MOREOB: Managing Obstetric Risk Efficiently: A Program for Patient Safety and High Reliability in Obstetrics

2019 ◽  
pp. 485-501
Author(s):  
Helen Looker
Keyword(s):  
Patient Safety ◽  
High Reliability

scholarly journals An Organizational Learning Framework for Patient Safety

2016 ◽  
Vol 32 (2) ◽  
pp. 148-155 ◽  
Author(s):  
Marc T. Edwards
Keyword(s):  
Patient Safety ◽  
Organizational Learning ◽  
Human Error ◽  
High Reliability ◽  
Organizational Capabilities ◽  
Organizational Learning Theory ◽  
Culture Of Safety ◽  
Learning Framework ◽  
Operational Improvement ◽  
Learning Modes

Despite concerted effort to improve quality and safety, high reliability remains a distant goal. Although this likely reflects the challenge of organizational change, persistent controversy over basic issues suggests that weaknesses in conceptual models may contribute. The essence of operational improvement is organizational learning. This article presents a framework for identifying leverage points for improvement based on organizational learning theory and applies it to an analysis of current practice and controversy. Organizations learn from others, from defects, from measurement, and from mindfulness. These learning modes correspond with contemporary themes of collaboration, no blame for human error, accountability for performance, and managing the unexpected. The collaborative model has dominated improvement efforts. Greater attention to the underdeveloped modes of organizational learning may foster more rapid progress in patient safety by increasing organizational capabilities, strengthening a culture of safety, and fixing more of the process problems that contribute to patient harm.

Self-Reported Adherence to High Reliability Practices Among Participants in the Children's Hospitals’ Solutions for Patient Safety Collaborative

2019 ◽  
Vol 45 (3) ◽  
pp. 164-169
Author(s):  
Kelly H. Randall ◽  
Donna Slovensky ◽  
Robert Weech-Maldonado ◽  
Patricia A. Patrician ◽  
Paul J. Sharek
Keyword(s):  
Patient Safety ◽  
High Reliability ◽  
Children's Hospitals ◽  
Children’S Hospitals

scholarly journals Surveillance, anticipation and firefighting: Perspectives of patient safety from a New Zealand case study

2020 ◽  
Author(s):  
J Wailling ◽  
Brian Robinson ◽  
M Coombs
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
New Zealand ◽  
Health Care Professionals ◽  
Nuclear Power ◽  
High Reliability ◽  
Health Care Systems ◽  
Tertiary Hospital ◽  
Structured Interviews

© 2018 John Wiley & Sons Ltd Aim: This study explored how doctors, nurses and managers working in a New Zealand tertiary hospital understand patient safety. Background: Despite health care systems implementing proven safety strategies from high reliability organisations, such as aviation and nuclear power, these have not been uniformly adopted by health care professionals with concerns raised about clinician engagement. Design: Instrumental, embedded case study design using qualitative methods. Methods: The study used purposeful sampling, and data was collected using focus groups and semi-structured interviews with doctors (n = 31); registered nurses (n = 19); and senior organisational managers (n = 3) in a New Zealand tertiary hospital. Results: Safety was described as a core organisational value. Clinicians appreciated proactive safety approaches characterized by anticipation and vigilance, where they expertly recognized and adapted to safety risks. Managers trusted evidence-based safety rules and approaches that recorded, categorized and measured safety. Conclusion and Implications for Nursing Management: It is important that nurse managers hold a more refined understanding about safety. Organisations are more likely to support safe patient care if cultural complexity is accounted for. Recognizing how different occupational groups perceive and respond to safety, rather than attempting to reinforce a uniform set of safety actions and responsibilities, is likely to bring together a shared understanding of safety, build trust and nurture safety culture.

scholarly journals Acting between checklists and reality. Managers’ balancing between standardization and adaptive behaviour in patient safety work- an interview study

2020 ◽  
Author(s):  
Mats Hedsköld ◽  
Magna Andreen Sachs ◽  
Thorleif Rosander ◽  
Mia von Knorring ◽  
Karin Pukk Harenstam
Keyword(s):  
Patient Safety ◽  
Safety Culture ◽  
Qualitative Content Analysis ◽  
High Reliability ◽  
Interview Study ◽  
Adaptive Behaviour ◽  
First Line ◽  
Line Managers ◽  
Safety Work ◽  
Promote Patient Safety

