Background

High-reliability organizations (HROs) are entities that operate in complex, high-risk environments where the consequences of errors can be catastrophic, yet they maintain remarkably low rates of failure. In the context of hospitals and healthcare delivery, the concept of high reliability is crucial due to the inherently risky nature of healthcare, where even small errors can lead to serious patient harm or death.

Key Characteristics of High-Reliability Organizations

1. Preoccupation with Failure: HROs are constantly on alert for signs of potential failures, no matter how minor. In healthcare, this means that hospitals continuously monitor processes and outcomes, actively looking for weaknesses in the system that could lead to errors.

2. Reluctance to Simplify: HROs resist the temptation to oversimplify interpretations of events or processes. In healthcare, this manifests as a thorough understanding of the complex interactions between various factors affecting patient care, and avoiding assumptions that might overlook potential risks.

3. Sensitivity to Operations: HROs maintain a keen awareness of the "big picture" and the current operational status. In hospitals, this involves a real-time understanding of patient care processes, staff workloads, and system capacities, ensuring that everyone is informed and aware of ongoing operations.

4. Commitment to Resilience: HROs are prepared to respond to unexpected events and have systems in place to recover from errors or failures. Healthcare organizations develop robust systems to manage adverse events and learn from them, ensuring that they can adapt and respond effectively when things go wrong.

5. Deference to Expertise: HROs value the input of front-line workers and subject-matter experts over hierarchical decision-making. In hospitals, this means that decisions are often made by those with the most relevant expertise, regardless of their position in the organizational hierarchy, fostering an environment where all voices are heard, especially in critical situations.

Implementation in Healthcare

1. Safety Culture: Developing a culture of safety is fundamental to becoming an HRO. In healthcare, this means encouraging open communication, where staff members feel comfortable reporting errors or near misses without fear of punishment. Leadership plays a crucial role in establishing and maintaining this culture.

2. Error Prevention Strategies: Hospitals that strive to become HROs implement systematic error-prevention strategies, such as checklists, standardized procedures, and continuous training programs. These tools help reduce variability in care processes and ensure that best practices are followed.

3. Continuous Learning and Improvement: HROs in healthcare are committed to continuous learning. They regularly analyze incidents and near-misses to identify the root causes of errors, and they apply this knowledge to prevent future occurrences. This requires a robust incident reporting system and a culture that prioritizes learning over blame.

4. Patient-Centered Care: High-reliability healthcare organizations focus on delivering patient-centered care, which involves tailoring healthcare services to meet the individual needs of patients. This approach ensures that patients are actively involved in their care and that their preferences, needs, and values are respected.

5. Leadership and Governance: Strong leadership is essential for healthcare organizations aspiring to high reliability. Leaders must be committed to the principles of high reliability and ensure that these principles are embedded throughout the organization. This includes providing the necessary resources, training, and support to foster a high-reliability culture.

Challenges and Barriers

• Resource Constraints: Achieving high reliability in healthcare requires significant investment in training, technology, and process improvement. Resource limitations can be a significant barrier, especially in smaller or underfunded institutions.

• Resistance to Change: Changing the culture within a healthcare organization can be difficult. Resistance from staff who are accustomed to existing practices can hinder the transition to high-reliability practices.

• Complexity of Healthcare Delivery: The sheer complexity of healthcare, with its numerous interacting components and human factors, makes achieving high reliability a challenging task.

Accountable Care Units and Structured Interdisciplinary Bedside Rounds

The Accountable Care Unit (ACU care model) is designed to improve healthcare delivery by restructuring the way care is provided in hospital units. A key component of the ACU model is patient-centered care, with Structured Interdisciplinary Bedside Rounds (SIBR rounds) playing a key role. SIBR rounds bring together the patient's interdisciplinary care team to collaboratively discuss and manage patient care at the bedside with the patient and their family present. This model aligns closely with the principles of High-Reliability Organizations (HROs) and can play a significant role in supporting and underpinning the formation of healthcare HROs.

ACU Features

The ACU care model reorganizes traditional hospital units to enhance accountability, teamwork, and patient-centered care. In an ACU, the entire team — nurses, physicians, pharmacists, case managers, and other allied health professionals — work together to optimize care delivery. This structure ensures that care is consistent, efficient, and aligned with best practices. Key features include:

1. Geographic Cohorting: Physicians are co-located with their the majority of their patients within a specific unit where the same multidisciplinary team provides care. This reduces variability and increases familiarity among team members with both the unit's processes and the patients. Familiarity builds trust within the team and improves communication, leading to happier staff and patients. We are aften asked do ALL of the physician's patients need to be on the same unit, and the answer is no: if approximately 80%+ of a physician's patients are on a single unit then it is more than enough.

2. Patient Centered Care: The ACU care model places patients at the center of care and supports units to implement patient-centered care processes: (1) at the change of shift to optimize the transfer of patient information from the off-going to on-coming shift and (2) during the shift to share updates and progress the plan of care and discharge.

