gap analysis in healthcare sector based on high
TRANSCRIPT
LEBANESE UNIVERSITY
Faculty of Sciences
Master Thesis
Gap analysis in healthcare sector based on High Reliability
Organization concept
Bilal Al Khatib
A thesis submitted in partial fulfillment of the requirements for the degree of
Master in Healthcare and Quality Management
Committee:
Dr. Patrick Tabchoury Supervisor
Dr. Ali El Hajj Co-supervisor
Ms. Nahida Jomaa Member
9/2/2015
LEBANESE UNIVERSITY
ii
Faculty of Sciences
Master Thesis
Gap analysis in healthcare sector based on High Reliability
Organization concept
A thesis submitted in partial fulfillment of the requirements for the degree of
Master in Healthcare and Quality Management
Bilal Al Khatib
©Bilal Al Khatib, 2015
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DEDICATION
To my beloved wife and my family who gave me love, hope and support.
To my cherished doctors and instructors.
To my supportive colleagues and friends, for wishing me success and luck.
To the Lebanese University, faculty of sciences – Hadath branch, for
embracing us two years.
To all hospital administrations and IRB's who facilitated my contact with
participants in the research study.
Special dedication to Dr. Patrick Tabshoury, Dr. Ali El Hajj and Ms. Nahida
Jomaa for their efforts and instructions to achieve success of my work.
To Colonel Dr. Mohammad Al Mahmoud, Captain Leila Ismail, Mr.
Mohammad Ali Hamandi and Dr. Tamima Al Jisr, without their direct
support I wouldn't be participating in this wonderful 2 years journey and
achieving my master degree.
To my friend and brother Ahmad Diab for his big contribution to achieve the
literature part of the study.
To Ms. Dalal Hassanein and Ms. Loubna Sinno for their guidance and help in
achieving this thesis.
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ACKNOWLEDGMENT
I would like to express the deepest appreciation to my thesis committee who
has the attitude and the substance of a genius: they continually and convincingly
conveyed a spirit of adventure in regard to research and knowledge, and an
excitement in regard to teaching. Without their guidance and persistent help this
thesis would not have been possible.
I continue to express my gratefulness to my faculty and Gate Company
especially the representative of the faculty - Dr. Jamal Charara and the
representative of Gates Group - Mr. Adel Olleik. Besides, I would like to thank my
teachers for their patience, knowledge and excellence. I thank them for support,
responsible work, and time.
Words aren’t enough to thank: my classmates especially the ones who helped
in the elaboration of the literature and data collection, to my work colleagues
because they were the booster to carry on in this exciting yet hard journey and my
family for their support throughout all stages of the thesis. Special thanks for all
participants who made the study valuable.
Finally, thanks God before and after everything.
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ABSTRACT
High Reliability Organization theory is a concept that helps reduce errors
which might lead, in certain cases, to catastrophe. It is applied in several industries
such as: aviation, nuclear power plants, military, and even NASA, yet this concept is
relatively new to healthcare. Several models were proposed for HRO by different
researchers, the most compelling of which is the five principles of Weick and
Sutcliffe’s that talks about “collective mindfulness”. These principles are grouped
under 2 categories: principle of anticipation which means the preoccupation with
failure, reluctance to simplify, and the sensitivity to operations; and containment
which means commitment to resilience and deference to expertise.
Considering the high risk lying in their operations, there’s a resemblance
between healthcare institutions and HROs. Unfortunately though, hospitals are far
away from reaching the state of high reliability. Several researches revealed the
presence of gaps in healthcare institutions’ capacity to reach error free operations
compared to HROs. Few studies even mentioned that healthcare act oppositely to
this desired status. Although it might seem difficult to achieve, some researchers
have considered different approaches that might help hospitals in assessing their
current status, then moving toward high reliability. One of these approaches was
proposed by the Joint Commission team Chassin and Loeb in their article “Getting
there from here”. In this article they suggested a framework to assess hospitals’
maturity toward the concept of High Reliability.
The researcher quoted this tool, and transformed it into a 25 items
questionnaire and applied it into 3 hospitals located in Beirut’s district. Around 300
employees from different specialties and backgrounds participated in this study.
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Results revealed that hospitals are lagging behind and are far away from what the
concept is supposed to be.
Undoubtedly the "High Reliability Organization" concept needs more
research if viewed in the light of healthcare, since it's relatively new to this sector.
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TABLE OF CONTENTS DEDICATION .................................................................................................................................................. IV ACKNOWLEDGMENT ................................................................................................................................... V ABSTRACT ....................................................................................................................................................... VI TABLE OF CONTENTS ............................................................................................................................... VIII LIST OF FIGURES ............................................................................................................................................. X LIST OF TABLES ............................................................................................................................................ XII LIST OF SYMBOLS ...................................................................................................................................... XIII LIST OF ABBREVIATIONS ....................................................................................................................... XIV CHAPTER 1 INTRODUCTION ...................................................................................................................... 1
1.1 BACKGROUND ................................................................................................................................... 1 1.2 PROBLEM STATEMENT .................................................................................................................... 3 1.3 OBJECTIVES .......................................................................................................................................... 4 1.4 THESIS OUTLINE ................................................................................................................................ 5
CHAPTER 2 LITERATURE REVIEW ............................................................................................................. 7 2.1 INTRODUCTION ................................................................................................................................. 7 2.2 HISTORY AND DEFINITIONS .......................................................................................................... 8 2.3 HIGH RELIABILITY ORGANIZATIONS MODELS: .................................................................... 10
2.3.1 Roberts and Libuser / organizational psychology ................................................................ 11 2.3.2 Weick and Sutcliffe/ social psychology: ................................................................................. 12
2.3.2.1 First principle: Preoccupation with failure .................................................................. 14 2.3.2.2 Second principle: Reluctance to simplify: .................................................................... 15 2.3.2.3 Third principle: sensitivity to operations: .................................................................... 15 2.3.2.4 Fourth principle: commitment to resilience: ................................................................ 17 2.3.2.5 Fifth principle: deference to expertise ........................................................................... 18
2.4 HIGH RELIABILITY ORGANIZATIONS IN HEALTHCARE .................................................... 19 2.4.1 Reliability definition as applied to healthcare ....................................................................... 19 2.4.2 Hospitals are high risk organization ...................................................................................... 19 2.4.3 Are hospitals Highly Reliable Organization? ........................................................................ 21 2.4.4 From concept to implementation ............................................................................................ 24
2.4.4.1 Leadership commitment ................................................................................................. 26 2.4.4.2 Safety culture .................................................................................................................... 30 2.4.4.3 Process improvement ...................................................................................................... 35
2.5 CONCLUSION .................................................................................................................................... 39 CHAPTER 3 RESEARCH DESIGN AND METHODOLOGY ................................................................. 41
3.1 INTRODUCTION ............................................................................................................................... 41 3.2 RESEARCH DESIGN ......................................................................................................................... 41 3.3 RESEARCH METHOD ...................................................................................................................... 42 3.4 DATA COLLECTION AND INSTRUMENTATION ..................................................................... 42 3.5 POPULATION AND SAMPLING DESIGN. .................................................................................. 44 3.6 SAMPLE OVERVIEW ........................................................................................................................ 44 3.7 SAMPLE DESCRIPTION ................................................................................................................... 45 3.8 DATA ANALYSIS .............................................................................................................................. 45
3.8.1 Descriptive analysis .................................................................................................................. 46 3.9 LIMITATIONS .................................................................................................................................... 46
CHAPTER 4 RESULTS AND DISCUSSION .............................................................................................. 48 4.1 OVERVIEW ......................................................................................................................................... 48 4.2 RESULTS AND FINDINGS ............................................................................................................... 49 4.3 CROSS TABULATION ...................................................................................................................... 73
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4.4 CONCLUSION .................................................................................................................................... 73 CHAPTER 5 CONCLUSION AND FUTURE WORK ............................................................................... 75
5.1 CONCLUSION .................................................................................................................................... 75 5.2 RECOMMENDATIONS .................................................................................................................... 76 5.3 FUTURE WORK ................................................................................................................................. 82
REFERENCES ................................................................................................................................................... 85 APPENDIX A JAMES REASON UNSAFE ACTS ALGORITHM .......................................................... 92 APPENDIXB ACCEPTANCE FORM ........................................................................................................... 94 APPENDIXC QUESTIONNAIRE ................................................................................................................ 96
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LIST OF FIGURES
Figure 2.1different models of high reliability .................................................................. 11
Figure2.2 The five specific concepts that help create the state of mindfulness needed
for reliability, which in turn is a prerequisite for safety ................................................. 14
Figure 2.3 [43] Average Rate per Exposure of Catastrophes and Associated deaths in
various industries and human activities ........................................................................... 20
Figure 2.4[45] a strategic view of safety in healthcare ...................................................... 24
Figure 2.5[56] Pantakar safety culture pyramid ................................................................. 31
Figure 2.6[59] The safety performance will improve as the culture matures, but there
can only start ......................................................................................................................... 32
Figure 2.7[61] Safety culture ladder .................................................................................... 33
Figure 2.8[70] Six Sigma ......................................................................................................... 36
Figure 2.9[70] A conceptual framework of LSS methodology ......................................... 38
Figure 4.1: distribution chart of participants by profession ........................................... 49
Figure 4.2: distribution chart for "top management commitment for zero patient
harm goal" ............................................................................................................................. 51
Figure 4.3: Chart distribution for "top management provide a climate for patient
safety" ..................................................................................................................................... 52
Figure 4.4: Chart distribution of "Action of hospital management show that patient
safety is a top priority" ........................................................................................................ 53
Figure 4.5: chart distribution of "hospital management consider quality as a top
priority" .................................................................................................................................. 54
Figure 4.6: Chart distribution for "physician involvement in quality committees" ... 55
Figure 4.7: chart distribution for "quality indicators" .................................................... 56
Figure 4.8: chart distribution for "medical equipment integration" ............................ 57
Figure 4.9: chart distribution for "IT providing statistical data" ................................... 58
Figure 4.10: chart distribution for "Trust between doctors and other clinical staff" .. 59
Figure 4.11: chart distribution for "policies, procedures, and educational programs
for trust" ................................................................................................................................. 60
Figure 4.12: chart distribution for" near miss reporting" ............................................... 61
Figure 4.13: chart distribution for “reporting near miss and unsafe conditions" ....... 62
Figure 4.14: Chart distribution for “resolving near misses and close .......................... 63
Figure 4.15: chart distribution for “feedback about changes” ....................................... 64
Figure 4.16: Chart distribution for “checking the validity and integrity of safety
barriers” ................................................................................................................................. 65
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Figure 4.17: chart distribution for “the existing of systems that prevent errors” ....... 66
Figure 4.18: chart distribution for”Surveys and safety indicators” .............................. 67
Figure 4.19: chart distribution for “implementation of a safety plan “ ........................ 68
Figure4.20: chart distribution for “ adoption of Robust Process Improvement” ....... 69
Figure 4.21: chart distribution for "training plan for Robust Process Improvement” 70
Figure 4. 22: chart distribution for “patient engagement” ............................................. 71
Figure 4.23: chart distribution for “career advancement” ............................................. 72
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LIST OF TABLES Table2.1 Reliability labels .................................................................................................... 19
Table 2.2 Relevant studies on adverse events in hospitals ............................................. 20
Table 2.3 Hospital leadership roles for quality and patient safety ............................... 28
Table 2.4Comparison between the two concepts: Six Sigma and Lean ........................ 37
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LIST OF SYMBOLS
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LIST OF ABBREVIATIONS
IOM: Institute Of Medicine
HRO: High Reliability Organization
HCO: Healthcare Organizations
ICU: Intensive Care Unit
NAT: Normal Accident Theory
HPO: High Performance Organizations
IHI: Institute for Healthcare Improvement
US: United States
JCAHO: Joint Commission on Accreditation of Healthcare Organizations
CEO: Chief Executive Officer
IT: Information Technology
PDCA: Plan-Do-Check-Act
DMAIC Define, Measure, Analyze, Improve, and Control
SS: Six Sigma
LSS Lean - Six Sigma
AHRQ Agency for Healthcare Research and Quality
HSPSC Hospital Survey on Patient Safety Culture
ICU Intensive Care unit
CCU Cardiac Care Unit
ICN Intensive Care Nursery
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ICP Intensive Care Pediatric
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CHAPTER 1
INTRODUCTION
1.1 BACKGROUND
The revolutionary report of IOM sheds the light on deficiencies in quality of
care and in patient safety; these issues became visible to healthcare professionals and
the public, when this report was published in year 2000.
In light of arising challenges, the health care sector turned to ‘‘high-reliability
organizations’’ (e.g., aviation) to follow their footsteps, because they have achieved a
high degree of safety or reliability despite operating in hazardous conditions. What
does reliability mean exactly in health care? And how do we know if hospitals are
reliable? The answers to these questions remain elusive.
To know what high reliability means for healthcare we should first know how
highly reliable organizations function.
The most compelling depiction of how high-reliability organizations (HROs)
stay safe is provided by Weick and Sutcliffe. They describe an environment of
“collective mindfulness” in which all workers look for, and report, small problems
or unsafe conditions before they pose a major problem to the organization, and
while they are still easy to fix. Rarely do these organizations, if ever, have significant
accidents. They award identification of errors and close calls or near misses, for the
lessons that can be extracted from a careful analysis of what occurred before these
events. These lessons show specific weaknesses in safety systems that can be fixed to
reduce or even to eliminate the risk of future failures.
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The five principles of high-reliability mentioned by Weick and Sutcliffe
further reveal potentials of high-reliability organizations to achieve and sustain an
extraordinary state of safety. The first principle is preoccupation with failure; HROs
never subdued by the fact that they had no accident for several months or years, and
they are always ready and alert to the smallest signs that a new threat to safety may
be developing.