Abstract Background: Safety culture can be described and understood through its manifestations in the organisation as artefacts, espoused values and basic underlying assumptions and is strongly related to leadership-yet it remains elusive as a concept. Even if the literature points to leadership as an important factor for creating and sustaining a mature safety culture, little is known about how the safety work of first line managers’ actually is done and how they balance the different and often conflicting organizational goals in everyday practice. The purpose of this study was to explore how health care first line managers perceive their role and how they promote patient safety and patient safety culture in their units. Methods: Interview study with first line managers in intensive care units in eight different hospitals located in the middle of Sweden. An inductive qualitative content analysis approach was used, this was then followed by a deductive analysis of the strategies informed by constructs from High reliability organizations. Results: We present how first line managers view their role in patient safety and exemplify concrete strategies by which managers promote patient safety in everyday work. Conclusions: Our study shows the central role of front-line managers in organizing for safe care and creating a culture for patient safety. Although promoted widely in Swedish healthcare at the time for the interviews, the HSOPSC was not mentioned by the managers as a central source of information on the unit’s safety culture.

Teaching the Culture of Safety

2011 ◽  
Vol 16 (3) ◽  
Author(s):  
Jane Barnsteiner
Keyword(s):  
Patient Safety ◽  
Nursing Education ◽  
Healthcare Professionals ◽  
High Reliability ◽  
Essential Elements ◽  
High Reliability Organizations ◽  
Culture Of Safety ◽  
Safety Science ◽  
Licensure Programs

Although a healthcare culture of safety has been a practice priority for many years, there has been less attention to incorporating culture of safety content into the education of healthcare professionals. Students need to become knowledgeable about system vulnerabilities and understand how knowledge, skills, and attitudes promoting utilization of safety science will lead to safer care for patients and families. Learning about both patient safety and system vulnerabilities needs to begin in pre-licensure programs and become an integral part of learning in all phases of nursing education and practice. In this article the author will begin by reviewing the essential elements of a culture of safety and considering what students need to know about a culture of safety. She will describe activities that promote safety, high reliability organizations, and external drivers of safety, and conclude by offering strategies for integrating a culture of safety into the curriculum.

Safety and quality assurance in anaesthesia

2017 ◽  
Author(s):  
Sven Staender ◽  
Andrew Smith
Keyword(s):  
Quality Assurance ◽  
Patient Safety ◽  
Clinical Medicine ◽  
High Reliability ◽  
Research Literature ◽  
International Standard Organization ◽  
Institute Of Medicine ◽  
Standard Organization ◽  
Definition Of ◽  
Based Medicine

Quality assurance has its roots in industry and therefore is strongly influenced by concepts from business, hence the reference to the definition of the term ‘quality’ according to the International Standard Organization (ISO), for example. In order to better understand the various concepts of quality assurance, this chapter clarifies concepts such as ‘effectiveness’, ‘efficiency’, ‘patient-centredness’, and ‘equity’. Of major importance in clinical medicine are guidelines, standards, recommendations, and their grade of evidence. Guidelines in particular have the advantage of facilitation of the practice of evidence-based medicine in that they can provide a practically orientated summary of the relevant research literature. Other important tools for quality assurance include ‘plan–do–study–act’ (PDSA) cycles, process mapping, monitoring of outcome indicators, auditing, and peer review. Patient safety is another rather young discipline in academic medicine. Triggered by the landmark publication of To Err is Human by the US Institute of Medicine (IOM) in 1999, patient safety gained widespread attention in healthcare. Anaesthesiology as a typical safety discipline was among the first to adopt safety measures such as ‘incident reporting’ or ‘human factors training’ years before the IOM report. Safety is closely related to outcome and therefore mortality, morbidity, as well as adverse events in general have to be considered. In order to improve, safety lessons can be learned from the so-called high-reliability organizations and transferred into clinical practice.

