygiene.

Though most of the strategies and focus areas in national LTC improvement initiatives were consistent with organizing for high reliability, two core processes were less directly addressed: (1) the workforce is valued and appreciated, and (2) care is resident-centered and tailored to individual needs and preferences. However, one could argue that deference to expertise (recognizing the knowledge and experience of frontline staff) necessitates that the workforce is valued and appreciated. A possible reason that resident-centered care was not directly addressed in high reliability literature could be that high reliability concepts originated from industries outside of health care, such as naval aviation and nuclear power, in which the output is very different from caring for a resident with idiosyncratic needs, perceptions, and feelings that change over time. 

Limitations of the literature review include possible missed articles due to databases included and choice of search terms. 

Although high reliability is generally an unfamiliar term in LTC, many of the core processes are relevant, appropriate, and already being applied, according to the literature. Strategies and focus areas consistent with high reliability are also inherent in many existing national improvement initiatives. We found that there was a great deal of consistency between the core processes of high reliability, those found in the literature, and those adopted by national LTC improvement initiatives. Although high reliability was rarely mentioned specifically in the literature, several studies addressed overlapping concepts, and the differences related more to terminology and semantics than substance. 

Readers interested in the remaining aims of this project can read about our methods and findings in a forthcoming article, which will focus on the responses to the call for examples of effective practices that prevent infections and an expert roundtable assessment of the responses to identify content for integration into an education module. 

Authors: 
Barbara I Braun, PhD¹; Beth Ann Longo, DrPH, MSN, MBA, RN¹; Salome Chitavi, PhD¹; Linda Kusek, RN, MPH, CIC¹; Laura Wagner, PhD, RN, GNP²; Daved van Stralen, MD, FAAP³; Deb Patterson Burdsall, PhD, RN-BC, CIC, FAPIC⁴; Jacqueline F Vance, RNC, BSN, CDONA/LTC, FACDONA⁵; Lona Mody, MD, MSc⁶  Mary Fran Clancy, RN, MSN⁷ ; Kristine M Donofrio¹ ; Susan Yendro, RN, MSN⁸

Affiliation:
¹The Joint Commission, Department of Health Services Research, One Renaissance Boulevard, Oakbrook Terrace, IL 2 UCSF School of Nursing, Department of Community Health Systems,
² Koret Way, Suite #N-505, San Francisco, CA
³ Strategic Reliability, 607 Via Vista Drive, Redlands, CA
⁴ Formerly affiliated with Lutheran Home/Lutheran Life Community, 800 W Oakton Street, Arlington Heights, IL
⁵ SavaSeniorCare Consulting, LLC, Field Support/Shared Services, 3008 Harbin Field, Ellicott City, MD
⁶ VA Ann Arbor Healthcare Systems, 11 G, GRECC, 2215 Fuller Drive, Ann Arbor, MI
⁷ Joint Commission Resources, Department of Publications and Education, 1515 W 22nd Street #1300, Oak Brook, IL
⁸ The Joint Commission, Department of Quality Measurement, One Renaissance Boulevard, Oakbrook Terrace, IL

Acknowledgments:
We wish to sincerely thank the following individuals for their important contribution to this project or manuscript: Janet Aleccia, MALS, BA, Laura Shedore, MLIS, BS, RN, Scott Williams, PsyD, Erin DuPree, MD, FACOG, and AHRQ project officer Deborah G Perfetto, PharmD.

Disclosures:
This project was funded in part by grant number 1R13HS022174-01 from the Agency for Healthcare Research and Quality (AHRQ). The views expressed in written materials and by speakers do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the US government. The funder had no role in decisionmaking, project implementation, or analysis.

Address correspondence to:
Beth Ann Longo, DrPH, MSN, MBA, RN
The Joint Commission Department of Health Services Research
One Renaissance Boulevard Oakbrook Terrace, IL 60181
Phone: (630) 792-5951 Fax: (630) 559-8443
Email: blongo@jointcommission.org