May 16, 2016

While the doctor’s office cannot be compared to a nuclear facility or a space program or an air-traffic control system, the need for more and more precision and elimination of errors cannot be emphasized enough. A strong safety program is a sine qua non in any good medical facility to reduce complications, mortality and morbidity. But it is also needed as part of compliance, quality, patient satisfaction and outcomes. Furthermore, any errors of commission, including erroneous billing or coding, poor auditing, poor adherence to various Federal and State regulations or mistakes can have deleterious consequences for the provider’s licensure, finances and ability to practice.

We have seen lately many practices being penalized and some providers arrested and incarcerated for fraud and abusive practices. While these may reflect flagrant violations, it is critical to realize that the focus on increasing reliability in the system, among the employees and information technology needs to be relentless. Any compromise to the security of patients, employees, their data and health, can be lethal to the organization.

It is in this context that the principle of High Reliability Organizations (HRO) become important for a medical practice. I believe that these principles must be followed to create an organization that is world-class and where patients get world-class care.

These principles are:

  • Integrity
  • Deep knowledge
  • Procedural compliance
  • Forceful backup
  • A questioning attitude
  • Formality in communication

Let us talk about these:

  • Integrity: Integrity to my mind is synonymous with humility. The desire to learn, to accept one’s limitations and errors in front of others, to not be wasteful or ostentatious or pretentious, to take responsibility and let others take credit and advance in life and career, is one of the keystones of a leader. The leader in a medical practice, usually a provider, is also its most influential. How the leader comports himself or herself, behaves with others, shows respect to everyone, no matter the rank or status, defines the culture of the organization. An HRO will not happen if the leader is not passionate, involved, fully engaged in the nuances and nitty-gritty and constantly willing to learn, adapt, grow and challenge himself or herself. An HRO is a Learning Organization on steroids. The word ‘integrity’ comes from a Latin root which means whole. When one is whole one has integrity or one has integrity when one is whole. The only way to be whole is not via pride or vanity or falsehood, but honesty and humility.
  • Deep knowledge: Deep knowledge comes from intense specialization and mastery of the subject at a personal level. At the institutional level, this would mean removal of silos so that one person’s strength is shared across the team and everyone’s deficiency is covered by the strength of each and the synergy in the team. Deep knowledge is useless if closeted and barricaded. But it becomes a powerful and empowering tool when shared equally and in an uninhibited manner. Deep knowledge leads to deep awareness not only of one’s abilities but weaknesses. This leads to the ability to uncover any potential chink in the armor that the enemy or competitor can exploit.
  • Procedural compliance: The rules of engagement, most of them regulatory or related to patient care, need to be drilled down into the DNA of each individual and the organization. The staff has to be trained and tested constantly, sometimes when least expected, and evaluated and appraised based on their ability to follow the procedures. It is not enough to have the best technology in the world or the best equipment. Their maintenance and the people handling them are often far more important. An organization that does not rest on its laurels and challenges itself is the one most capable of withstanding any challenge from outside.
  • Forceful backup: This is where strong supervision and review makes the difference between life and death. It is not enough for the supervisor to know the art of managing people. The supervisor needs to have deep knowledge and share that knowledge among his or her underlings. He or she should observe directly, interview or hire personally and give feedback face to face. But forceful backup does not mean rigid hierarchy. It implies a strong sense of common purpose and shared ownership. Delegation is a tool that empowers the supervisor if done with mutual desire to excel; then, supervision is not onerous but welcome.
  • A questioning attitude: This will derive from institutionalized humility, deep knowledge and strong teams where ego is not at the forefront but only the purpose and work that unites. A systemic and systematic awareness of possible pitfalls and quick sharing of any concern or instinctive discomfort with the team are sometimes the only way to prevent a possible disaster at its early stages. Constant checking up of one’s defenses and measuring of vital signs, usage of secret shoppers, and spot-checks may be one way to emphasize that the leadership means business. A questioning attitude also encompasses an organizations’ encouragement of their staff to question and not just follow others blindly and to share new ideas or a different way to approach something. Or at the very least, to make sure that they understand the intent of the policy, procedure, instruction, etc. and to offer appropriate alternatives or to be able to point out possible flaws.
  • Formality in communication: Recent developments in Advanced Cardiac Life Support (ACLS) protocols are not new medications but making the team effort to resuscitate the patient non-hierarchical and creating a manner of communicating that minimizes errors in hearing or comprehension. This may involve the nurse asking the doctor if he would consider trying another medication or repeating the request for a particular infusion for the patient to confirm that he or she heard it correctly. The newest recommendations in ACLS is again an attempt to improve reliability in the ad hoc organization formed quickly by professionals to save an acutely ill patient.

  • An HRO is nimble and resilient, sensitive and open, transparent and committed. Complacency is eschewed, learning is prized and errors not minimized so that failures are prevented.

    The HRO paradigms have also been developed for Intensive Care Units (ICUs) besides disaster response situations. In the physician’s office one tends to be more lax and less stressed. However, ensuring that important data points are not missed, patient safety is kept foremost and ennui does not detract from the seriousness of one’s vocation, might be an important milestone in the scaling of medical operations in the outpatient setting.

    Reference: Cybersecurity’s Human Factor: Lessons from the Pentagon by James A. “Sandy” Winnefeld Jr., Christopher Kirchhoff, and David M. Upton, Harvard Business Review, September 2015

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