3. Dedicated Unit Co-Leadership: Each ACU is typically led by a unit medical director and nurse director who are responsible for the performance of the unit, ensuring that the team works cohesively towards shared goals. The medical directors can of course work on other units in the hospital, but will spend most of their work days on their ACU.

4. Performance Metrics: ACUs track and report on specific performance metrics, such as patient outcomes, safety indicators, and efficiency, fostering a culture of continuous improvement. Units report back performance to the frontline teams at regular intervals, and engage and empower unit staff in local improvement initiatives to build a sense of ownership and responsibility.

Structured Interdisciplinary Bedside Rounds (SIBR)

SIBR rounds are the centerpiece of the ACU model, bringing together all members of the care team to discuss each patient's care plan at the bedside. The structured nature of these rounds ensures that all relevant aspects of a patient's care are reviewed and that each team member's expertise is utilized.

How SIBR Rounds Work:

• Interdisciplinary Participation: SIBR rounds include physicians, nurses and sometimes the patient and their family at a minimum. Then dependent on the unit's resources pharmacists, social workers or therapists may also participate. This ensures that all perspectives and updates are shared and considered in the care plan.

• Structured Agenda: SIBR rounds follow a structured format, which typically includes a review of the reason for hospitalization, the patient's status and interval test results and updates, identification of potential risks or concerns, discussion of the care plan, and confirmation of the discharge plan. This structure minimizes the chance of overlooking important details.

• Patient-Centered Care: By conducting rounds at the bedside, SIBR ensures that patients are actively involved in their care. This promotes care transparency, improves patient satisfaction, and enhances the alignment of care with patient goals and preferences.

How ACUs with SIBR rounds support and underpin healthcare HROs

1. Enhancing Communication and Teamwork:

   • The ACU model with SIBR rounds fosters robust interdisciplinary communication and collaboration, a critical component of high-reliability healthcare. By bringing the entire care team together at the bedside, SIBR rounds ensure that all team members are on the same page regarding the patient’s care plan, reducing the risk of miscommunication and errors.

2. Preoccupation with Failure:

   • SIBR rounds align with the HRO principle of preoccupation with failure by systematically addressing potential issues before they become problems. The structured discussion during rounds allows the team to proactively identify and mitigate risks, enhancing patient safety.

3. Commitment to Resilience:

   • The ACU model’s emphasis on continuous monitoring and adjustment of care plans contributes to organizational resilience. By regularly reviewing and updating care strategies during SIBR rounds, the team is better prepared to respond to unexpected changes in a patient’s condition.

4. Sensitivity to Operations:

   • SIBR rounds enhance the team’s sensitivity to operations by providing real-time, on-the-ground insights into patient care. The entire care team gains a deeper understanding of the patient’s current status and the operational dynamics of the unit, allowing for more informed and agile decision-making.

5. Deference to Expertise:

   • The interdisciplinary nature of SIBR rounds exemplifies deference to expertise. By bringing together professionals from various disciplines, the ACU model ensures that decisions are informed by the best available knowledge, regardless of hierarchy, which is a core principle of HROs.

6. Cultural Shift Toward Safety and Accountability:

   • The ACU model promotes a culture of safety and accountability, key tenets of HROs. By assigning specific teams to specific units and making them accountable for outcomes, the model ensures that everyone is responsible for maintaining high standards of care and safety.

7. Continuous Learning and Improvement:

   • Performance metrics in the ACU model support the HRO focus on continuous learning and improvement. Regular tracking of outcomes and safety indicators allows the unit to identify areas for improvement and implement changes, thus fostering a culture of continuous learning.

8. Patient and Family Involvement:

   • By involving patients and their families directly in the care process during SIBR rounds, the ACU model enhances transparency and ensures that care is aligned with the patient’s values and preferences, reinforcing the HRO principle of patient-centered care.

Implementation Challenges and Considerations

• Cultural Resistance: Shifting to an ACU model with SIBR rounds may encounter resistance from staff accustomed to traditional care models, with lower levels of accountability and transparency. Effective change management and strong leadership are crucial to overcoming this barrier. Thankfully there is significant evidence regarding the benefits of ACUs and SIBR rounds to encourage staff to keep an open mind about the potential improvements and efficiencies that could be achieved.

• Resource Requirements: Implementing the ACU model requires some resources, including limited time for training, monitoring, and managing the unit, though this is the work that units should be doing to optimize care delivery. Hospitals must be prepared to invest in these areas to realize the benefits.

• Sustainability: Maintaining the ACU model and SIBR rounds requires ongoing commitment from leadership and frontline staff. Continuous monitoring and adaptation are necessary to sustain high reliability over time. We at 1Unit have developed software solutions to optimize the upskilling of staff and the process monitoring, with on-demand reports available about each unit's current status and recent activity.