Q: Could you start by explaining the concept of "High Reliability"?
Mr. Byrum — A High Reliability Organization, by definition, is an organization that routinely operates in an environment where an error, any error, can have potentially dangerous and even catastrophic results. Surgery, due to its invasive nature, is a high-risk environment where employees must be focused on implementing standardized best practices in a consistent manner in order to avoid accidents, infections and errors.
Q: What drew you to this concept in the first place?
Mr. Byrum — I was immersed in it at the beginning without really even knowing it. I originally started out as a Coast Guard pilot. Back in those days, we didn't have a lot of High Reliability tools. Pilots did things in a fairly organized manner, but we didn't always fully utilize checklists, Crew Resource Management and things like that. As a result, planes crashed much more frequently than they do today.
The industry decided there had to be another way to do things. So, we embraced this idea of High Reliability, and flying became much safer. Other organizations, including healthcare, started to look at how aviation standardized these best practices, and they wanted to see how it could apply to them. I've been working in healthcare now for 20 years, and have helped more than 600 facilities implement these practices.
Q: So, what does a High Reliability surgical facility look like?
Mr. Byrum — It looks like a facility that standardizes processes and procedures wherever possible. It does not rush through site verification, marking, the time out or the count. It values the inputs of all team members and ensures that someone is able to speak up if there is something that causes them concern. Most importantly, it is an organization that says that its goal is to have absolutely no avoidable errors, zero, in its facility. Look, errors are going to happen. Human beings will make errors. But the whole premise is to avoid those errors, whenever possible, and to catch and correct them before they lead to more serious harm to the patient.
Most "never events" are errors that are entirely avoidable if everyone followed standardized practices. But, one of the biggest challenges I see is that in facilities, I'll ask why they do something a particular way and most of the time they say Well, that's how we've always done it. That's not always wrong if there's a sound reason behind it, but many times it precludes you if you're thinking that your way is always the best way without backing it up with evidence. Facilities should be changing their practices — including everything from pre-op antibiotic delivery to marking the site — to ensure that they're following the very best, evidence-backed process.
Q: Are there traits that make a HRO stand apart from others?
Mr. Byrum — These organizations are focused on improving care by taking specific actions. Too often healthcare facilities hop from initiative to initiative, looking at whatever the flavor of the month is in terms of patient safety, without really considering what they're doing. As a consequence, those organizations never really accomplish meaningful, sustainable improvements because they're almost always onto yet another initiative.
High Reliability Organizations defer to expertise. While you want to be questioning if there"s a better, proven way of doing things, you also don't want to just randomly change things for the sake of changing things. Instead, the successful facilities will look at their practices, find experts in those areas, enlist their help and learn from them.
Q: So, that includes things like more checklists, right?
Mr. Byrum — Checklists can be a key point in the concept. In healthcare, some think checklists are a bad word. We've heard people say that checklists take away the individual's ability to think. But in HROs, it's the opposite. The checklist keeps you from forgetting the most important things, so it frees your mind to think, analyze and reason, therefore making you a better deliverer of care.
But, you can't just hand out a checklist and think that it's going to implement itself and instantly make patients safer. It won't. The pre-procedure time out (PPTO) is a great example of this. The Joint Commission has mandated the PPTO for more than a decade, but unfortunately, they didn't give specifics to how it should be carried out, and that's one reason why we haven't yet eliminated avoidable adverse events.
Another problem is that surgeons or staffers are often disengaged with the checklist. I compare it to flying a plane. If you got on a plane with a pilot who said that he didn't feel like doing the pre-takeoff briefing, or just rushed through his pre-flight checks, would you want to get on that plane? Clinicians need to look at each patient in that light, since the patients trust them with their lives each and every time they enter that OR.
Q: We often hear about staff and surgeons resisting change. How can our readers tackle that problem?
Mr. Byrum — There's a saying: The only person who likes change is a baby with a dirty diaper. And frankly, we see this inside and outside of healthcare. People tend to like to do things they're own way.
One way to inspire change is to make sure that if you are implementing a new checklist or patient safety initiative, you give the specifics and expectations to your team. You can't just say do the time out — you need to tell them how to do it, when to do it, why they're doing it, who needs to participate, and how they'll know that they accomplished their goal.
I feel that in general, healthcare workers are often "tired" and resistant to change simply because they're constantly bombarded with new initiatives from both inside and outside their organization. It's overwhelming. However, if the many initiatives are managed for HRO progress, and they stepped back and looked at this as a concrete way to give their patients better care, I guarantee that much of this resistance would fade away.
Q: You also say that this is "evolutionary, not revolutionary" process. Could you explain?
Mr. Byrum — A lot of this is already intuitive for healthcare managers. Good ASCs especially are already laser-focused on standardization in terms of things like reducing the number of supplies, maintaining schedules, fully implementing SOPs, etc., because their business depends on it. You're already addressing your daily problems in a way that involve much of the High Reliability approach to patient safety and efficiency. You're not reinventing the wheel, but High Reliability changes do make a major impact. It's the difference between being an acceptable facility and an excellent one. You don't want to just provide adequate care to patients — you want to offer them the best care possible.