The second principle is resistance to simplify, where HRO staff resists the temptation
to simplify their observations and their awareness of the environment where they
operate. Threats to safety can be complex and present themselves in many different
forms. Therefore, being able to identify the often subtle differences among threats
may make the difference between early and late recognition—between finding an
unsafe condition when it is easy to correct, and failing to recognize a problem until it
is getting out of control.
The third principle of high reliability is sensitivity to operations. HROs recognize
that small changes that typically appear in the organization’s operations are the
earliest indicators of threats to organizational performance. They focus on making
sure that all intimately involved workers in operations always report any deviations
from expected performance. Because HROs value information as a vital component
of its ability to achieve the highest priority, which is near-perfect safety, they make
sure that everyone not only, feels free to speak up with any concern, but also
recognizes an obligation to do so.
The fourth principle is commitment to resilience. HROs recognize that regardless of
all their safety measures and their precautions done, errors will occur and safety
might be compromised. “The hallmark of an HRO is not that it is error-free but that
errors don’t disable it”. Resilience refers to an organization’s capability to recognize
errors as quickly as they emerge and immediately contain them, thereby preventing
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the potential harm that may result from small errors propagation: they can easily
accumulate, and develop into major problems.
HROs strengthen their resilience by adhering to the fifth principle: deference to
expertise. When confronted by a new threat, HROs have mechanisms in place to
identify individuals with the greatest relevant experience to manage the specific
situation at hand, and to place decision-making authorities in this individual hand.
They do not invoke organizational hierarchy or expect that the person with the most
seniority or highest rank will be the most effective in dealing with the problem.[1]
1.2 PROBLEM STATEMENT
Studies revealed that typical hospitals are considerably far from the state of
high reliability organizations.
The five principles of Weick and Sutcliffes on high reliability that guide the
actions of organizations are rarely seen in the healthcare sector. Healthcare
organizations act as if failure is an inevitable and acceptable feature of their daily
operations. As opposed to the first principle: preoccupation with failure, the scarcity
of adverse events gives a false sense of security to HCOs, and they remain under the
impression that they will never experience them again, which leads to the
assumption that their safety system is intact. This complacency hinders the alertness
of teams, such as surgical teams, to minor risks that might be around them and that
can lead to several incidents: surgical fire or wrong site surgery… HROs identify
complacency as a threat to safety, so HCOs should focus on preventing this behavior
from becoming a part of their system. One of the most pervasive safety problems is
failure in sensitivity to operations.
An example is that all healthcare workers from different levels ignore unsafe
conditions, behaviors and practices. In most cases they fail to report problems to
their superiors, like what the joint commission’s 2013 report revealed concerning the
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problem that caregivers face with devices alarm, especially in ICU departments
where the total number of alarms can reach several hundred per day and 85 % to 99
% of these alarms do not signify danger (equipment malfunction, inappropriate
alarm setting, poor integration of devices, equipment malfunction, and gaps in staff
training). The outcome of these false calls will make the caregiver experience “alarm
fatigue”, and it might drive him to take unsafe actions, such as turning off the alarms
entirely, turning down the sound volume to the point of inaudibility, resetting the
alarm to unsafe levels, or ignoring the alarm altogether. “If it sounds like a
dangerous mix of unsafe conditions, it is” [1]. Imagine the risks to safety if a nuclear
power plant had alarm systems that functioned in this fashion. No HRO would
permit a condition this unsafe to exist. Hospitals and health care organizations do
not exhibit the features of resilience that characterize HROs. In a high-reliability
environment, errors and unsafe conditions are recognized early and prevented by
rapid remedies from causing harm. But in HCOs, uncoordinated and poorly
designed or poorly maintained mechanical systems (like medical device alarms), are
tolerated even though they are not safe. Errors are also not seen as valuable
information that is essential to a hospital’s ability to improve patient safety. Finally,
in attempting to solve safety and quality problems, hospitals do not regularly permit
the most expert individual to implement solutions. Instead, multiple hierarchies
dominate the authority structures of most hospitals. [1]
1.3 OBJECTIVES
The objective of this study is to assess the stage at which Lebanese hospitals
are at when it comes to the High Reliability Organization concept, and to analyze,
where existing, the gaps between the concept and the actual performance in the
Lebanese health sector.
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This study aimed to also: shed the light on safety culture, and leadership
perception of patient safety in local healthcare institutions.
Elaborate on an assessment tool that will help in detecting gaps in hospital
performance regarding patient safety issue.
Enhance hospitals’ performance from the point of view of patient safety,
based on the assessment tool results that will give us an idea on the existing gap in
each institution, and on how to figure out a solution to close these gaps.
Encourage hospitals to adopt transparency policies (through applying High-
reliability concept). These policies will help them prevent major errors from
occurring (sentinel and adverse events) through motivating employees to report
errors of any kind whether big or small in order to enhance the safety net for the
patient.
Guide hospitals toward the proactive approach, rather than the reactive one,
in order to close latent holes that might exist in safety barriers.
1.4 THESIS OUTLINE
This thesis is composed of five chapters.
The first chapter includes necessary background, problem statement and the
objectives to be achieved throughout the study.
The second chapter includes an ample literature about the topic. It provides
previous related researches by experienced researchers in the same field.
The third chapter presents the design and methodology used to accomplish
the objectives (or the main hypothesis) of the study, the data collection methods, the
tools used for analyzing data and the limitations of the study.
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The fourth chapter covers all findings and results of the research. This chapter
encompasses the discussion and the analysis of the findings.
The last chapter in this thesis includes a summary of the research efforts as a
conclusion, and some recommendations on how to fill in the gaps (if they exist)
concerning the mentioned concepts.
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CHAPTER 2
LITERATURE REVIEW
2.1 INTRODUCTION
Every industry faces safety issues related to its operations but in the
healthcare sector, this problem is immense and disseminated.
"Do no harm" the famous used safety slogan represents a challenge for
healthcare sector since the opposite has been occurring for decades. Increasing
evidences revealed that many people are harmed during their stay at hospitals and
while receiving their decided care plan.
There are several studies and researches about the problem of safety in
complex sociotechnical institutions or systems, where much is known about these
issues. They cover the organizations and management theory, cognitive psychology,
sociology, and human factors engineering. Not until recently, did the findings from
these researches begin to emerge into the healthcare industry from the patient-safety
perspective. This was achieved "thanks to" medical errors been brought to the public
spotlight that has followed high-profile events, and called for a higher focus on
organizational systems. [2]
HRO is one of the concepts used to examine system safety. High Reliability
Organization theory describes the extent and nature of efforts that people, at all
levels in an organization, have to engage in to ensure a consistent, safe operation
despite its inherent complexity and risks. [3]
This concept might be useful in resolving the Dilemma that faces every
healthcare institution concerning patient safety, due to the resemblance between
hospitals and HRO'S regarding complexity and the risks lying in their operations.
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2.2 HISTORY AND DEFINITIONS
The HRO paradigm was developed by a group of researchers at the
university of California, Berkeley (Todd LaPorte, Gene Rochlin, and Karlene
Roberts) to capture observed commonalities of operations among aircraft carriers (in
partnership with a retired Rear Admiral Tom Mercer on the USS Carl Vinson), the
Federal Aviation Administration Air Traffic Control System (and commercial
aviation), and nuclear power plant operations. [4][5][6][7]
In April of 1987, an initial conference at the University of Texas brought
researchers together to focus attention on HROs. Further research on each of the
previously mentioned three sites included Karl Weick and Paul Schuman. Other
studies focused on fire incident command system and other organization. [8][9][10]
Although these organizations are from diverse background but they have
number of similarities. First they operate in a harsh social and political environment.
Second, the technology or equipment they operate with are risky and present a
potential for errors. Third, the scale of possible consequences from errors or mistakes
precludes learning through experimentation. Finally, these organizations use
complex processes to manage complex technologies and complex work in order to
avoid failures [11]. Like High performing organizations, high reliability
organizations have common properties including: highly trained-personnel,
continuous training, effective reward systems, frequent process audits and
continuous improvement [12] [13] [14] [15]. Yet HROs are distinctive in other
properties like: organization-wide sense of vulnerability, widely distributed sense of
responsibility and accountability for reliability, widespread concern about
misperception, misconception, and misunderstanding that’s formalized across a
wide set of tasks, operations, and assumptions that are pessimistic about possible
failures [12], and finally redundancy and a variety of checks and counter checks, as a
precaution against potential mistakes. [16][17]
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Defining High reliability and specifying what constitutes a high reliability
organization presented some challenges.
Roberts initially proposed that ”HROs are a subset of hazardous
organizations that have enjoyed a record of high safety over long periods of time”
and she precisely mentioned “one can identify this subset by answering the
question, how many times could this organization have failed resulting in
catastrophic consequences that it did not? If the answer is on the order of tens of
thousands of times the organization is “high reliability”” [4]. Other definitions built
on Roberts’ as a starting point, and emphasized on the dynamic nature of achieving
reliability (e.g.: constantly striving to improve reliability and intervening both to
prevent errors and failures and to manage and recover quickly when they do
become visible). [18]
In other words there has been an increased focus on thinking of HROs as
reliability-seeking rather than reliability-achieving [19]. Reliability- seeking
organizations are distinguished by their “effective management of innately risky
technologies” rather than their absolute errors or accident rate, and that is achieved
“through organizational control of both hazard and probability”. [20]
The reconceptualization of the literature on high reliability done by Karl
Weick, Kathleen Sutcliffe, and David Obstfeld was a key turning point that
reinvigorated HRO research [21]. They showed how the infrastructure of high
reliability was bound to the process of collective mindfulness. They elaborated that
HROs are distinctive because of their efforts to reorganize in ways that increase the
quality of attention across the organization, thus enhancing people’s alertness and
awareness to details so they are more capable of detecting the subtle ways in which
context varies, and then call for contingent responding (collective mindfulness) [22].
They mentioned that “mindful organizing forms a basis for individuals to interact
continuously as they develop, refine and update a shared understanding of the
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situation they face and their capabilities to act on that understanding; it proactively
triggers actions that forestall and contain errors and crises, it requires that leaders
and other organizational members pay close attention to shaping the social and
relational infrastructure of the organization, and to establish a set of interrelated
organizing processes and practices, which jointly contribute to the system’s overall
culture of safety”. [23]
High reliability theory is sometimes contradicted with Charles Perrow’s
‘Normal Accident Theory, which takes a more pessimistic view and hypothesized
that regardless of the effectiveness of management and operations, accidents in
complex systems are inevitable. [24]
2.3 HIGH RELIABILITY ORGANIZATIONS MODELS:
Many researchers proposed several models for HRO, where each one worked
on a different aspect: Perrow’s described in his Normal Accident Theory, that
accidents are unpreventable and unanticipated therefore staff cannot be trained for.
It focus on the social and organizational underpinning of system safety and accident
causation and prevention [24][25][26] [27][28]. Slagmolen focused on performance
and reliability seeking to reach high performing organizations or HPO.[29] Van
Stralen stated using Neuropsychology (brain based response to uncertainty) that
High Reliability individuals use inductive reasoning, increasing the strength of
evidence to increase the strength of conclusion [30], and Mercer quoted his Naval
Aviation model from aircraft carrier operations.
The most important and widely used models however are Roberts – Libuser's
organizational psychology, and Weick and Sutcliffe's social psychology models.
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2.3.1 Roberts and Libuser / organizational psychology
Roberts studied HRO’s and how these organizations avoid catastrophes or
enjoy a high safety record over decades knowing the fact that they operate in a
hazardous environment. She concluded that this status is achieved through the
structure of the organization.
Roberts stated that HRO have three things in common:
- They aggressively seek to know what they don’t know
- Design their reward and incentive system to recognize cost of failures
as well as benefits of reliability
- Consistency communicate the big picture of what the organization
seeks to do, and try to get everyone to communicate with each other
about how they fit in the big picture. [26]
Roberts and Libuser found five characteristics of an HRO:
1) Process auditing: process auditing permit HRO to identify weaknesses.
Figure 2.1: different models of high reliability
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2) Vigilance for quality degradation: HROs make comparison through a
referent system generally through peers. With time and development of
expertise, a successful organization may compare itself to others, and quite
different HRO’s.
3) Reward system: HRO should have a well-balanced reward system
4) Perception of risk: risks must not only be acknowledged but must be acted
upon
5) Command and control: this concept was quoted from the military it have
several components:
- Migration decision making
- Redundancy (people/ hardware)
- Managers who can see “the big picture”
- Formal rules and procedures, standardization where proper,
existence of hierarchy but not on the negative sense such bureaucracy.
[31]
2.3.2 Weick and Sutcliffe/ social psychology:
Weick and Sutcliffe provide the most compelling depiction of how high-
reliability organizations (HROs) stay safe and that is fulfilled through mindfulness.
They stated in their book that Mindfulness as opposed to mindlessness is a mental
orientation that continually evaluates the environment.
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They studied multiple and diverse organizations that must remain intact and
function in uncertainty where potential errors might lead to catastrophe. They found
that not only do HRO have a unique structure, but they also think and act differently
than other institutions. HRO use mindful organizing for both the expected and the
unexpected. [32]
For HROs to manage the unexpected, they should be aware of how
expectations work and how to engage them mindfully. They mention that when
people form expectations, they assume that certain sequences of events likely to
happen, this set of assumptions, which are embedded in routines, rules, norms,
training, and roles, establish an orderly guide for performance and interpretation.
However, the same expectations that produce order and efficiency can also
undermine reliable resilient performance since they encourage confirmation seeking,
reliance on existing categories, and simplification. Undermining instances result in
unexpected and unimagined events that grow in complexity and can endanger
operations the longer they remain unnoticed. These expectations and their terrible
outcomes can be countered by practices that produce awareness of discriminatory
details that are relevant to failure, simplification operations, resilience, and expertise.
Weick and Sutcliffe argue that awareness improves when attention is not distracted,
is focused on the here and now, is able to hold on to the problem of interest, is wary
of preexisting categories, and is committed to implementation of the five principles.
