A Systems Approach to High Reliability Organizing in Aging Services

For decades, health care organizations have been striving—and struggling—to reduce preventable patient harm and improve the quality of patient care and outcomes. Many have implemented changes that align their business and clinical operations with those of high reliability organizations (HROs) in support of this effort. These organizations maintain high levels of safety despite their complexity through a culture of "collective mindfulness," in which all workers are engaged in the early identification of unsafe conditions and the proactive implementation of solutions to prevent harm. These behaviors are so common that they are considered normal activities and processes that are imbedded in daily operations.¹ 

Health care organizations can use the structure and guiding principles of HROs to bridge gaps among key pillars of care and service delivery: quality assurance, performance improvement, and patient and worker safety (see Figure 1). 

Leadership commitment and engagement, robust process improvement, and safety culture create the infrastructure, processes, and underlying cultural habits and normative expectations within an organization needed to drive purposeful change. Together, they help guide people to adjust their behaviors and allow for continuous quality improvement through embodying the following principles:²

1. Preoccupation with failure. Maintaining a constant awareness of the potential for error so solutions are created proactively rather than reactively.
2. Deference to expertise. Prioritizing expertise over seniority when building teams for quality improvement efforts.
3. Sensitivity to operations. Recognizing that even small operational changes can have a major impact on care delivery.
4. Reluctance to simplify. Resisting the urge to generalize about a problem rather than looking at the deeper or more subtle issues involved.
5. Commitment to resilience. Using the fact that errors are inevitable as the motivation for continuous quality improvement.

To effectively promote resident safety and quality of life, aging services leaders must think in terms of redesigning care processes and environments. Taking a systems-thinking approach to this redesign recognizes the system as a whole is dependent on the effective functioning of and interactions among its parts—an approach that is often used to operationalize HRO principles in support of quality improvement efforts.

Working directly with health care leaders and frontline staff, ECRI's team of safety experts guide health care providers in implementing a pragmatic focus on three key actions for high reliability through systems safety (see Figure 2).  

#1 Develop a Learning and Improvement System 

Under the Affordable Care Act, long-term care facilities that participate in Medicare and Medicaid have been required since 2010 to establish a quality assurance and performance improvement (QAPI) program to identify opportunities for improvement, develop and implement interventions or countermeasures, and continuously monitor the effectiveness and sustainability of the improvements.³ While an organization may participate in multiple, consecutive performance improvement projects (PIPs), organizations cannot rely solely on such projects since they tend to be reactive to adverse events. Instead, they must foster a learning culture aimed at continuous robust process improvement. Incorporating HRO principles into this work only enhances the effectiveness of reporting systems. For example, embodying a preoccupation with failure charges staff with constantly analyzing their performance through defined metrics and customer and employee feedback—not only in response to safety events. They report all safety events, including near misses; they provide opportunities for continued education; they monitor progress in causal-analysis and corrective-action development and implementation; and they follow guidance provided by safety committees and PIP findings.

Organizational leaders who defer to expertise within their clinical and administrative teams provide frontline staff and other stakeholders the opportunity to contribute to improvement activities. These experts can lead improvement activities—such as daily safety huddles—and encourage team members to express concerns and brainstorm solutions. Once solutions are identified, pilot projects in a specific department or facility can test the effectiveness of changes and identify unintended consequences, allowing staff to redesign portions of the plan that do not work as imagined. The final solutions should be standardized and shared widely through transparent communication to create synergies and a shared mental model (ie, collective mindfulness). This level of strong and robust process improvement is essential to meeting aging services providers' safety goals.

#2 Demonstrate Leadership Commitment to Culture and Workforce Safety

A key driver to advancing resident safety through high reliability is maintaining a culture of safety through designing systems that reduce at-risk behaviors and cultivate an environment of mutual trust and respect for reporting safety issues. An organization whose leaders embrace such a culture makes safety its number one priority. 

How we choose to view problems can either expand or limit potential solutions to drive improvements. From an HRO perspective, safety events are seen as opportunities for learning safer approaches to care rather than relying on quick or convenient workarounds or punishing staff involved in safety incidents. A true just culture of safety empowers staff to speak up, to actively participate in improvement, and to foster collective mindfulness to improve resident outcomes. According to the Institute for Safe Medication Practices (ISMP),⁴ organizations that practice just culture understand it "is so much more than a trendy metaphor for what was previously called a 'nonpunitive' or 'blame-free' culture. It's a robust set of values, beliefs, and actions that provide solid guidance on how an organization can best manage safety." 

One strategy for communication openness is to conduct leadership rounds to create an environment in which leadership is visibly sensitive to operations. People share information face-to-face through conversation, body language, and a willingness to speak up that may not otherwise happen. By taking the opportunity to speak directly to staff members, hear about their concerns, and celebrate their successes, leaders "walk the talk" of commitment to the well-being of their team members, which helps embed trust within the safety culture.

A healthy workforce that finds joy in work is the backbone of any health care system. Building a culture that is responsive to the physical, mental, and psychosocial needs of the workforce shows a true commitment to resilience. People who dedicate their professional lives to caring for others consider errors, mistakes, or poor decision-making as personal failures. Regardless of how well-developed health care systems are, errors will occur because humans are fallible. Everyone, including peers, leadership, and even patients and residents, must show support for the workforce when failures occur and help find solutions to prevent recurrence.⁵

3. Prioritize Patient, Family, and Community Engagement

Traditionally, health care systems were built around caring for patients without truly including them in making decisions that greatly impact their lives. However, the evolution of person-centered care has increasingly emphasized shared decision-making, advance care planning, and addressing social determinants of health—all of which support integrating patient, family, and community engagement as a key component of a systems approach to safety. By holding discussions with residents that solicit their care goals, priorities, and preferences, aging services providers can create care plans that align with resident wishes and account for changing needs over time. This high level of engagement can contribute to mitigation of risk and therefore increase the likelihood of better resident outcomes and satisfaction.

It is important to note that only 20% of a person's health outcomes are tied to clinical care, while socioeconomic factors (40%), health behavior factors (30%), and the physical environment (10%) drive the remaining 80% of health outcomes, making social determinants of health (SDoH) a significant factor and a high priority for providers to understand.⁶

SDoH—and one's life expectancy—can vary widely depending on geographic location. But aging services organizations can aid in improving outcomes by effectively screening residents for social needs, connecting them with community resources, and implementing system-wide initiatives aimed at strengthening community partnerships. Seeking to identify and address the complexities and challenges SDoH can create, illustrates a reluctance to simplify as providers attempt to solicit an individual's needs informed by the full context of their circumstances.

When patients, residents, and families believe they are both listened to and supported both providers and the community, organizations can better navigate the evolution of health care and respond to changing circumstances. 

Although organizing for high reliability in aging services may seem a tall order given the health sector's current struggles with high staff turnover and staff shortages, ever-changing regulatory requirements, and a rapidly growing population of older adults, many aging services organizations may already have informally embarked on this journey—meaning it is within reach for all.