High Reliability Organization Theory

In contrast to these rather pessimistic views of the organizational challenges to safety is the HROT view that, while not easy, proper organization of people, technology, and processes can handle complex and hazardous activities at acceptable levels of performance. While accidents can never be totally eliminated, high reliability organizations must be judged in comparison to the benefits we derive from their activities and their small absolute risk of failure. This view seems particularly appropriate in anesthesiology because forgoing surgical treatment is not a viable option for many patients and challenges to safety must often be met head-on. Although the concepts of HROT have varied over the years, the core characteristics of HROs are shown in Table 83-12 and Table 83-13 .

A key aspect of HROT is that of a culture of safety (or "safety culture"). Since publication of the reports from the IOM, health care has begun paying attention to certain elements of "culture." However, most of the attention has been devoted to the "culture of blame" in a system whereby problems are addressed largely in terms of who is to blame rather than in terms of what can be done to prevent them. Safety culture goes beyond these issues dealing with how individuals and groups conduct their work. Culture is made up of values (what is important), beliefs (how things should work), and norms (the way things work). These elements are shown in Table 83-12 . It is equally important that the culture is highly uniform throughout the organization and reinforced continually by peers, more so than by enforcement of rules.

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Asymmetry Between Safety and Production

An additional difficulty in achieving optimal safety is an inherent asymmetry of information and concern about safety versus production ( Table 83-14 ).^[82] Investments for production are easy to plan for and measure; feedback about production is easy to obtain and to interpret. Investments

TABLE 83-13 -- Key elements of a high reliability organization in medicine

Established Culture of Safety (see Table 83-12 )

Optimal Structures and Procedures

• Decision-making rests with those with greatest knowledge or experience about specific issues regardless of rank, or job type.

• The unit integrates crews from different departments (e.g. cardiac surgery, cardiac anesthesia, OR nursing, perfusion, ICU) into a coherent clinical team. Teamwork and resiliency are emphasized.

• There are formal procedures to maximize information transfer to all team members before a case (e.g., briefings or time-out procedures).

• Schedules are designed to keep work hours and duty periods at reasonable levels to avoid undue fatigue. Personnel under excessive stress are supported or replaced as needed.

• Standardized procedures, techniques, and equipment are adopted whenever possible so that similar tasks or operations are performed similarly regardless of personnel involved; conversely, when necessary (in an emergency or adverse event), the team is resilient and responds as needed to the situation without slavish dependence on standard routines.

• The use of pre-planned algorithms, checklists, and cognitive aids is actively encouraged.

• Easy access to current information systems is available at all times and all locations.

Training and Practice in Routine Cases and Simulations

• Debriefings are conducted after each case.

• Non-punitive assessment instruments are used on a regular basis to provide current feedback and identify elements requiring special training (see Table 83-15 ).

• There is initial and recurrent simulation-based single-discipline and multidisciplinary training in Crew resource management (see Chapter 84 ).

• Actual clinical crews and teams conduct periodic drills or simulations of critical situations in the real OR, PACU, and ICU.

• Resident training uses guided curriculum; training goals and level of responsibility assigned to resident match current proficiency level of trainee with complexity of case.

Organizational Learning

• Robust mechanisms are in regular use for organizational learning, both prospectively (considering in advance how to optimize protocols and procedures, such as failure mode and effects analysis) and retrospectively (from analyzing reports of adverse events, near misses, or problems such as root cause analysis).

• Problems are analyzed primarily to determine what can be improved rather than whom to blame. Altered procedures are assessed and adopted as appropriate. Process changes reflect appropriate analysis.

ICU, intensive care unit; OR, operating room; PACU, postanesthesia care unit.

for safety are harder to plan for, and the costs are harder to measure. Most importantly, feedback about safety is inherently weak and ambiguous. How can one measure the accidents that could have occurred but did not? Only after a catastrophe takes place do the costs of a safety failure become apparent.

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High Reliability Organization Theory in Anesthesiology

Anesthesiology has traditionally been strong at some elements of an HRO, particularly in redundancy and technical safety measures. There is a growing movement in anesthesia to implement more fully HRO philosophies and techniques. In fact, anesthesiologists have not only been promoters of the patient safety movement in general^[2] but also have been leaders at applying HRO principles to health care. In 2003 the Anesthesia Patient Safety Foundation (APSF) began initiatives in high reliability perioperative health care (see Special Issue of APSF Newsletter, Summer, 2003, at www.apsf.org). Table 83-12 summarizes key elements of an HRO adapted to health care.