This pattern of awareness is called mindfulness. This mindfulness was observed by
the authors on carrier decks, and in other settings were reliable performance
sustained under trying conditions. [23]
Mindful engagement is built around five principles that are quoted from
observing high reliability organization in action. These principles are grouped under
2 categories: principles of anticipation (failure, simplification and operations) and
principles of containment (resilience, expertise). [23]
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Anticipation is foreseeing or imagining an eventual unchecked outcome
caused by small disparities; it is not only sensing but also stopping the development
of undesirable events. Anticipation slows down the escalation and the spread of
small events while containment stops them. [23]
Figure2.2: The five specific concepts that help create the state of mindfulness
needed for reliability, which in turn is a prerequisite for safety
2.3.2.1 First principle: Preoccupation with failure
HROs “embrace” failure by paying close attention to small signs that are
indications of bigger problems in the system, and by adopting strategies that spell
out mistakes that people don’t often dare to make. These organizations are better
able to create practices that prevent mistakes from occurring. In HROs the earlier a
discrepancy is detected the more options are available for the staff to deal with it.
Preoccupation with failure is based not only on detecting small failures but
also on reporting it, HROs increase their knowledge-base by encouraging and
rewarding error reporting , even going so far by rewarding those who have
committed these errors. [23]
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2.3.2.2 Second principle: Reluctance to simplify:
Because “expectations simplify the world and steer observers away from the
very disconfirming evidence that foreshadows unexpected problems” [23], HRO are
always preoccupied with complicating their simplification while probing their
failures; people in these organizations launch a relentless attack on simplification.
This does not mean that HRO don’t work to make their processes simple, they do
but they encourage staff to think beyond the simple explanation for a failure and to
try to recognize small failures without assuming that these events are due to a single,
simple cause [33]. HRO and through building diverse teams with diverse
“expectations”, are better able to grasp variations in their environment and see
specific changes that need to be made.[23]
2.3.2.3 Third principle: sensitivity to operations:
HROs are responsive to the chaotic reality inside most systems, and enable
them to monitor “expectable interactions with a complicated [and] often opaque
system” and to respond immediately to those unexpected [34], it’s sound similar to
the first two principles of reliable organizing (failure and reluctance), sensitivity to
operation is about monitoring what’s actually done regardless of what it was
supposed to do based on intentions, designs and plans. [35]
What distinct HROs are that when they put the third principle into action,
they perform activities that accept ambiguities of intentions and work hard to give
undivided attention to small deviations and interruptions in operations [23]. There
are several threats that affect sensitivity to operations:
- Engineering culture: place a higher value on quantitative,
measurable, hard, objective and formal knowledge and a low value
16
on experiential knowledge needed by operators (HRO refuse to draw
a hard line between quantitative and qualitative knowledge) [36]
- Tendency of routine to become mindless [37] (in HROs,
operators execute operations mindfully; it means they rework the
routine to fit changed conditions and to update the routine when
there’s new learning).
- Overestimation of their soundness: HROs view Near
misses as a failure that reveals a potential danger, unlike other
institution where near misses are viewed as a proof that the system
has enough barriers to prevent errors which encourage complacency
rather than reliability. [23]
HROs deal with difficulties (errors, surprises, and the unexpected) by
improving their ability to anticipate. They allocate resources in such activities like
developing contingency plans, imagining worst-case scenarios and early detection of
hazards in their development. The aim of all of these measures is to prevent small
unexpected outcomes from worsening. But HROs are also aware of the limitations of
foresight and anticipation (precautions might fails and unexpected events escalate
into a crisis), that’s why they are guided by at least two principles commitment to
building resilience and deference to expertise that give them the opportunity to
bounce back from problems in a mindful way [23]. These two principles lie under
the containment category which differ from anticipation in that it aims to prevent
unwanted outcomes after an unexpected event has occurred rather than preventing
the unexpected event itself. [38]
17
2.3.2.4 Fourth principle: commitment to resilience:
Resilience is the capability of a system to maintain its function and structure
when facing an internal or external changes and to degrade, or in both gracefully
when it must [39], it occurs when the system carry on with it tasks despite failures in
some of its parts. It’s a form of control; a system is in control if it’s able to minimize
or to eliminate unwanted variability, in its own performance, or in the environment.
The fundamental characteristic of a resilient system that it does not lose control of
what it does, but is able to continue and rebound. [40]
Weick and Sutcliffe found 3 abilities in Resilience including:
- The ability to absorb damage and carry on functioning despite the
presence of difficulty (internally like rapid change, awful leadership,
production and performance pressures, and externally like increasing
competition and demands from stakeholders)
- Ability to recover and bounce back from annoying events the system
absorbs the surprise becoming better and stretch rather than collapse.
- Ability to learn and grow from previous episodes of resilient action.
[23]
They mentioned that HROs assume that they will be surprised, so they focus
on developing general resources to cope with and respond to change swiftly. It
means they work to develop knowledge, capability for swift feedback, faster
learning, speed and accuracy of communication, experiential variety, skill at
recombination of existing response repertoires, and comfort with improvisation.
To learn without knowing in advance just what you will learn or how it will
be applied, this cumbersome situation make commitment to resilience difficult to
sustain. [23]
18
2.3.2.5 Fifth principle: deference to expertise
HROs created a set of operating dynamics that are grounded in deference to
expertise, in order to stay mindful in the face of unexpected operating contingencies.
When the unexpected events become to materialize, someone somewhere sees early
warning signs. [23]
“Migrating decision, both up and down” [41], this property is perhaps the
most cited one of HROs. Decision migrates around these organizations in search of a
person who has specific knowledge of the event. Expert reacting occurs when
authority and expertise are decoupled and decision making migrates to expertise
rather than rank. It resides as much in relationship as in individuals, meaning that
interrelationships, interactions, conversations, and networks embody it. HRO’s look
downward toward the front line to find credible expertise. [23]
19
2.4 HIGH RELIABILITY ORGANIZATIONS IN HEALTHCARE
2.4.1 Reliability definition as applied to healthcare
The Institute for Healthcare Improvement (IHI) innovation team defined
reliability as a “failure-free operation over time,” it also adopted a nomenclature
using calculated failure rate (as 1 minus reliability, or unreliability) as an index,
expressed in an order of magnitude. So 10-1 means approximately one defect per 10
process opportunities, 10-2 is around 1 defect per 100 process opportunities and so
on. Researchers at IHI found that 10-1 or below indicates the absence of any
documented common process. [42]
Chassin and Loeb translated Weick and Sutcliffes definition of “collective
mindfulness” to healthcare “where the staff look for, and report, small problems or
unsafe conditions before they pose a substantial risk to the organization and when
they are easy to fix”. [1]
Table2.1: Reliability labels [42]
2.4.2 Hospitals are high risk organization
The influential report of the Institute Of Medicine documented the existence
of risks in American hospitals. The report estimated the number of deaths per year
20
due to occurring adverse events is around a minimum number of 44.000. Then they
compared this figure to other numbers of deaths due to diseases, car accidents, and
commercial aviation accidents that happened per year. They found that death due to
medical errors were significantly higher. A recent systematic review confirms a
widespread problem in patient safety issues at hospitals not only in the US but also
in many hospitals around the globe, where one researcher summarized nine relevant
studies from seven countries:
There were many other studies on the same topic, which might have been
biased due to difficulty in reporting because of fear of increased medical litigations,
lack of clear definitions about adverse events and resources, unclear benefits, blame
culture and other aspects that characterize the medical organization. These adverse
Table 2.2: Relevant studies on adverse events in hospitals [44]
Figure 2.3: Average Rate per Exposure of Catastrophes and Associated deaths in various
industries and human activities [43]
21
events are costly due to litigations not to mention the significant human and
economic cost which is unacceptable.
Altogether these studies demonstrate that Hospitals are “high–risk
organizations” and actions need to be taken to reduce if not eliminate adverse
events. [44]
2.4.3 Are hospitals Highly Reliable Organization?
As proved before, healthcare institutions are, like HROs, classified under
“high-risk organizations” [44]. But are hospitals acting like highly reliable
organizations?
Many researchers have found multiple gaps in healthcare organizations
regarding the HRO concept. IHI focused on reliability of processes in healthcare and
found four common “themes” that kept hospitals at "low reliability organizations"
level:
- Current improvement methods in healthcare are excessively
dependent on vigilance and hard work.
- The current practice of benchmarking to mediocre outcomes in
healthcare gives clinician and leaders a false sense of process
reliability.
- A permissive attitude toward clinical autonomy creates and allows
for wide, and unjustifiable, performance variation:
- Processes are rarely designed to meet specific, articulated reliability
goals. [42]
Another research about the gaps in Healthcare performance was led by the
joint commission team M. R. Chassin and J.M. Loeb, where they compared the five
principles of Weick and Sutcliffe HRO model to the current performance of
22
Healthcare organizations; they concluded that typical hospitals are far from the state
of high reliability, moreover healthcare institutions act as the opposite of every
single principle of the concept
First principle: preoccupation with failure: although deadly, adverse events
are rare in healthcare and, this fact tend to reinforce belief that hospitals safety
systems are adequate, so this complacency will prevent medical teams to detect
small signs of failures which might lead to bigger failures or problems, as opposed to
HRO.
Second principle: reluctance to simplify: trying to simplify complex processes
such surgical process will not eliminate the problem like wrong site surgery on the
contrary it will lead to ignore the risks that may be introduced to it.
Third principle sensitivity to operations: in healthcare, staff in all levels
routinely observes unsafe conditions, behaviors, and practices such poor
communication during handoffs, intimidating behaviors and medical devices
alarms, failing to report these problems to seniors will lead to much bigger problem
like adverse and even sentinel events, in contrast to what happens in HROs.
Fourth principle: commitment to resilience: in hospitals, errors and unsafe
conditions aren’t recognized earlier, they are not seen as valuable information,
essential to a hospital ability to improve patient safety.
Fifth principle: deference to expertise: in hospitals multiple hierarchies
dominate the authority structures. Unlike HRO (where they migrate the decision
making up and down in search for the most experienced and knowledgeable person)
there’s a “fallacy of centrality” that dominate the scene in healthcare institutions
especially with seniority. This mindset is particularly risky for organizational leaders
because it encourages the risky belief that “no news is good news.” [1]
23
Other studies compared the social climate or the so called safety climate of a
hospital with a well-known HRO (naval aviation), that was achieved through safety
climate surveys, where they found that hospitals’ staff reported the presence of
unsafe climate three times more than the aviation's personnel. Assuming that safety
perception is a relevant indicator for HROs, the results reveal that the most sensitive
and critical areas of the hospital still need a lot of effort to reach HRO status.
Moreover some researchers showed that a considerable number of hospitals don’t
use the available Incident Reporting System nor they do analyze the incidents
occurring, unlike HROs. [44]
the social-cultural analysis done by Amalberti to find whether hospitals or
healthcare organizations could become ultra-safe systems, found five “systemic”
barriers that prevent hospitals from becoming Highly Reliable Institutions. [44]
- The first barrier refers to the fact that, in hospitals, the principle and
practice of ‘‘limitations on maximum performance’’ is hardly
accepted.
- Second barrier relates to the ‘‘resistance to abandon professional
autonomy’’ by healthcare professionals.
- Third barrier relates to the resistance to the ‘‘transition from the
mindset of craftsman to that of an equivalent actor.’’
- Fourth barrier results from the ‘‘tendency of healthcare workers to
protect themselves at an individual level’’.
- Last barrier comes from the ‘‘perverse effect of excellence’’. [44][45]
24
Figure 2.4: a strategic view of safety in healthcare [45]
2.4.4 From concept to implementation
The examples provided by aviation, nuclear power, military and public safety
industries have remarkable records of safety that are obtained thanks to the adopted
strategies such the High-Reliability Organizations concept, even though they are
hazardous industries and are classified under “high-risks organizations”. [44]
As a “high-risk organization”, there are multiple attempts to implement HRO
concept into healthcare. As mentioned earlier, healthcare is somewhat unique
compared to these other industries. In healthcare, adverse events can happen
frequently and may affect single patients rather than a large group. Organizations
need to be structured in such a way as to support various safety processes, and
safety must be an organizational goal to them. [44][46]
Although the strategy to implement the HRO concept into healthcare is hard
and may not be successful [44], yet its adoption is increasing. Thomassen et al.
indicated that a checklist approach would be useful in reducing risk [47]. Other
25
researchers focused on training methods such as reliability teams training [48], while
some provided a narrative approach that documented the implementation of HRO
concept in two facilities [49]. Many studies gave practical applications to transform
processes into more reliable ones [42], while other focused on the role of leadership
and the establishment of a fair and just culture [50]. Weick and Sutcliffe provided
“audits and scales that examine the degree to which organization is acting like HRO
and gave some general advice on how to improve, and Reason gave similar
assessment tools, and adapted it for healthcare [1]. The Lucian Leape Institute
suggested that to become safe, effective, and highly reliable, institutions must
implement five major transforming concepts that are considered the essential core of
transformation. These concepts are: transparency, integrated care platform, patient
engagement, joy and meaning in work, and medical education reform [51].
The Institute for Healthcare Improvement (IHI) proposed a multiple steps approach,
where acute health settings should implement in order to achieve high reliability,
this approach will differ between hospitals depending on the development stage of
each of them [52].
Chassin and Loeb introduced an interesting assessment tool called “the High
Reliability Healthcare Maturity Model”. It is a framework derived from the
integration of High-Reliability science and the Joint Commission experience with
thousands of healthcare institutions that JCAHO accredits, and some studies that
showed how some hospitals have started to adopt high-reliability concept to their
work. They explored three major changes healthcare organizations need to
undertake in order to make an important move toward high-reliability:
1- The leadership’s commitment to the ultimate goal of zero patient harm.
2- The incorporation of all the principles and practices of a safety culture
throughout the organization.
