FROM THE C-SUITE:
Aim for safety of planes, nuclear plants
Hospitals should aim to become high-reliability organizations
Everyone counts on high-reliability organizations to ensure their safety when flying on commercial airlines or traveling near nuclear power plants. Air traffic control, nuclear submarines, nuclear aircraft carriers and naval aviation all have well-deserved reputations for highreliability operation.
But can hospitals be evaluated by HRO standards? In general, the answer seems to be no, beginning with the Institute of Medicine’s 2000 publication of To Err is Human and continuing to the 2010 report by HHS’ inspector general’s office that 13.5% of Medicare beneficiaries suffer a preventable serious adverse event during hospital stays.
In 2006, the Memorial Hermann Healthcare System in Houston embarked on a quest to become an HRO. The high-reliability program is a key element of Memorial Hermann’s drive to provide “Best of the Best” care and be ranked in the upper few percentiles of all health systems in the country. The Memorial Hermann system has nine acute-care hospitals, including an academic medical center, a children’s hospital, two rehabilitation hospitals, 19 ambulatory surgery centers and 100 ambulatory locations.
The HRO program is called “Breakthrough in Patient Safety,” or BIPS. Engineers and other experts from nuclear power, commercial aviation and other HROs trained all health system employees to perform tasks in a safe, highly reliable manner. Among other safety behaviors, employees were trained to take a one-second stop before taking an action, because a onesecond stop has been proven to reduce errors by 90%. That behavior is called STAR for Stop, Think, Act and Review.
BIPS was required for everyone, so eventually 20,000 employees received training. New internal goals rewarded 100% compliance with CMS/Joint Commission core measures and 0% occurrences of hospital-acquired infections, patient-safety indicators and hospitalacquired conditions, also called “never events.” HRO methods were applied to blood sampling and blood administration. Check- lists were implemented in all intensive-care units and operating rooms. Memorial Hermann worked with the Joint Commission’s Center for Transforming Healthcare to radically improve hand hygiene.
In 2010-11, the results of these initiatives became apparent. Zero cases of blood incompatibility (transfusion reaction) occurred from January 2007 to present among a population of 867,000 adjusted admissions, 4.3 million days of care and nearly 500,000 transfusions. Several hospitals had gone for years without a ventilator-associated pneumonia or a central-line-associated blood-stream infection. Serious medication errors decreased to zero most months while nearly a million medications per month were being administered. Many of our hospitals had gone a full year without the occurrence of a particular HAI, PSI or HAC.
A new award, the Memorial Hermann High Reliability Certified Zero Award, was created to honor hospitals going 12 months between adverse events. Blood incompatibility and air emboli were excluded because they had long since achieved HRO status. In April 2011, 28 recipients of Certified Zero Awards were announced.
Prior to the BIPS initiative, these HAIs, PSIs and HACs were occurring almost monthly in Memorial Hermann hospitals. The Certified Zero Award has crystallized Memorial Hermann’s determination to become a highreliability organization in all respects, providing safe and efficient care to every patient and family. In 2011, the Memorial Hermann board adopted a simple mantra: “Patient safety is our core value.” Memorial Hermann’s staff and physicians are working every day to live up to that standard. Dan Wolterman is president and CEO of Memorial Hermann Healthcare System. Dr. M. Michael Shabot is the system’s chief medical officer. Editor’s Note: A longer version of this column is available at modernhealthcare.com/csuite.