By Nathaniel Luce
What do aircraft carrier flight decks, nuclear reactor control rooms and air traffic control towers have in common? They are all highly reliable organizations—operations where one might expect to observe a lot of errors, but errors are actually rare. These organizations operate enormously complex technologies, but do so in a nearly error-free manner, because their errors can be harmful, even deadly.
Hospitals are not highly reliable organizations. Errors in the health care system result in up to 98,000 deaths each year, according to a 1999 study from the Institute of Medicine. A more recent study in the Journal of Patient Safety puts the death toll closer to 400,000.
A new study from Vanderbilt University examines how hospitals can apply the principles of highly reliable organizations to reduce errors and improve patient care. The role of habit is central to the health care organizations that have done this successfully, the authors argue. Those health care organizations that fail often do so because, while they may attempt to adopt the principles of high reliability, they do so superficially. Building on the classic work of John Dewey, the father of American pragmatism, the study lays out the five components of habits and illustrates how high-reliability and mindful organizing represent particular habits of thought and action.
“Many health care organizations don’t translate these highly reliable principles into the everyday habits of health care professionals and how they carry out their work,” said study co-author Timothy Vogus, associate professor of management at the Vanderbilt Owen Graduate School of Management. “That is, in part, due to a lack of understanding about what it means to build habits.”
The study was published in September in the journal BMJ Quality & Safety. Brian Hilligoss, assistant professor in health services management and policy at The Ohio State University was also an author on the study.
The study re-analyzed a set of case studies of health care organizations, from those that have successfully implemented highly reliable principles and seen patient outcomes improve, to those that have attempted to implement these principles but have failed to reduce harmful errors.
The study shows how well-developed habits underlie the highly reliable performance of the Virginia Mason Production System and the Johns Hopkins’ Comprehensive Unit Safety Program that reduced central line bloodstream infections to zero in the state of Michigan.
“They’ve experienced some real success there. We wanted to know why,” Vogus said.
On the other end of the spectrum, the authors point to Saint Mary’s Medical Center in Florida as well as the Bristol Royal Infirmary and Mid Staffordshire in the United Kingdom, all of which have been locked in sustained low reliability. The study authors also examined a case study of the Loma Linda Pediatric Intensive Care Unit in California, where they were unreliable, became highly reliable, and then reverted to being unreliable again.
One major hurdle to making health care highly reliable is that the inputs are so variable because “you never know what’s going to walk through the door,” Vogus said. Still, hospitals have many ways that they could standardize processes, according to the study.
“There is a lot of evidence that Virginia Mason is successful because they standardize things so well,” Vogus said. “Johns Hopkins does that too with checklists. Putting that infrastructure in place helps.”
The study argues that standardization helps because it frees peoples’ attention to focus on other things, like deviations from expected outcomes.
“Standardization frees up attention to make sense of those unusual things that occur when you treat a patient unlike any you’ve ever seen before,” Vogus said. “You’ve freed yourself up to make sense of the moments when you say, ‘Wow, there’s some weird stuff going on here. How do we figure it out?’”
One of the core elements of high reliability is mindful organizing. Mindfulness, in part, means deferring to the individual or individuals with the greatest expertise with the problem at hand. That’s often difficult in a status-based system such as a hospital. There deference to formal authority is more common. However, when people fail to heed the advice of the person with the local expertise, serious errors can occur.
“The mindless habits we observed in these consistently unreliable hospitals were things like explaining away discrepancies,” Vogus said. “People in these organizations will often say, ‘Well, we just take the toughest cases,’ or ‘We’re getting there,’ or ‘We’re still learning.’ But then do little to actually change or learn.”
Mindful organizing can be distilled into habits in a health care setting when handing off a patient to another care provider consistently entails actively discussing what could go wrong with the patient over the course of the next shift and each of the other four components of mindful organizing.
“They’re repeatedly asking the kind of questions that ensure a more mindful mode of action by establishing a detailed and nuanced understanding of the patient and the current condition of the system,” Vogus said. “That recurrent tendency toward specific modes of action and thinking, i.e., mindful organizing, is the core of effective habits.”
The five components of mindful organizing are:
- Preoccupation with failure
- Reluctance to simplify interpretations
- Sensitivity to operations
- Commitment to resilience
- Deference to expertise
“If you’re paying attention to what can go wrong, if you’re asking for better ways to do your work, asking where does expertise reside, then if you get into trouble you know where to draw upon that expertise,” Vogus said. “When you encounter a problem, you are better able to locate the people with the local expertise, rather than just following the formal hierarchy.”
CITATION: Vogus, T., Hilligoss, B. “The underappreciated role of habit in highly reliable healthcare,” (BMJ Quality & Safety, 2015). http://dx.doi.org/10.1136/bmjqs-2015-004512
Contact Person: Brett Israel Director of Business News & Communications Vanderbilt Owen Graduate School of Management
Contact Phone: (615) 322-NEWS
Contact Email: brett.israel@owen.vanderbilt.edu