26
3- The widespread adoption and deployment of the most effective tools and
methods. [1]
These different approaches revealed that there’s still no clear road-map that
organizations can use or implement to seek and achieve High reliability.
2.4.4.1 Leadership commitment
2.4.4.1.1 Hospitals board
Two major events (the 2002 Sarbanes Oxley legislation and the US Institute Of
Medicine reports on medical errors and healthcare quality published in 1999 and
2001) shifted hospitals boards from focusing their talents and energies only to
financial issues (fund-raising, capital expenditures, and operating margins) and
made pressure toward improving quality and safety in hospitals.
Before, the board’s efforts toward quality and safety were more form than
function. First the appointment of board members was an honor, a recognition and
reinforcement of community, they were chosen for their attributes and not their
knowledge. Second due to the rapid change and the technology intensive industry
boards hire managers with high level of education and expertise. Finally the unique
relationship between medical staff and the hospital conspired to keep boards away
from direct oversight of clinical care.
The specific duties of boards are often ambiguous and may vary, there’s a
general consensus on the following broad governance responsibilities:
- Formulate organization mission and key goals
- Ensure high levels of executive performance
- Ensure high quality of care
- Ensure high quality financial management
A board exercising the duty of care must consider quality and patient safety
in all of its decision, obligations under this duty require the board to circulate
27
written bylaws or process to ensure that medical staff is accountable to the
governing body for the quality of care provided to patients. The oversight activities
for hospital commitment toward quality and patient safety require discussing,
investigating, monitoring performance and allocating sufficient resources. Due to
lack of knowledge in clinical aspects, the capacity of the board to be effective in this
role hinge in large part on functional relationship with the medical staff and a robust
system to monitor quality of care. [53]
2.4.4.1.2 Physician involvement in quality and patient safety
The growing pressure to address quality and safety problems has increased
interests in physician-board collaboration.
In order to create a quality and patient safety improvement that is
meaningful, measurable and manageable the board requires technical and adaptive
work and a combination of business acumen, clinical knowledge, and courage.
Physician involvement not only essential in the technical work of improvement
(which include identifying known solutions to performance problems, ensuring
patients reliably receive evidence-based therapies, and monitoring performance), but
also to adaptive work, which involves changing attitudes, beliefs, and behaviors
needed to provide high-quality and safe patient care. The board cannot successfully
address adaptive challenges, unless individual physicians and medical staff leaders
work cooperatively with them through appointing them to leadership roles or by
participating in hospital committees and medical staff meetings [53] also in strategic
planning, policymaking, and related governance activities. Through involvement in
governance, physician leaders can shape the hospital's quality vision and directly
influence decisions about implementation and cost-quality trade-offs. Physician
involvement in governance may not only improve communication among
physicians, managers, and boards, but may also build trust by assuring clinical staff
that their professional values and goals are represented in policy decisions. [54]
28
2.4.4.1.3 Top management commitment
Although physicians are independent body of the hospital still they are
sensitive to the message that they are communicated by hospital management.
Physicians may respond more positively to quality initiatives when Top
management shows on the field that the hospital is committed to providing high-
quality medical care. Leading by example, senior managers build credibility and
trust with clinical staff, which in turn, may spur greater clinical involvement in
quality. Further, by creating a corporate culture for quality, senior managers may
encourage clinical staff to initiate or participate in quality improvement projects. [54]
2.4.4.1.4 Recommended Governance Practices for Quality Improvement and Patient
Safety
Most of researches related to the board focused on their attributes and
structural elements: size of the board, composition including the existence of
physician board members, board orientation and the ongoing education for the role
and a prior experience. However, in complex organizational systems such hospitals
the increasing researches suggest that board interconnect with hospitals leaders and
medical staff members, who perform in a mutually reinforcing and systemic
manner. Governance of quality and safety in hospitals continues to be shaped by a
combination of scant but growing evidence and tacit knowledge for structures and
functions that seem to be effective at improving quality. Some of the most widely
accepted practices include:
Table 2.3: Hospital leadership roles for quality and patient safety [52]
29
1- Board should have a separate quality and patient safety committee that
meets regularly and report to the full board. Evidence suggests boards that
have such a committee their hospitals may have better outcome.
2- Board should ensure the existence and annual review of a written quality
improvement and patient safety plan that reflects system thinking and
contains valid empirical measures of performance. Physician interested in
leading quality and safety efforts or growing toward a governance role
should ask to see the plan and contribute to it.
3- Boards should have an auditing mechanism for quality and safety data, like
the financial data processing
4- Boards should routinely hear stories of harm that occurred at the hospital,
putting a face on the problem of quality and patient safety.
5- Board should base compensation for the CEO on achievement of measurable
improvement targets for key responsibilities including quality of care and
patient safety.
6- Like CEO and medical staff, board should identify specific, measurable, valid
quality indicators consistent with strategic goals and hospital services, the
indicators should be reviewed quarterly and it include:
a- Regular quantitative measurement against benchmarks
b- Reported compliance with rigorous data quality standards
c- Performance transparency
d- Methods for active intervention to improve care:
i. Survey of quality and safety culture
ii. Use of survey results to shape improvement efforts
iii. Routine mechanism to tap the wisdom of bedside caregivers.
[53]
30
2.4.4.1.5 Leadership commitment to Information Technology:
Chassin and Loeb mention that “IT plays a major role to an HRO, it is
frequently the vehicle by which nearly perfect process sustain their performance. If a
process has been so effectively redesigned as to be highly reliable, automating it is
the most effective way to maintain it in that state”[1]. Automation should be applied
wisely because when deployed in an unsafe manner and without the proper
integration with the existing medical devices along with poor planning, it can
increase the risk to: first produce harm to patients and second create resistance from
staff to use this new technology [1] [55]. So hospitals seeking high reliability status
should consider an IT solution that provides a coordinated and well integrated
manner following the principles of safe adoption. [1]
2.4.4.2 Safety culture
The Advisory Committee on the Safety of Nuclear Installations define safety
culture as: “The safety culture of an organization is the product of the individual and
group values, attitudes, competencies and patterns of behavior that determine the
commitments to, and the style and proficiencies of, an organization’s health and
safety programmes. Organizations with a positive safety culture are characterized by
communications founded on mutual trust, by shared perceptions of the importance
of safety, and by confidence in the efficacy of preventive measure”. [57]
31
Pantakar and Sabin defined safety culture as “a dramatically-balanced,
adaptable state resulting from the configuration of values, leadership strategies, and
attitudes that collectively impact safety performance at the individual, group, and
enterprise level”. [57]
Ron Westrum identified three kinds of safety culture: (1) Generative – the
desired state, characterized by deep learning; (2) Pathological – the worst state, with
the organization taking minimal efforts to keep ahead of the regulator; and(3)
Bureaucratic – the middle and most common state, where procedural partial fixes
outnumber systematic solutions [58]. Patrick Hudson extended Westrum’s
classification into five stages of safety culture [59], with the most difficult step
according to Reason and Hobbs being the move from the penultimate stage to the
ultimate, desired stage:
• Pathological (“who cares as long as we don’t get caught”)
• Reactive (“safety is important; we do a lot every time we have an
accident”).
• Calculative (“we have systems in place to manage all hazards”)
Figure 2.5: Pantakar safety culture pyramid [57]
32
• Proactive (“we work hard on the problems we still find”)
•Generative (“we know that achieving safety is difficult; we keep
brainstorming new ways in which the system can fail and have contingencies
in place to deal with them”). [60][61]
Figure 2.6: The safety performance will improve as the culture matures, but there can only start
to be talk of a Safety Culture once the calculative stage has been passed[59]
In order to achieve this type of culture (that will help reduce errors)
leadership must instill a clear, supportive culture that nurtures individual efforts.
[62] James reason argued that in order for institutions to reach this level it must have
an informed culture [63], the components of an informed culture are: reporting
culture, just culture, learning and a flexible culture. [23]
33
Figure 2.7: Safety culture ladder [61]
2.4.4.2.1.1 Reporting culture
Since safety cultures are dependent on the knowledge gained from rare
incidents, mistakes, near misses, and other “free lessons,” they need to be structured
so that people feel willing to discuss their own errors. A reporting culture is about
protection of people who report (this is also a provision of a just culture). It is also
about what kinds of reports are trusted. Without knowing what is going on,
hospitals have no idea how safe it is for the patient to be there, no idea how to take
corrective action, no learning, and a high risk that it will happen again. [23]
2.4.4.2.1.2 Just culture
Reporting system will not be achieved unless there’s an environment of trust
and that is provided by a just culture. [63]
34
“A culture of safety crucially requires the creation of an open, free, non-
punitive environment in which healthcare professionals can feel safe to report
adverse events and near misses.” [64] An organization is defined by how it handles
blame and punishment, and that, in turn, can affect what gets reported in the first
place [23]. A just culture is described as “an atmosphere of trust in which people are
encouraged, even rewarded, for providing essential safety-related information—but
in which they are clear about where the line must be drawn between acceptable and
unacceptable behavior [65][66].”That is crucial because it separates unacceptable
behavior that deserves disciplinary action from acceptable behavior for which
punishment is not appropriate and the potential for learning is considerable. It is
impossible to do away with such a line altogether because [23] “a culture in which
all acts are immune from punishment would lack credibility in the eyes of the
workforce.” [63]
2.4.4.2.1.3 Learning culture
The organization and its members are able to observe weaknesses and errors,
reflect on the causes, create effective solutions to address them, and act on
implementing and institutionalizing the solutions. [23]
2.4.4.2.1.4 Flexible culture
Is one that adapt to changing demands. James reason equates flexibility with
the shifting authority structures that was discussed by Weick and Sutcliffe as the
fifth principle of mindfulness, which is deference to expertise where the information
tends to flow more freely when the hierarchies are flattened and rank defers to
technical expertise. [23]
35
Finally the progress toward these elements of a culture should be measured,
this is done through safety culture surveys and it is used by many hospitals to assess
their status but few analyze the content of the surveys data in order to detect the
missing parts that will help to improve hospital performance regarding safety. In
order to progress toward high reliability, hospitals should integrate safety culture
metrics as a part of their strategic plan, and to set goals to improve those metrics and
to report them to the board like they do concerning the metrics of the financial
performance. [1]
2.4.4.3 Process improvement
Many researches done concerning quality improvement programmes led to
the conclusion that there’s little evidence any of the large scale quality programmes
(total quality management, continuous quality improvement, and PDCA approach)
brings significant benefits or is worth the cost [67]. Moreover other researches
yielded that these tools were largely ineffective in solving clinical safety and quality
problems. [68]
To Move healthcare institutions toward high reliability organizations,
maintaining a highly reliable process is a must, especially in their clinical aspect.
Chassin and Loeb suggested that in order for hospitals to achieve this state in their
clinical processes they should adopt a new generation of industrial quality methods
and apply them to all issues of clinical safety and quality. The suggested “new
approach” is a combination of many quality tools: Six Sigma, Lean management and
Change management, then they gave the name “Robust Process Improvement” to
these collections of tools; this instrument helps hospitals in dissecting complex safety
problems and guides them to deploy highly effective solutions. [1]
36
2.4.4.3.1 Six Sigma
Six Sigma was developed in the mid-1980s at Motorola as an improvement
concept that focused on reduction of errors by establishing aggressive goals for
quality. Six Sigma measures quality in terms of defect rates and sets a target error
rate of no more than 3.4 defects per million opportunities, or 6 standard deviations
from the process mean, it mainly focus on reducing variability by using a tightly
controlled process [69]. More recently, this quality concept was applied in financial,
healthcare, engineering and construction, as well as the research and development
sectors.
It uses the DMAIC methodology (Defining, Measuring, Analyzing,
Improving and Controlling).
The healthcare principle of zero tolerance for mistakes and the potential for
reducing medical errors are well matched with the SS principles. [70]
Figure 2.8: Six Sigma[70]
37
2.4.4.3.2 Lean Management
The basic Lean concepts are: the relentless elimination of waste through the
standardization of processes and the involvement of all employees in process
improvement. Lean can be described as a set of principles and techniques that drive
organizations to continually add value to products or services by enhancing process
steps that are necessary, relevant, and valuable while eliminating those that are not.
In recent years, Lean has been adopted by various service sectors, such as healthcare
institutions. With the continued increase in healthcare costs, many process
improvement methodologies have been proposed to address inefficiencies in
healthcare delivery; Lean is one such method. [70]
2.4.4.3.3 Lean and Six Sigma
Since Lean is an approach that seeks to improve flow by eliminating all forms
of waste, the process identifies the least wasteful way to provide value to customers.
Meanwhile, SS uses a powerful project management framework and statistical tools
to identify root cause variation to avoid jumping to solutions. A pragmatic approach
can therefore be taken, picking the best bits of each approach. Hence, Lean and SS,
both of which provide a systematic method to facilitate incremental process
Table 2.4 : Comparison between the two concepts: Six Sigma and Lean[69]
38
improvement, have been successfully integrated by companies at a strategic and
operational level across the whole value stream. Several studies in healthcare
showed the significant importance of the implementation of LSS tool in terms of
efficiency, productivity, quality, and enhancing medical processes. [70]
2.4.4.3.4 Change management
Moving hospitals toward highly reliable organizations is a systematic
approach that needs to be done smoothly and within the frame of a given plan,
because every unplanned change cannot be effective and might face a lot of
resistance from staff and eventually suffer failure.
The Management of change is all about handling the complexity of the
process. It is done by evaluating, planning and implementing operations, tactics and
strategies, then making sure that the change is worthwhile and relevant. There are
Figure 2.9: A conceptual framework of LSS methodology[70]
39
several models and theories on how to conduct change; adopting the right model
depends on several factors, including how resistant the organization is to change.
