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  • Becoming a High Reliability Organization

  • by Timothy Babineau, MD, President and CEO, Rhode Island Hospital

    American health care has often been described by management experts as among the most complex industries in the world-and academic medical centers are at the forefront of the industry. Frequently compared to other highly complex endeavors such as aviation, nuclear energy and strategic defense operations, health care shares many of the same challenges to perform reliably and optimally under high stress situations.

    Also, like other complex industries, failure to do so can result in devastating consequences. However, unlike the other industries mentioned, health care has lagged behind in its efforts to transform its organizations (i.e., hospitals and health care systems) into what are referred to as "High Reliability Organizations." What does that mean?

    The definition of a High Reliability Organization (HRO) is an organization or industry that has succeeded in creating systems that prevent catastrophes from occurring despite a risky and complex environment where "normal" accidents can be expected to occur. Put more simply, HROs can be defined as organizations which have fewer than the normal, "expected" rate of accidents. This decrease in accidents occurs primarily through a change in culture. Technology has some influence but not in isolation. Witness the impressive safety records of the nuclear energy and aviation industries over the past several decades. Those industries recognized the complexity of their work and took steps years ago to put in place systems that prevented mistakes from happening.

    The reasons why health care has lagged behind other industries are numerous, complex and a topic for another time. But if we-the Rhode Island and The Miriam hospitals-are to become true national leaders in patient safety and quality, we need to begin to understand and adopt some of the tools and techniques that have led to exponential and dramatic improvements in other industries. Let me expand.

    High reliability organizations are characterized by a total pre-occupation with the possibility of "failure"-meaning every employee in the organization is constantly asking the questions: what can go wrong and how can we prevent it? There is also a reluctance to simplify complex events into the first and simplest explanation. Complex problems often have multiple causes and we have to resist the temptation to seize upon the first and most simple explanation (this serves as the core of our Root Causes Analysis Process). Other characteristics of high reliability organizations include a deep understanding of process, process improvement and how to engineer fail-safe and recovery modes into their daily operations. Finally, HROs hold a deep seated belief that the person with the most expertise on a particular matter should lead decision making irrespective of rank within an organization.

    Unfortunately, health care in this country is anything but highly reliable. Many pundits refer to our industry as "occasionally reliable." Of course there are pockets of excellence in every hospital, just as there are in ours, but as an industry we have a long way to go.

    Regrettably, many of us in health care have become so accustomed to things not "working as they should" that we gradually learn to accept them as the norm. But the culture of "that's just how things work around here" must change if we are to advance the safety and quality of health care both in our hospitals and throughout our nation. Starting today, we need to set a goal (at our hospitals at least) of 100% compliance with the policies we created to ensure safe, high quality care. And if the policies are out of date or out of sync with best practices, we need to fix them. Now.

    If this were easy, it would have been done already and health care would already be a high reliability industry. We have lots of hard working and dedicated people who care deeply about their jobs and taking excellent care of patients. What has been lacking? Well, the answer is a complex one but a key element in all high reliability industries (that has been missing in health care) is a deep commitment to rigorous process improvement leading to the creation of safe, reliable systems. We are about to change all that at Rhode Island and the Miriam hospitals.

    In the coming months you will be hearing about a new initiative called OpX, which stands for operational excellence. This initiative has two components, "Lean" and "Six Sigma."

    Six Sigma was developed in the late 1980s by Motorola and widely embraced in the manufacturing sector because of its proven ability to improve productivity and reduce process variation. To digress for a moment, the maturity of a manufacturing process can be described by a sigma rating indicating its yield, or the percentage of defect-free products it creates. A six-sigma process is one in which 99.99966% of the products manufactured are statistically expected to be free of defects (3.4 defects per million).

    The concept of Lean comes from the Toyota Production System and is a philosophy and an organizational culture that looks to evaluate processes and to minimize or eliminate steps in existing processes that are not absolutely necessary. A phrase that has been used is "eliminating waste to promote growth." When combined (we will use the term "Lean Six Sigma" to describe the fact that we will use both of these methodologies in our hospitals), these tools have the ability to create and sustain continuous process improvement throughout an organization-a critical step in becoming a high reliability organization.

    You may not think that strategies popularized by the manufacturing industry would translate to health care. After all, we take care of patients-we do not make widgets. But the ultimate goal of using Lean and Six Sigma for any business is to improve the experience of their customers-in our case, our patients.

    So how will we introduce Lean and Six Sigma into our organizations? Recently, we began collaborating with experts from Covidien-a health care company with expertise in this area-to help us launch these concepts within both of our hospitals. Our colleagues from Covidien will visit both Rhode Island Hospital and The Miriam this month to meet with senior leadership and front-line staff in various units and departments. From these meetings, we will identify two pilot projects at each hospital with the goal of improving our work environment, engaging our employees in new and innovative ways and improving the overall quality, reliability, safety and efficiency of the care we deliver. It is a beginning.

    Our hope and belief (and this has been widely demonstrated in other hospitals) is that by using Lean Six Sigma concepts, we'll be able to make major improvements in some of our most vexing and stubborn challenges that have plagued our institutions for years such as patient throughput, discharge planning, medical errors and the like. This will be accomplished by educating and empowering our staff and giving them specific tools to not only "think outside the box," but also to analyze and change processes.

    Overall, we expect the initial phase of this transformation to take approximately 18 months, with the first 12 months focused on preliminary work and trainings. Although we don't expect to see improvements overnight, we believe these projects will have a meaningful and tangible impact before long. I believe that we often overestimate what we can accomplish in a year, and underestimate what we can accomplish in five. It is time to start now. OpX also represents the first time the leadership teams from Rhode Island and The Miriam hospitals have worked together on a single strategic process and we expect that we will attain our goals together.

    We need to begin to adopt the tools that will move us further along the path to becoming a high reliability organization. Together, we will do what is necessary to advance our three most important priorities of advancing quality and safety, improving the patient experience and engaging our employees and physician partners in all that we do. OpX and striving to become a high reliability organization are simply more steps along that journey.

    In the steadfast pursuit of excellence, I remain,

    Sincerely yours,


    Timothy J. Babineau, MD
    President and Chief Executive Officer
    Rhode Island Hospital & The Miriam Hospital