A Framework for Patient Safety: A Defense Nuclear Industry–Based High-Reliability Model

2013 ◽  
Vol 39 (5) ◽  
pp. 233-240 ◽  
Author(s):  
David J. Birnbach ◽  
Lisa F. Rosen ◽  
Lorena Williams ◽  
Maureen Fitzpatrick ◽  
David A. Lubarsky ◽  
...  
Keyword(s):  
Patient Safety ◽  
High Reliability ◽  
Nuclear Industry ◽  
Reliability Model

Next level of board accountability in health care quality

2018 ◽  
Vol 32 (1) ◽  
pp. 2-8 ◽  
Author(s):  
Peter J. Pronovost ◽  
C. Michael Armstrong ◽  
Renee Demski ◽  
Ronald R. Peterson ◽  
Paul B. Rothman
Keyword(s):  
Patient Safety ◽  
Quality Of Care ◽  
Health System ◽  
Management System ◽  
Health Care Quality ◽  
High Reliability ◽  
Care Quality ◽  
Quality And Safety ◽  
Content Type

Purpose The purpose of this paper is to offer six principles that health system leaders can apply to establish a governance and management system for the quality of care and patient safety. Design/methodology/approach Leaders of a large academic health system set a goal of high reliability and formed a quality board committee in 2011 to oversee quality and patient safety everywhere care was delivered. Leaders of the health system and every entity, including inpatient hospitals, home care companies, and ambulatory services staff the committee. The committee works with the management for each entity to set and achieve quality goals. Through this work, the six principles emerged to address management structures and processes. Findings The principles are: ensure there is oversight for quality everywhere care is delivered under the health system; create a framework to organize and report the work; identify care areas where quality is ambiguous or underdeveloped (i.e. islands of quality) and work to ensure there is reporting and accountability for quality measures; create a consolidated quality statement similar to a financial statement; ensure the integrity of the data used to measure and report quality and safety performance; and transparently report performance and create an explicit accountability model. Originality/value This governance and management system for quality and safety functions similar to a finance system, with quality performance documented and reported, data integrity monitored, and accountability for performance from board to bedside. To the authors’ knowledge, this is the first description of how a board has taken this type of systematic approach to oversee the quality of care.

Understanding Patient Safety in Surgical Care

2018 ◽  
Author(s):  
Amir Ghaferi
Keyword(s):  
Patient Safety ◽  
Systems Engineering ◽  
Human Performance ◽  
High Reliability ◽  
Surgical Care ◽  
Organizational Factors ◽  
Systems Science ◽  
System Failures ◽  
Hand Off ◽  
Safety Systems

This chapter describes the growing knowledge of factors that affect human performance and how these factors contribute to adverse surgical outcomes. Highlights include factors that affect performance, including teamwork, communication, and environmental and organizational factors. Tables and figures include a schematic depiction of the process by which system failures may lead to injury, accepted definitions of patient safety related terms, hand off coordination and communication objectives, and the Systems Engineering Initiative for Patient Safety model of work system and patient safety. This review contains 3 figures, 3 tables, and 78 references Key Words: Patient safety, systems science, medical error, adverse events, systems engineering, teamwork, communication, organizational resilience, high reliability organizations

The United States Army Medical Command, becoming a learning organization

2021 ◽  
Vol ahead-of-print (ahead-of-print) ◽  
Author(s):  
Bonnie Hartstein ◽  
Edward Yackel
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
High Reliability ◽  
Safety Data ◽  
The United States ◽  
Care Quality ◽  
The Body ◽  
Content Type ◽  
Army Medical ◽  
System Changes

Purpose This study aims to describe how the Army and the Army Medical Department matured as a learning organizations (LOS) during the period after the 2014 Military Health System Review through the incorporation of changes aimed at improving patient safety, data transparency and becoming a high reliability organization. This study explores the relationship between HRO and LO concepts by adding to the body of knowledge in both disciplines. Design/methodology/approach Four large scale system changes are presented and evaluated against the principles of the LO. Metric data were collected longitudinally and presented as submitted to several nationally recognized organizations in health-care quality and safety. Post initiative observations are paired with a corresponding LO principle to assess MEDCOM’s maturation as a LO. System changes/improvements and the advancement of LO principles are discussed. Findings System improvements, analyzed critically alongside paired LO principles, show strong correlation between high reliability and LO principles. Despite inherent institutional barriers, this study demonstrates that when leveraged effectively, the leadership hierarchy and command culture can accelerate transformation into an LO. Originality/value This study explores changes implemented in the U.S. Army Medical Command (MEDCOM), as it evolved as a stronger LO. It demonstrates how health-care organizations and other high-risk industries that embrace high reliability concepts will become better LO, and expands current knowledge on how LO concepts in health care can affect better system accountability and improved patient safety. Organizations can learn from MEDCOM’s journey changes that can hasten progress toward adoption of LO principles, especially in hierarchical organizations.

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