Adopting a structured approach is also beneficial to switch hospitals into high
reliability organization as the approach will move organizations from being
resistance to change to providing a solid framework for engaging involved
employees. To avoid failure organizations should also have a top management
commitment toward change, a wide integration with other systems and processes, a
well-conceived implementation plan and a clear established vision about the
direction of the change process. We must not forget that measuring and monitoring
the outcomes is essential for recognizing whether or not the process of change has
fulfilled its purposes. [71][72][73]
2.5 CONCLUSION
“High reliability Organizations” is an interesting concept, that the near future
will reveal its capacity to make radical changes in Healthcare performance
(regarding safety and quality), and whether or not it will be the cure for adverse and
sentinel events that are pandemics ravaging hospitals around the world. It’s up to
the institution’s leaders to grasp this promising concept and disseminate it into their
own organizations, since researches have already shown that without commitment
from top managements or leadership, this concept will stay on book shelves and in
articles and will never see the light of implementation. It is up to every leader to
think of the positive aspects of implementing this concept (from points of view of:
efficiency, reputation, patient safety, and quality) and how it can help hospitals ease
the enormous pressure they lie under.
There’s still no clear guideline that healthcare institutions can follow to
achieve the HRO state, that’s why every hospital should apply the most suitable
40
model for its own situation, taking into consideration the internal and external
factors or environments that surround each institution.
41
CHAPTER 3
RESEARCH DESIGN AND METHODOLOGY
3.1 INTRODUCTION
This chapter discusses the research design and the methodology used to
perform this study. It describes the procedure of data collection, targeted sample,
and the instrument used to collect the required data. It also explains in brief the
facilities where the survey was conducted.
3.2 RESEARCH DESIGN
The explorative descriptive survey technique is used in this research. The
researcher used this technique instead of collecting data on safety indicators due to
the rejection of the majority of hospitals’ administrations to provide this kind of data,
because for them adverse events and sentinel events are deemed classified. This
method was also preferred because the used variables aren’t subject for experimental
manipulation. The data collected through-out the survey will contribute in
developing a consensus about the concept of High Reliability Organization, and lead
the way toward revealing the absence or the presence of gaps in the healthcare sector
based on the mentioned concept.
The descriptive approach is used to determine frequencies and other
statistical calculations. Often the best approach, prior to writing descriptive research,
is to conduct a survey investigation.
42
3.3 RESEARCH METHOD
A quantitative approach using a descriptive design was proposed for this
study. A Questionnaire was used as a data collection tool. The questionnaire was
distributed on three hospitals located in Beirut. Every employee who’s related to
patient safety was targeted, such as: Registered Nurses, Medical Lab Technologists,
X-ray Technicians, Pharmacists, Physicians, managers (lab and floors), and Heads of
departments when possible.
The questionnaire contains a clear justification of the purpose of the study
and a notification about confidentiality and anonymity of participants.
Before the researcher started collecting data, he got an acceptance form signed
by the Lebanese University – Faculty of Sciences – Hadath Branch represented by Dr.
Jamal Charara and Gates group represented by Mr. Adel Olleik, so that he could
contact hospital administrations formally. This form was a facilitator to complete the
researcher’s thesis requirements, and was submitted along with a copy of the
proposal to the IRB committee of Hospital A, and was submitted along with a copy
of the questionnaire to hospitals B and C’s administrations.
3.4 DATA COLLECTION AND INSTRUMENTATION
Data was collected through conducting a questionnaire survey with coded
questions. The coded questions follow the rule of Likert scale. The questionnaire was
mainly quoted from the Joint Commission team: Chassin and Loeb article “Getting
there from here” and more precisely from the proposed High- Reliability Health
Care Maturity Model framework (the “approaching phase” of the framework) [1],
and spiced with the AHRQ HSPSC survey on safety culture. [74]
The research tool (questionnaire) consists of 25 items measuring 14
components that cover three domains. All of the survey’s questions are short, close
43
ended, and elaborated using simple, easy to understand English. To ensure the full
understanding and cooperation of participants, the researcher made an Arabic
version of the questionnaire. The first three items relate to the background of
participants such as: profession, current experience in the surveyed facility, and
work hours. Answers to questions number 4 till the end are standardized following
the five points Likert scale (strongly disagree, disagree, neither, agree, and strongly
agree) and aim to explore the perception of participants toward the three domains of
the questionnaire: commitment of the top management, safety culture and the
existence of a Robust Process Improvement (according to Chassin and Loeb these are
the components to seek high reliability in healthcare). The answers also serve to
assess, through findings, the existence of gaps in the surveyed facilities (see
Appendix C).The percentage of Positive answers from the Likert scale questions
were calculated by the summation of percentages of "Strongly Agree" and "Agree"
categories.
An introductory page was used in the beginning of the questionnaire to
identify the researcher and the purpose of the project, and to assure the
confidentiality and anonymity of the participants. Each participant was instructed to
read carefully, understand the content and then start filling the questionnaire. They
were made aware of their right to refuse participation and their opinions were
respected.
The acceptance form and a sample of the questionnaire are attached in the
Appendix.
Appendix B: the acceptance form.
Appendix C: the questionnaire form.
44
A pilot testing phase was done for Arabic and English versions of the
questionnaire prior to data collection to ensure the validity and reliability of both
versions.
3.5 POPULATION AND SAMPLING DESIGN.
From the 120 hospitals covering the majority of the Lebanese territories, the
researcher chose only three to apply his tool on. He distributed his questionnaires on
568 participants (targeted population), around 300 employees replied over a period
of 2 months, where he paid weekly visits to encourage non responders to fill the
questionnaire. Due to lack of time the researcher collected only 300 questionnaires
(response rate of 52 %) to conduct his analysis on, and detect where there’s existence
of gaps in the Lebanese healthcare institutions regarding the high reliability
organizations concept and eventually answer his main hypothesis question.
3.6 SAMPLE OVERVIEW
The researcher chose the Beirut district because the most important healthcare
institutions are localized in it. The questionnaires were distributed in three different
types of hospitals which represent a small example of the different sectors of existing
healthcare institutions in Lebanon:
Hospital A a 200 bed non– profit private university hospital, ISO and MOH
accredited. Number of participants: 128
Hospital B a 500 bed Governmental university hospital, accredited by MOH.
Number of participants: 148
Hospital C a 40 bed Private for profit Hospital. Number of participants: 20
The targeted population was chosen because of its involvement in safety
issues and more precisely patient safety. Participants are from different specialties
45
and working in different places of the hospitals, they are mainly: nurses, medical lab
technologists, pharmacists, X-Ray technologists, lab managers, nurse managers, lab
and pharmacy directors, and also physiotherapists.
.
3.7 SAMPLE DESCRIPTION
The sample of 300 participants was formed of: 60 % registered nurses, 20 %
lab technologists, 5 % managers, 5 % pharmacists, 3 % midwives, 3% X-Ray
technologists, 2% resident physicians, 1% physiotherapists, 1 % heads of
departments. Participants have had the following work experience in their current
positions: 4 % less than one year of experience, 30 % between one and five years of
experience, 40 % between six to ten years of experience, and 26 % have had eleven or
more years of experience. As for work hours: 55 % work 40 hours per week, and 45
% work above 40 hours per week, and there were no part timer included. The
4%which represent participants that have an experience of less than one year was
considered ineligible and was eliminated from the sample because they represent a
category of fresh graduates and newcomers and their judgments aren’t quite mature
about policies and procedures that exist in the targeted institutions.
3.8 DATA ANALYSIS
As in any survey, and in order to analyze the data, a conceptual framework
must be built. Therefore the SPSS 20.0 for windows (Statistical Package for Social
Science) was the software chosen for the analysis, as for the chart drawing the
Microsoft Excel program was used.
One type of analysis was conducted on the data in order to explore the view
of employees from different backgrounds and experiences, concerning top
46
management commitment to safety, safety culture, and the existence of Robust
Process Improvement in their hospitals.
3.8.1 Descriptive analysis
Since descriptive statistics is usually the main discipline for quantitatively
describing the features of data collection, descriptive analysis was the only method
used to arrange and order the data into a form that will render it easier to
understand and analyze. The main test performed to detect gaps in the targeted
hospitals was the frequency determination. Also a Cross tabulation was performed
to detect the relationship between the independent variable that is leadership
commitment and the rest of the questionnaire dependent variables.
3.9 LIMITATIONS
In this research, the researcher faced many obstacles, but they neither affected
the validity nor the reliability of the obtained results.
First, Lack of transparency led the researcher to change the data collection
instrument from a simple collection of safety indicators to a 25-items questionnaire.
This type of social and behavioral research particularly one that includes self-reports
such as surveys, is subject to "Common Method variances" or CMV. Some items of
the questionnaire were considered by many of the participants complex and
ambiguous, which drove some of them to develop their own understanding of these
items. This may either increase random responding or increase the probability of
respondents to use their own response tendency, such as affectivity. That led to
diverting the results from their core purpose. In an attempt to resolve this issue the
researcher made several control steps to decrease the CMV effect on the study such
as:
- Using simple English and short questions
47
- Translating the questionnaire to Arabic to eliminate the complexity
and ambiguousness issue.
- Requesting that participants stick to existing policies and procedures
at the targeted hospitals in order to diminish the affectivity issue.
- Ensuring the confidentiality and anonymity of participants
Second, From a small sample of 300 participants -which represents around 2.5
% of the total number of employees that work in the healthcare sector- and three
hospitals- which represent also 2.5 % of the total number of Lebanese hospitals- we
simply cannot generalize the results of this study.
Another constraint was the shortage of time, knowing that the researcher
works a double shift, and he didn’t have enough days off to effectively conduct the
data collection.
Last, Many healthcare institutions rejected to participate in this study because
the topic was a taboo for them, especially that it circle’s around the patient safety
issues and indirectly deals with the problems of adverse and sentinel events.
Hospital C accepted to conduct the survey in its facility but under the
condition that an insider from the hospital would distribute the questionnaire and
not the researcher himself. That was considered a major constraint, and findings
from this hospital are doubtful.
48
CHAPTER 4
RESULTS AND DISCUSSION
4.1 OVERVIEW
This chapter will start off the discussion by identifying the participants, and
describing their current experiences and work schedule. It will then go in depth by
carefully explaining and detailing each question and its purpose, then provides the
corresponding results and data that will reveal the existence or absence of a gap. The
results will be displayed by hospital and by the whole sample. The criteria relied on
to detect the presence of a gap, were quoted from AHRQ’s HSPOS, where a cut-off
above 75 % is considered as a point of strength for the hospital.
A cross tabulation performed using Chi-Square between the independent
variable (question 4: management commitment toward zero harm for patient) and
the rest of the variables (only with the Likert scale questions), will be shown to
confirm the relationship hypothesized by the literature about the leadership
commitment and its positive effect on the different aspects of the hospital, including
the hospital safety culture and the process improvement.
In conclusion the 21 questions related to the topic will be summarized in a table that
will detail the results for each hospital and for the whole sample, thereby clarifying
the existing gaps.
49
4.2 RESULTS AND FINDINGS
1. What is your staff position in this hospital? Select ONE answer that best
describes your staff position.
This statement was used to determine the participants’ occupation, in order to
observe the hospital’s staff perception on the several composites of the questionnaire
from different specialty points of view. Employees were mainly divided as shown in
the chart:
a. Registered Nurse i. Manager
b. Respiratory therapist j. Physical Therapist
c. Medical lab Technician
d. Midwife
e. Department chairman k. Other, please specify:
f. Resident Physician
g. Pharmacist
h X-ray technician
Figure 4.1: distribution chart of participants by profession
60%
2%
5%
1%
20%
3%5%
1%
3%
Distribution of participants by Profession
Registered Nurse
Resident Physician
Pharmacist
Physical therapist
Lab technologist
Midwife
Manager
Dept chairman
X-ray technologist
50
2. How long have you worked in this hospital?
a. Less than 1 year d. 11 or more years
b. 1 to 5 years
c. 6 to 10 years
This question aimed to assess the current experience level at the targeted
hospitals. its purpose was to know the degree of hospitals’ employees’ knowledge of
policies, procedures, and rules and regulations related to safety issues. The
participants that belong to the category “less than 1 year” were later eliminated from
the sample. The distribution of employees was as follows:
< 1 year 1 to 5 years 6 to 10 years ≥ 11 years
Hospital A 11 48 20 49
Hospital B 0 31 95 22
Hospital C 2 9 3 6
3. Typically, how many hours per week do you work in this hospital?
a. 20 hours or less per week
b. 21 to 40 hours per week
c. more than 40 hours per
week
This question aimed to detect the weekly schedule of participants.
Employees, who work less than 20 hours per week, were considered part timers who
didn’t fit the selection criteria, and were eventually deemed ineligible. The
distribution of employees was as follows:
51
< 20 hours/week 21 – 40 hours/week ≥ 41 hours/week
Hospital A 0 69 48
Hospital B 0 72 76
Hospital C 0 13 5
Question 4: Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
Hospital management commits to the goal “zero patient
harm” for all clinical services………… 1 2 3 4 5
This question aimed to detect the hospitals’ top management’s commitment
toward the goal of zero harm to patients, the participants answers were distributed
as follows:
0% 20% 40% 60% 80% 100%
Hospital A
Hospital B
Hospital C
Overall
2%
7%
4%
13%
14%
13%
25%
16%
11 %
20%
45%
50%
50%
48%
15%
13%
39%
15%
Strongly Disagree
Disagree
Neither
Agree
Strongly Agree
Figure 4.2: distribution chart for "top management commitment for zero
patient harm goal"
52
0% 20% 40% 60% 80% 100%
Hospital A
Hospital B
Hospital C
Overall
3%
7%
5%
13%
22%
17%
19%
10%
5%
13%
55%
53%
67%
55%
10%
8%
28%
10%
Strongly Disagree
Disagree
Neither
Agree
Strongly Agree
From hospital A, 60 % of participants gave positive answers, from hospital B
63 % gave positive answers, and from hospital C 89 % gave positive answers. In
general 63 % of participants gave positive answers for this question. The results
reveal either that there's no real commitment from top management for "zero patient
harm" goal, or that this goal doesn't exist. Eventually hospital A, B and the whole
sample represent a gap concerning this issue.
Question 5: Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
Hospital management provides a work climate that promotes
patient safety……………………………………………………………… 1 2 3 4 5
This question aimed to observe Hospitals management abilities to provide a
climate that helps enhance patient safety (work schedule, work load, staffing),
results indicated the following:
Figure 4.3: Chart distribution for "top management provide a climate for
patient safety"
53
From hospital A, 66% of participants gave positive answers, from hospital B
61% gave positive answers, and from Hospital C 94 % gave positive answers. In
general 65 % of participants gave positive answers. Hospitals A, B and the whole
sample results show that top management is not consistently providing a climate
that promotes patient safety. Eventually findings for these institutions represent a
gap concerning this issue.
Question 6: Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
The actions of hospital management show That
patient safety is a top priority ................................................................... 1 2 3 4 5
Question number 6 aimed to detect the opinion of participants toward the
top management actions, if they do reflect a great interest in patient safety issues or
not. The results were as follows:
0% 20% 40% 60% 80% 100%
Hospital A
Hospital B
Hospital C
Overall
1%
4%
3%
11%
13%
12%
19%
19%
6%
18%
49%
51%
55%
50%
20%
13%
39%
17%
strongly disagree
disagree
neither
agree
strongly agree
Figure 4.4: Chart distribution of "Action of hospital management show that
patient safety is a top priority"
54
From hospital A, 69 % of participant gave positive answers, from hospital B
64 % gave positive answers, and from hospital C 95 % gave positive answers. In
general 67 % of participants gave positive answers for this question. Hospitals A, B
and the whole sample show that participants don’t completely agree with top
management actions that reflect a great interest in patient safety. Eventually a gap
exists in these institutions concerning this issue.
Question 7: Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
Quality is considered as the organization’s highest
priority 1 2 3 4 5
This question aimed to assess the hospitals’ managements’ consideration of
quality as the highest priority. This issue was meant to be evaluated by the
participants through policies and procedures related to quality, and implemented by
top management. The results for this question were as follows:
0% 20% 40% 60% 80% 100%
Hospital A
Hospital B
Hospital C
Overall
4%
6%
5%
16%
12%
13%
24%
20%
11%
21%
46%
46%
50%
46%
10%
16%
39%
15%
Strongly Disagree
Disagree
Neither
Agree
Strongly Agree
Figure 4.5: chart distribution of "hospital management consider quality
as a top priority"
55
From hospital A, 56 % of participants gave positive answers, from hospital B
62 % gave positive answers, and from hospital C 89 % gave positive answers. In
general 61 % of participants gave positive answers. Hospitals A, B and the whole
sample Results show that top management also doesn't perceive quality as a top
priority. Eventually a gap exists in these institutions concerning this issue.
Question 8: Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
Physicians are involved in improving the quality of services in the
hospitals through the uniform participation in quality
improvement activities……………………………………………… 1 2 3 4 5
This question aimed to detect the physicians' participation in various quality
committees formed by hospitals. Wide participation from physicians is known to be
essential to the enhancement of quality and safety (through the reduction of
autonomy, and the adoption of evidence-based medicine). The results for this
question were as follows:
0% 20% 40% 60% 80% 100%
Hospital A
Hospital B
Hospital C
Overall
3%
5%
4%
9%
16%
6%
12%
40%
23%
11%
29%
45%
48%
61%
48%
3%
8%
22%
7%
Strongly Disagree
Disagree
Neither
Agree
Strongly Agree
Figure 4.6: Chart distribution for "physician involvement in quality
committees"
56
From hospital A, 49 % of participants gave positive answers, from hospital B
56 % gave positive answers, and from hospital C 83 % gave positive answers. In
general 55 % of participants gave positive answers. Results from Hospitals A, B and
the sample combined reveal that there's no wide participation from physicians in
quality committees. Eventually a gap exists in these institutions concerning this
issue.
Question 9: Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
Key quality indicators are announced (staff &publicly), and employees
who accomplish quality goals are fairly rewarded..............................… 1 2 3 4 5
This questions aimed to detect the degree of compliance of hospitals toward
publishing the quality indicators internally (to staff) and externally (to the public),
and the presence of a reward system which is an essential part of Libuser’s High
Reliability model. The results for this question were as follows:
0% 20% 40% 60% 80% 100%
Hospital A
Hospital B
Hospital C
Overall
13%
10%
10%
32%
29%
22%
30%
37%
19%
22%
26%
15%
39%
50%
30%
3%
3%
6%
4%
strongly disagree
disagree
neither
agree
strongly agree
Figure 4.7: chart distribution for "quality indicators"
57
From hospital A, 19 % gave positive answers, from hospital B 43 % gave
positive answers, and from hospital C 56 % gave positive answers. In general 34 % of
participants gave positive answers. Results from the three hospitals reveal that
there's no publication of indicators internally or externally (benchmarking), there's
also no reward system. Eventually a gap exists in the three institutions concerning
this issue.
Question 10: Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
All medical equipment are well integrated into the main
computer system of the hospital………………………………… 1 2 3 4 5
This question aimed to observe the integration of all medical equipments of
different clinical departments into the main hospital information system. For Highly
reliable organizations integration of equipment is a must to insure an error-free and
efficient automated process. Results for this question were as follows:
0% 20% 40% 60% 80% 100%
Hospital A
Hospital B
Hospital C
Overall
2%
3%
2%
27%
19%
44%
24%
20%
19%
17%
19%
44%
52%
39%
48%
7%
7%
7%
Strongly Disagree
Disagree
Neither
Agree
Strongly Agree
Figure 4.8: chart distribution for "medical equipment integration"
58
From hospital A, 51 % of participants gave positive answers, from hospital B
59 % gave positive answers, and from hospital C 39 % gave positive answers. In
general 55 % of participants gave positive answers. Findings concerning medical
equipment integration show that in the three hospitals, equipments aren’t fully
integrated into the main Hospital Information System. Eventually a gap exists in the
three institutions concerning this issue.
This question aimed to detect the participation of the IT department in the
implemented quality and safety policies, by providing statistical data on quality and
safety indicators to all clinical departments. Without this department involvement,
clinical areas will remain unaware of what’s happening in their own units, which
will reflect badly on process improvement and quality of services provided, then
eventually increase medical errors. Results for this question were as follows:
Question 11:
Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
IT department consistently provides clinical department
with statistical data………………………………… 1 2 3 4 5
0% 20% 40% 60% 80% 100%
Hospital A
Hospital B
Hospital C
Overall
2%
8%
6%
5%
21%
20%
61%
23%
35%
26%
17%
29%
38%
43%
17%
39%
4%
3%
0%
4%
Strongly Disagree
Disagree
Neither
Agree
Strongly Agree
Figure 4.9: chart distribution for "IT providing statistical data"
59
From hospital A, 42 % of participants gave positive answers, from hospital B
47 % gave positive answers, and from hospital C 43 % gave positive answers. In
general 43 % of participants gave positive answers. Results reveal that the IT
department in all three hospitals doesn’t consistently provide statistical data to
clinical units. Eventually a gap exists in the three institutions concerning this issue.
Question 12:
Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
High level of trust and respect exist between physicians and other
clinical staff (pharmacist, lab technologist, nurses)…… 1 2 3 4 5
This question aimed to detect the level of trust between physicians and
employees from multiple clinical departments such as: nurses, medical lab
technologists, etc….. Chassin and Loeb article specifically determined that trust
between doctors and other clinical personnel is essential to reduce errors that might
arise from intimidating behaviors. Results for this question were as follows:
0% 20% 40% 60% 80% 100%
Hospital A
Hospital B
Hospital C
Overall
1%
5%
0%
3%
24%
13%
0%
17%
26%
24%
11%
24%
40%
50%
56%
46%
9%
8%
33%
10%
Strongly Disagree
Disagree
Neither
Agree
Strongly Agree
Figure 4.10: chart distribution for "Trust between doctors and other
clinical staff"
0% 20% 40% 60% 80% 100%
Hospital A
Hospital B
Hospital C
Overall
1%
5%
0%
3%
24%
13%
0%
17%
26%
24%
11%
24%
40%
50%
56%
46%
9%
8%
33%
10%
Strongly Disagree
Disagree
Neither
Agree
Strongly Agree
60
From hospital A, 49 % of participants gave positive answers, from hospital B
58 % gave positive answers and from hospital C 89 % gave positive answers. In
general 56 % of participants gave positive answers. Findings in hospital A, B, and the
whole sample, show that a lack of trust and respect still exists between physicians
and other clinical staff. Eventually a gap exists in the mentioned institutions
concerning this issue.
This question aimed to see the hospitals’ concern with the enhancement of the
trusting environment between different medical staff. And also to see if they were
promoting this trust through policies, procedures and educational programs, in
order to prevent medical errors from occurring. Results for this question were as
follows:
Question 13: Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
Policies, procedures, and educational programs exist to
ensure a trusting environments……………………… 1 2 3 4 5
0% 20% 40% 60% 80% 100%
Hospital A
Hospital B
Hospital C
Overall
3%
3%
3%
22%
9%
6%
14%
33%
14%
11%
22%
37%
64%
72%
53%
5%
10%
11%
8%
Strongly Disagree
Disagree
Neither
Agree
Strongly Agree
Figure 4.11: chart distribution for "policies, procedures, and educational programs
for trust"
61
From hospital A, 42 % of participants gave positive answers, from hospital B
74 % gave positive answers and from hospital C 83 % gave positive answers. In
general 61 % of participants gave positive answers. Results from Hospital A, B, and
the whole sample show that a code of conduct between staff is absent. Eventually a
gap exists in hospital A and B concerning this issue.
This question aimed to determine the type of culture present in hospitals:
blame culture or just culture. An essential component of safety culture in highly
reliable organizations is the just culture. If the blame culture still dominates the
hospital, some errors will remain unreported, which also leads to a problem in the
reporting culture. Results for this question were as follows:
From hospital A, 40 % of participants gave positive answers, from hospital B
47 % gave positive answers and from hospital C 39 % gave positive answers. In
general 44 % gave positive answers. Results show that blame culture still dominates
Question 14: Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
If I report a near miss or an error I know I won’t be
punished .................................................................................................................... 1 2 3 4 5
0% 20% 40% 60% 80% 100%
Hospital A
Hospital B
Hospital C
Overall
8%
6%
17%
7%
27%
28%
33%
28%
25%
18%
11%
21%
38%
42%
33%
40%
2%
6%
6%
4%
Strongly Disagree
Disagree
Neither
Agree
Strongly Agree
Figure 4.12: chart distribution for" near miss reporting"
62
the scene of the three hospitals that means they don’t implement a just culture.
Eventually the 3 institutions represent a gap concerning this issue.
This question aimed to detect the reporting of "unsafe conditions" by the
targeted staff, it is one of the essential components of Chassin and Loeb High
reliability safety culture. Results for this question were as follows:
From hospital A, 90 % of participants gave positive answers, from hospital B
68 % gave positive answers, and from hospital C 84 % positive answers. In general
78 % of participants gave positive answers. Results for Hospital B showed that
employees don’t report near misses or unsafe conditions. Eventually a gap exists in
this institution concerning this issue.
Question 15: Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
I feel free to report near misses and unsafe conditions that might
affect patients ............................................................................................................ 1 2 3 4 5
0% 20% 40% 60% 80% 100%
Hospital A
Hospital B
Hospital C
Overall
1%
2%
18%
10%
8%
13%
17%
12%
65%
53%
55%
58%
25%
15%
28%
20%
Strongly Disagree
Disagree
Neither
Agree
Strongly Agree
Figure 4.13: chart distribution for “reporting near miss and unsafe conditions"
63
0% 20% 40% 60% 80% 100%
Hospital A
Hospital B
Hospital C
Overall
5%
3%
4%
13%
14%
13%
12%
19%
17%
16%
53%
53%
72%
54%
17%
11%
11%
13%
Strongly Disagree
Disagree
Neither
Agree
Strongly Agree
This question aimed to determine the department managers follow upon
reported near misses or errors in order to solve these issues and prevent them from
occurring again. The question was also meant to observe part of the learning culture,
another essential component of HRO's safety culture. Results for this question were
as follows:
From hospital A, 70 % of participants gave positive answers, from hospital B
64 % gave positive answers and from hospital C 83 % gave positive answers. In
general 67 % of participants gave positive answers. Results at hospital A, B, and the
whole sample show that managers don’t implement the “problem solving “part of
the learning culture. Eventually a gap exists in the mentioned institutions concerning
this issue.
Question 16: Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
Unit / dept., managers /administration work hard with the
frontline workers to resolve problems and to prevent same
errors from happening again in the future................................................... 1 2 3 4 5
Figure 4.14: Chart distribution for “resolving near misses and close
calls”
64
0% 20% 40% 60% 80% 100%
Hospital A
Hospital B
Hospital C
Overall
4%
3%
3%
12%
17%
22%
15%
23%
22%
22%
23%
54%
52%
45%
52%
7%
6%
11%
7%
Strongly Disagree
Disagree
Neither
Agree
Strongly Agree
This question aimed to see the communication of resolved near misses or
close calls to the staff in order to learn from these events and avoid their occurrences.
It can be considered as the other part of the learning culture, which is the
dissemination of solutions on personnel (especially those who reported the near
miss). Results for this question were as follows:
From hospital A, 61 % of participants gave positive answers, from hospital B
57 % gave positive answers and from hospital C 56 % gave positive answers. In
general 59 % of participants gave positive answers. Results for the three hospitals'
reveal that resolved near misses are not communicated to employees, not even those
who committed the error. Eventually the 3 institutions represent a gap concerning
this issue.
Question 17: Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
Feedback about changes (after resolving near
Misses) are routinely addressed………………………….… 1 2 3 4 5
Figure 4.15: chart distribution for “feedback about changes”
65
0% 20% 40% 60% 80% 100%
Hospital A
HospitalB
Hospital C
Overall
3%
3%
3%
7%
14%
10%
38%
20%
17%
27%
46%
55%
50%
51%
6%
8%
33%
9%
Strongly Disagree
Disagree
Neither
Agree
Strongly Agree
Question 18: Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
Policies, procedures and checklist related to patient
safety are reviewed periodically to ensure their integrity
and validity……….......................................................... 1 2 3 4 5
This question aimed to see the continuous checking or testing of the integrity
and validity of the safety net or barriers of the hospitals; so that if a breach is
detected it can be solved before it reaches the patients. This is known as the
proactive approach. Results for this question were as follows:
From hospital A, 52 % of participants gave positive answers, from hospital B
63 % gave positive answers and from hospital C 83 % gave positive answers. In
general 60 % of participants gave positive answers. Results for hospitals A, B and the
whole sample reveal that they don't usually use the proactive approach (like FMEA)
to assess their safety barriers and to prevent errors from happening. Eventually these
hospitals represent a gap concerning this issue.
Figure 4.16: Chart distribution for “checking the validity and integrity of
safety barriers”
66
0% 20% 40% 60% 80% 100%
Hospital A
Hospital B
Hospital C
Overall
5%
3%
4%
22%
15%
6%
17%
30%
22%
11%
25%
38%
54%
83%
49%
5%
6%
5% Strongly Disagree
Disagree
Neither
Agree
Strongly Agree
This question aimed to assess the perception of staff on the hospitals’ policies
and procedures: whether they can prevent errors from occurring or not. This is a
complementary question to the previous one regarding the proactive approach.
Results for this question were as follows:
From hospital A, 43 % of participants thought that the hospital has good
policies and procedures, 60 % of hospital B’s participants thought that the hospital
has good policies and procedures, 83 % of hospital C’s participants thought that the
hospital has good policies and procedures that prevent errors from occurring. In
general 54 % of participants gave positive answers. Results from hospital A, B, and
the whole sample reveal that these hospitals don't have solid barriers (system) to
prevent errors from occurring. Eventually institution A and B represent a gap
concerning this issue.
Question 19: Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
Our procedures and systems are good at preventing errors
from happening ........................................................................................................ 1 2 3 4 5
Figure 4.17: chart distribution for “the existing of systems that prevent
errors”
67
This question aimed to determine the routine assessment of the safety culture
in the targeted hospitals, whether by conducting surveys or by periodically
publishing safety indicators. These surveys and indicators usually help detect any
signs of weakness in the safety net that might lead to errors. The results for this
question were as follows:
From hospital A, 60 % of participants gave positive answers, from hospital B
52 % gave positive answers, and from hospital C 73 % gave positive answers. In
general 56 % of participants gave positive answers. Findings from the three hospitals
show that they do not assess their safety culture, nor publish their safety indicators.
Eventually the three institutions represent a gap concerning this issue.
Question 20: Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
Surveys about patient safety are performed and safety indicators
are routinely published in order to assess safety culture in the
hospital ........................................................................................................................ 1 2 3 4 5
0% 20% 40% 60% 80% 100%
Hospital A
Hospital B
Hospital C
Overall
2%
5%
3%
11%
18%
11%
15%
27%
25%
17%
26%
54%
47%
55%
50%
6%
5%
17%
6%
Strongly Disagree
Disagree
Neither
Agree
Strongly Agree
Figure 4.18: chart distribution for "Surveys and safety indicators”
68
0% 20% 40% 60% 80% 100%
Hospital A
Hospital B
Hospital C
Overall
1%
4%
3%
6%
8%
7%
17%
15%
5%
15%
62%
66%
67%
64%
14%
7%
28%
11%
Strongly Disagree
Disagree
Neither
Agree
Strongly Agree
This question aimed to detect the implementation of a safety plan in the
hospitals’ facilities, to gradually reduce harm and move toward a state of high
reliability organization. Results for this question were as follows:
From hospital A, 76 % of participants gave positive answers, from hospital B
72 % gave positive answers, and from hospital C 93 % gave positive answers. In
general 75 % of participants gave positive answers. Results reveal that hospital B
isn't implementing a safety plan in order to reduce harm on patients. Eventually this
institution represents a gap concerning this issue.
Question 21: Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
The administration is implementing a safety plan to reduce or
even eliminate potential harm to patients (patient fall program,
hand hygiene, etc.)…………………………………………………… 1 2 3 4 5
Figure 4.19: chart distribution for “implementation of a safety plan “
69
This question aimed to observe if the targeted hospitals’ use of a combination
of quality tools (Six Sigma, lean and change management) or so called Robust
Process Improvement which will help reduce errors and eliminate waste in the
processes. Chassin and Loeb consider this tool to be the new quality instrument that
will replace the old approach (Total Quality Management, Continuous Quality
Improvement and PDCA). Results were as follows:
From hospital A, 4 % of participants gave positive answers, from hospital B 31
% gave positive answers and from hospital C 61 % gave positive answers. In general
22 % of participants gave positive answers. The results reveal a remarkable gap
(hospital A, B, C and for the whole sample) for this question and the percentage of
neutral answers were significant (57 % for A and 39 % for B, 46 % for the whole
Question 22: Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
In our hospital / department they use a combination of Six
Sigma, Lean and change management (or so called Robust
Process Improvement) to improve processes……………….. 1 2 3 4 5
0% 20% 40% 60% 80% 100%
Hospital A
Hospital B
Hospital C
Overall
10%
4%
6%
29%
26%
11%
26%
57%
39%
28%
46%
3%
27%
61%
19%
1%
4%
3%
Strongly disagree
Disagree
Neither
Agree
Strongly Agree
Figure4.20: chart distribution for “ adoption of Robust Process
Improvement”
70
sample) which means the responders didn’t know or maybe never heard of this new
approach. Eventually we observe that the targeted hospitals don’t use this tool as the
main process improvement instrument.
This question aimed to detect the establishment of a mandatory plan by the
targeted hospitals to train the involved staff on using the new quality tool. Results
for this question were as follows:
Question 23: Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
Our hospital have established a mandatory training plan for all
concerned employees on RPI (Robust process improvement)….. 1 2 3 4 5
0% 20% 40% 60% 80% 100%
Hospital A
Hospital B
Hospital C
Overall
15%
7%
10%
37%
30%
22%
33%
44%
34%
50%
39%
2%
25%
28%
15%
2%
4%
3%
Strongly Disagree
Disagree
Neither
Agree
Strongly Agree
Figure 4.21: chart distribution for "training plan for Robust Process
Improvement”
71
0% 20% 40% 60% 80% 100%
Hospital A
Hospital B
Hospital C
Overall
14%
8%
10%
32%
26%
6%
27%
32%
29%
33%
31%
21%
34%
55%
30%
1%
3%
6%
2%
Strongly disagree
Disagree
Neither
Agree
Strongly Agree
From hospital A, 3 % of participants gave positive answers, from hospital B
29 % gave positive answers and from hospital C 28 % gave positive answers. In
general 18 % of participants gave positive answers. Findings from this question
reveal that the three hospitals don't have a training plan to implement RPI in their
facilities. Eventually these institutions represent a gap concerning this issue.
This question aimed to detect, the targeted hospitals’ degree of patients
involvement while using the Roust Process Improvement tool to redesign the care
process. Engaging patients in the design of the care process will reduce waste in the
clinical process and eventually improve the quality of services. Results for this
question were as follows:
From hospital A, 22 % of participants gave positive answers, from hospital B
37 % gave positive answers, and from hospital C 62 % gave positive answers. In
Question 24: Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
Patients are totally engaged in redesigning the care processes .......................... 1 2 3 4 5
Figure 4. 22: chart distribution for “patient engagement”
72
general 32 % of participants gave positive answers. Results for this question reveal
that the hospitals don’t engage patients in the care plan, which will affect on quality
of services provided. Eventually the three institutions represent a gap concerning
this issue.
This question aimed to observe the involvement of proficiency in using
Robust Process Improvement as part of every employee’s performance appraisal; it
is a mandatory requirement for career advancement within the targeted hospitals.
Results for this question were as follows:
From hospital A, 5 % of participants gave positive answers, from hospital B 29
% gave positive answers, and from hospital C 33 % gave positive answers. In general
20 % of participants gave positive answers. The findings for this question show that
Question 25:
Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
In our hospital, RPI is a mandatory requirements for career
advancement……………………………………………………. 1 2 3 4 5
0% 20% 40% 60% 80% 100%
Hospital A
Hospital B
Hospital C
Overall
14%
9%
10%
26%
27%
11%
25%
55%
35%
56%
45%
3%
26%
33%
17%
2%
3%
3%
Strongly Disagree
Disagree
Neither
Agree
Strongly Agree
Figure 4.23: chart distribution for “career advancement”
73
there's neither empowerment nor involvement of employees in the process
improvement at the targeted institutions. Eventually a gap exists in the three
institutions concerning this issue.
4.3 CROSS TABULATION
In their article “getting there from here”, Chassin and Loeb argued that
leadership commitment” is an essential initial requirement, because the success of all
the other changes depends on it” [1]. To confirm this statement, and since Likert –
scale questions can be treated as categorical variables, a cross tabulation was made
between the independent variable (question 4: hospital management commit to the
goal “zero patient harm” for all clinical services) and the rest of the following
dependent variables (question 5 till question 25). CHI- Square was used in the cross
tabulation to test the significance of the relationship between the independent and
the dependent variables. The results were significant for the majority of the variables
(p< 0.001) except for question 15 (p= 0.126) and question 17 (p= 0.173).
4.4 CONCLUSION
In summary, the results for each hospital will be displayed in a table that
details the 21 Likert-scale questions (which represent the 14 components of the
questionnaire). The cells will be labeled with green if the hospital was compliant
with the question criteria and red if it wasn’t.
74
75
CHAPTER 5
CONCLUSION AND FUTURE WORK
5.1 CONCLUSION
Findings from data analysis are organized below in order of responses to the
questionnaire, they revealed that:
- Hospital administrations don't have a decisive commitment toward
achieving “zero harm” to patients.
- Although quality and safety are a part of hospitals’ operations to
enhance performance, they're not considered a top priority and they
are not clearly stated in hospitals strategic plan.
- Top management actions don't provide a climate (staffing, work load,
work schedule, and policies and procedures) that really reflects a
great interest in reducing errors.
- There's no wide participation by physicians in the different
committees that exist in hospitals especially quality committees.
- There's no transparency inside and between hospitals that is clear
from the prohibiting of announcement of quality indicators both
internally and externally. Moreover there's no reward system for
accomplishing a certain goal
- Medical Equipment aren't fully integrated into the main HIS, and the
IT departments don't provide statistical data periodically.
- There's lack of trust and respect between physicians and other clinical
staff of hospitals. Healthcare institutions also ignoring this situation
and never interfere to eliminate the intimidating environment.
76
- Blame culture still rules.
- Although employees feel free to report unsafe conditions, yet the
learning culture is still weak and rarely implemented.
- The Majority of hospitals don't have a solid system that prevents
errors from occurring and they are still reactive and not proactive to
events.
- Hospitals in their majority are implementing a safety plan yet there's
still no real assessment of the effectiveness of these plans and no
assessment of hospitals’ safety culture in general.
- None of the targeted hospitals are using Robust Process Improvement
and they have no plans to train the concerned personnel on this tool’s
use. There are also no talent management programs to empower or to
involve employees in case this instrument was later on implemented
in their facilities.
- There's no engagement of patients in their own care plan process.
As mentioned by the literature and quoted articles, Lebanese hospitals are
also lagging behind and far from reaching the “approaching phase “of the Joint
Commission team’s maturity framework.
5.2 RECOMMENDATIONS
Although this study reflected a bleak image of the healthcare industry in
Lebanon, there's still so much that can be done in order to move forward from this
situation. The responsibility to enhance performance lies in the hands of hospitals’
leaders, ministry of health, and legislators. Therefore the recommendations will be
divided to actions that hospitals, ministry of health and legislators have to take in
order to set a corner stone to enhance patient safety and then move forward towards
a high reliability status.
77
a) Hospitals:
1. Improvement must start at the top management level with a well
established strategic plan that clearly mentions commitment toward
“zero harm” on patients, a mission that is oriented to enhancing patient
safety and quality, and finally a vision where the institution is eager to
become a highly reliable organization. The goal of zero harm should be
monitored through measurable metrics (for hospitals A, B and general
use).
2. A committed top management should perform periodic walkrounds.
The information gathered through conversation with field
workers(also called sit-around) and the direct observations should be
documented, analyzed and regularly discussed in meetings including
clinical chairs, chiefs, and senior leaders(for hospital A,B and general
use).
3. Wide Involvement of physicians in quality committees is critical to
enhance quality and safety. This engagement is provided by a
physician champion or leader who considers quality and safety a top
priority, where this leader will help disseminate the participation idea
among colleagues by eliminating the resistance to this approach. The
involvement of physicians will help in eliminating the autonomy and
eventually reducing errors by adopting evidence-based medicine (for
hospital A, B and general use).
4. In tightly coupled systems like Healthcare, transparency must be
precondition for safety; its absence inhibits learning from mistakes,
distorts collegiality and erodes patient trust. Transparency could be
achieved by publishing indicators (quality and safety) internally which
will inform staff about the current situation of their unit and will
motivate them through a set of incentives to improve current figures.
78
Indicators should also be published externally through a website
owned and operated by the Syndicate of Hospitals, and accessible by
hospitals’ leaders (for hospital A, B, C and general use). The external
publication aims to share information between caregivers just like in
aviation: if a company detects any problem with their planes every
aviation company is informed about it to take precautions or to add
this issue to their checklists
5. Establishing an Electronic Medical Record (EMR) and Computerized
Physician Order Entry (CPOE) would help in error reduction, also all
medical equipment should be interoperable between each other (at
ICU, CCU, ICN and ICP) and fully integrated to the main Hospital
Information System. This integration reduces errors by directly
uploading results (lab, X-RAY) to hospitals’ floors and clinics. The use
of new technologies such as Remote Frequency Identification (RFID),
along with bar-coded wristbands can be useful in reducing errors
related to lab and blood bank departments (for hospital A, B, C and
general use).
6. The internal transparency should be adopted by indicators publishing
to staff that is done periodically by the IT department. This helps in
informing each unit or department about their indicators, because
without their participation, departments will be blind of what’s
happening and this leads to error-prone environment (hospital A, B, C
and general use).
7. Trust is essential between different clinical bodies of the hospital,
without it an environment of intimidating behaviors reigns in the
institution which might lead to errors. To eliminate this behavior
hospitals’ should adopt approaches that encourage or enhance
communication, and flatten the hierarchy between doctors and other
79
clinical staff (for hospital A, B and general use). There are numerous
programs that can be quoted from highly reliable organizations such as
aviation like Crew Resource Management which helped in accidents
reduction. An assessment tool must be used to assess the effectiveness
of these programs, in detecting if intimidating behavior still exists. An
example is the Institute for Safe Medication Practices survey about
intimidation.
8. Hospitals should move their safety culture from punishment and
blame toward just culture. This can be done by: First what we
previously mentioned about trust, because without it some events will
stay unreported. And second by holding Staff accountable for their
acts, that can be done by managers using a tool like the James
Reason’s unsafe act algorithm (see appendix A) to discriminate
between blameless and blameworthy act. Informed culture
components should be implemented by the introduction of an
electronic reporting system, operated by a multidisciplinary team, this
team receives incident reports (near miss, adverse events, and sentinel
events) from different departments of the hospital, it investigates each
incident, and how it happened(for hospital A, B, C and general use).
The data provided by this system helps through conducting root cause
analysis to determine the real cause of the incident, and it disseminates
the convenient adjustments to the concerned departments and other
units that might be indirectly affected by these incidents (since
healthcare is tightly coupled). As mentioned by the strategic plan for
safety and High reliability this multidisciplinary team assesses the
safety culture of the hospitals by conducting surveys on safety culture
and gathering safety indicators in a periodic manner to determine if the
goal of “Zero Harm” on patients is achieved.
80
9. Audits (by top management, safety officers or by the newly designed
multidisciplinary team) on policy and procedures should be performed
on regular basis to assess the validity and the integrity of safety
barriers that help prevent errors from occurring. Hospitals should
adopt the proactive approach in order to prevent errors from
occurring; this proactive approach will start by a Root Cause Analysis
to remedy the problems and then switch to Failure Mode and Effect
Analysis (FMEA). This will help in detecting any potential risk or harm
that might affect machines, processes, programs, and people(because
these risks will eventually cause medical errors to patients), and
working on every potential problem to avoid it’s occurrence (for
hospital A, B, C and general use).
10. Hospitals should gradually shift from the Total Quality Management,
Continuous Quality Improvement, and Plan-Do-Check-Act approaches
towards new effective tools that help reduce waste and prevent errors
from happening. The best quality tool that suits the healthcare industry
is a combination of Six Sigma and Lean Management. The
transformation toward these quality tools should be in an organized
manner by using the change management concept that will help in the
reduction of resistance and the dissemination of the new quality
approach, and by involving and empowering the concerned employees
(for hospital A, B, C and general use).
11. Hospitals should adopt teamwork between their staffs, because it is
proved that teamwork will help in reducing errors unlike individual
work (for hospital A, B, C and general use). There are numerous
programs that emphasize teamwork for example: Situation
Background Assessment Recommendation (SBAR) and AHRQ’s team
Strategies and Tools to Enhance Performance and Patient Safety (Team
81
STEPPS), and also Crew Resource Management. These different
programs are effective in certain departments and ineffective in others
therefore hospitals should consider using a combination of these
programs where each unit has different taxonomy.
12. “Nothing about me, without me” [51] the Lucian Leape slogan about
Patient’s engagement should be Implemented, patients and their
families should participate in the care plan because their involvement
is an essential part for achieving quality and safety(for hospital A, B, C
and general use). Doctors, nurses should share knowledge and medical
information with patients and their relatives, organizations should also
affirm the centrality of patient and family centered care publicly and
consistently. Patients should be partners with clinicians in the decision
making process, guided by on how to self-manage, and how to develop
their own care plans
b) Ministry of health : the Ministry of health should play a role in
encouraging hospitals to establish a zero harm goal and eventually to
adopt the High Reliability Organization concept through several actions:
1. Establishing a National Patient Safety Agency equipped with an
electronic Reporting System, and operated by a multidisciplinary
committee, must be a priority. Like communicable disease
reporting, this agency should receive detailed safety reports (near
misses, adverse events, and sentinel events) on monthly basis from
every registered hospital. The committee’s mission would be to
investigate these reports, analyze each one and give
recommendations on how to prevent them from reoccurring. The
committee recommendations would be in the form of policies,
procedures, and checklists and can be disseminated to all hospitals
82
in order to prevent unwelcomed events’ occurrence in other
healthcare facility.
2. Each component of the joint commission framework from which
the questionnaire was quoted, can be transformed into a set of
standards, and criteria or measurable elements for each standard
can be elaborated. Since the accreditation committee is under the
ministry’s jurisdiction, and the safety issue is a national concern, the
ministry should easily be able to perform accreditation on High
reliability using these standards, and this accreditation will be
gradual and voluntary at first like the Baldrige award.
Legislators play a small but significant role through the elimination
of barriers that prevent hospitals from enhancing their
performance. This is done by removing the financial burden that
the majority of Lebanese healthcare institutions lie under (delayed
and reduced reimbursements, taxes, customs, etc…). When the
barriers are removed the accreditation then becomes mandatory;
where it is recommended that the ministry adopts the Baldrige
Framework as a start, because although it is difficult some studies
have found that it is still easier to achieve than the High Reliability
framework.
5.3 FUTURE WORK
This thesis represents a drop in the sea of healthcare safety field, and knowing
that it’s focus is on gaps in MOH and ISO accredited institutions, further researches
might involve Joint Commission International (JCI) Accredited hospitals. And since
the researcher chose hospitals in an urban area to implement his tool on, future
83
studies could measure the extent of the gap in healthcare institutions located in rural
areas.
Further researches might be done to assess the impact of Robust Process
Improvement on hospital performance from the point of view of quality and safety,
and to see the extent of applicability of this tool to existing clinical processes in
hospitals, also to determine if it's the right instrument that will lead toward zero
harm on patient.
Studies can also be conducted to find the degree of preparedness of Lebanese
hospitals towards the Baldrige framework, and the extent of its suitability as an
accreditation program before moving towards the high reliability framework. A
study of the future role of Ministry of health in patient safety through the
establishment of a National Agency for Patient Safety might also prove to be
important.
Further researches could be able to detect the impact of new technology like
EMR, CPOE, RFID, on patient safety and if they are the right tools to achieve High
reliability status.
Since Middle East Airline (MEA) is considered the only HRO operating in
Lebanon (since it never faced any serious problems), future researches can probably
detect the impact of the partnership between the Lebanese University, the Syndicate
of Hospitals and the MEA and how this partnership will enhance hospital
performance from the point of view of patient safety, and help them move towards
the HRO concept.
High reliability Organizations concept proved its effectiveness and excellence
in managing hazardous processes in industries outside healthcare (aviation, Nuclear
power plants, and aircraft carriers), and in maintaining the same pace for a long
time. Yet, in healthcare, this concept is still new and under investigation. Further
84
researches could go in depth and detect the impact of this theory on healthcare
institutions from the points of view of: efficiency, effectiveness, patient safety and
quality. As mentioned earlier there are no blue prints or clear road- maps for
hospitals to adopt in seeking the state of High Reliability; this was obvious through
multiple articles that discussed about this issue and recommended several
approaches to reach this state. Therefore further researches can help detect the most
suitable approach that fits healthcare, and researchers can elaborate on new
indicators to assess the current status of the institutions.
Finally, this study is a wide spectrum research that assessed the
organizational level, so researchers can shift the exploration toward the
departmental level and detect better approaches for each department.
85
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92
APPENDIX A
JAMES REASON UNSAFE ACTS ALGORITHM
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APPENDIXB
ACCEPTANCE FORM
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APPENDIXC
QUESTIONNAIRE
Background: The Hospital Survey on high reliability is a staff survey designed to
help hospitals assess the existence of high reliability concept in their institutions.
There is a growing recognition that organizational change toward high reliability
requires leadership commitment, a general culture of safety among its staff and
continuous improvement process.
In order to come up with a solid and reliable data, your answers must be based on
physical evidence (such policies, procedures, rules, regulations, and even internal memos),
rather relying on emotions, or attitudes (positive or negative) toward your organization.
This will help the researcher by giving him the opportunity to objectively assess the
organizations maturity toward this concept, and enable him to make recommendations on
how to fill in the gap (if it exists) and eventually to give hospitals ideas to enhance their
performances.
Your answers will not be released to anyone and your identity will remain
anonymous. Your name will not be written on the questionnaire or be kept in any other
records. All responses you provide for this study will remain confidential. When the
results of the study are reported, you will not be identified by name or any other
information that could be used to infer your identity. Only researchers will have
access to view any data collected during this research
If you have any questions, you may contact:
Name Phone number Email address
Bilal Al Khatib 71161817 [email protected]
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Hospital Survey on High Reliability framework
Instructions
This survey asks for your opinions about leadership commitment, safety culture and continuous
improvement issues, in your hospital and will take about 10 to 15 minutes to complete.
An “error” is defined as any type of mistake, incident, accident, or deviation, regardless of whether or not it
results in patient harm.
“Patient safety” is defined as the avoidance and prevention of patient injuries resulting from the processes of
health care delivery.
“Near miss Situation in which a medical error has been found and stopped before affecting a patient
“Robust Process Improvement” a process improvement tool that uses Six Sigma, Lean and Change
management to reduce safety and quality problems.
In this survey, think of your “unit” as the work area, department, or clinical area of the hospital where
you spend most of your work time or provide most of your clinical services.
1. What is your staff position in this hospital? Select ONE answer that best describes your staff
position.
2. How long have you worked in this hospital?
a. Less than 1 year d. 11 or more years
b. 1 to 5 years
c. 6 to 10 years
3. Typically, how many hours per week do you work in this hospital?
a. 20 hours or less per week
b. 21 to 40 hours per week
c. more than 40 hours per week
a. Registered Nurse i. Manager
b. Physician Assistant/Nurse Practitioner j. Physical Therapist
c. Medical lab Technician
d. Midwife
e. Department chairman l. Other, please specify:
f. Resident Physician
g. Pharmacist
h X-ray technician
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Please indicate your agreement or disagreement with the following statements about your work area/unit.
Think about your hospital
Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
4. hospital management commit to the goal “zero patient harm” for all clinical
services .................................................................................................................. 1 2 3 4 5
5. Hospital management provides a work climate that promotes patient safety ........ 1 2 3 4 5 6. The actions of hospital management show that patient safety is a top priority......
1 2 3 4 5
7. Quality is considered as the organization’s highest priority ................................. 1 2 3 4 5 8. physicians are involved in improving the quality of services in the hospitals
through the uniform participation in quality improvement activities .................... 1 2 3 4 5
9. Key quality indicators are announced ( staff &publicly), and employees who
accomplish quality goals are fairly rewarded ....................................................... 1 2 3 4 5
10. All medical equipments are well integrated into the main computer system of
the hospital ............................................................................................................. 1 2 3 4 5
11. IT department consistently provides clinical department with statistical data ....... 1 2 3 4 5 12. High level of trust and respect exist between physicians and other clinical
staff (pharmacist, lab technologist, nurses) ............................................................. 1 2 3 4 5
13. Policies, procedures, and educational programs exist to ensure a trusting
environments .......................................................................................................... 1 2 3 4 5
14. If I report a near miss or an error I know I won’t be punished ............................. 1 2 3 4 5
15. I feel free to report near misses and unsafe conditions that might affect
patients ................................................................................................................... 1 2 3 4 5 16. Unit / dept, managers /administration work hard with the frontline workers
to resolve problems and to prevent same errors from happening again in the
future ...................................................................................................................... 1 2 3 4 5
17. Feedback about changes (after resolving near misses) are routinely addressed ... 1 2 3 4 5 18. Policies, procedures and checklist related to patient safety are reviewed
periodically to ensure their integrity and validity .................................................. 1 2 3 4 5 19. Our procedures and systems are good at preventing errors from happening .........
1 2 3 4 5
20. Surveys about patient safety are performed and safety indicators are routinely
published in order to assess safety culture in the hospital ..................................... 1 2 3 4 5
21. The administration is implementing a safety plan to reduce or even eliminate
potential harm to patients (patient fall program, hand hygiene, etc.) ..................... 1 2 3 4 5
22. In our hospital / department they use a combination of Six Sigma, Lean and
change management (or so called Robust Process Improvement) to improve
processes ............................................................................................................... 1 2 3 4 5
23. Our hospital have established a mandatory training plan for all concerned
employees on RPI (Robust process improvement) ................................................ 1 2 3 4 5
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24. Patients are totally engaged in redesigning the care processes ............................. 1 2 3 4 5
25. In our hospital, RPI is a mandatory requirements for career advancement ........... 1 2 3 4 5
Domain component questions
Leadership
Top management 4, 5, 6
physician 8
Quality strategy 7
Quality measures 9
Information
technology
10, 11
Safety culture
Trust 12, 13
Accountability 14
Identifying unsafe
conditions
15, 16, 17
Strengthening
systems
18, 19
Assessment 20, 21
Processs
improvement (RPI)
Method 22
training 23
spread 24, 25