The question always comes up is why the healthcare delivery system is not as reliable as other industries and especially like the airline industry? In recent years, healthcare consumers, providers, payers, and other key stakeholders have demanded better patient care and business outcomes and have asked similar questions about achieving a high reliability organization status and reliable performance results [9].
An HRO model is an environment of “collective mindfulness” where all physicians, caregivers, employees, management, and key stakeholders look for, and report, small problems or unsafe conditions before they pose a substantial risk to their patients and when they are easy and affordable to fix. Contemporary literature reveals the implementation of HRO model in clinics and physician-based practices creates improvement in the following outcomes: organizational effectiveness, organizational efficiency, customer satisfaction, compliance, documentation, and organizational culture [9]. Implementing an effective HRO model helps physician practices’ leaders and practitioners design their organizations around anticipating and preventing problems [6].
As the healthcare industry sets its target to improve patient care outcomes and business performance results, it becomes clear this industry needs to invest more resources and effort to catch up to other consumer-based industries with solid track record implementing high reliability organization model. The HRO model is a mission-critical for clinics and physician-based practices to address current healthcare needs and anticipated future requirements [20]. Achieving consistent and reliable patient care outcomes and sustainable business performance results should be a shared vision and a common destiny.
In recent years, the U.S. healthcare industry has been active in responding to major reform initiatives and evolving socioeconomic trends. These initiatives and trends range from the Patient Protection and Affordable Care Act (PPACA), Accountable Care Organization (ACO), population health, bundled payment system, patient safety, the transition to valuebased reimbursement, to the rise of healthcare consumerism and increasing complexity in clinical care climate [24]. These significant forces are leading Healthcare Organizations (HCOs) including physician practices and clinics to seek better medical care coordination inside and outside their walls. These entities have learned they can benefit tremendously from embracing high reliability organization model to manage these forces and trends and addressing anticipated needs. The critical goal for clinics and physician-based practices is to ensure they are doing everything they can to improve outcomes and experiences for patients, their families, communities, and key stakeholders [27].
In this case study, the HRO model and its relevance to healthcare industry will be introduced. An in-depth analysis of how HRO model facilitates innovation and promotes performance excellence in the healthcare industry will be covered. Also, this paper will assess the path forward to HRO Model implementation and transformation in the healthcare industry and the risks and roadblocks that may impact how healthcare organizations use HRO model to deliver reliable, quality, and value patient care services. Finally, this paper will review the resources available to promote and implement HRO and how future trends in healthcare will shape the HRO model.
HRO Guiding Principles |
Explanation and Relevance |
Preoccupations with failure |
Embrace failures and weak signals |
Reluctance to simplify |
Categories unavoidable, but carried lightly |
Sensitivity to operations |
Recognize accidents are not results of 1 error |
Commitment to organization resilience |
Identify, control, and recover from errors |
Deference to qualified and relevant expertise |
Encourage communication from all levels |
In a recent Senate hearing, a 2014 patient safety study was cited as preventable medical errors persist as the number three killer in the U.S. – third only to heart disease and cancer – claiming the lives of some 400,000 people each year [2]. Do the airline and healthcare industries have similar outcomes? Despite several high-profile airline accidents, the year 2014, turned out to be a very safe year for commercial aviation, according to recently published aviation safety data. Most airline accidents in 2014 involved cargo flights (10) and passenger flights (8). Given the expected worldwide air traffic of 33,000,000 flights a year, the accident rate is one fatal passenger flight accident per 4,125,000 flights [1]. Obviously, the difference in reliability outcomes between the two industries is significant, and it should compel healthcare organizations and their leaders to consider what types of evidence-based models and strategies to use to address critical healthcare issues. Implementing a high reliability organization model is essential to address complex clinical and business challenges and opportunities [5].
Recently released data from different government and private sources show an increasing number health systems, rural hospitals, clinics and physicians based practices, and academic medical centers face significant financial challenges [26]. On the contrary, the recent two years for the airline industry were the most profitable ever. Again, shouldn’t healthcare organizations consider implementing HRO model to cut waste, improve business performance outcomes, and to enhance the financial position and viability?
As the U.S. economy transitions itself due to emerging business, population, socioeconomic and political trends and forces, many industries have successfully developed sustainable, reliable, and systematic strategic and operational plans to cope with these evolving trends and forces. The airline industry after the 9/11 attacks in 2001 and the great economic recession of 2009 has successfully been able to survive and thrive. This industry successfully managed to address complex operational, logistical, security, and resources demands despite the fact of facing challenging business conditions, complex and costly government mandates and regulations, and global competitive forces. At the same time, no one can ignore the fact the healthcare industry has made noticeable strides and improvements over the last decade. However, the results achieved do not quite simply justify or support the investment, resources, and or efforts made. In other words, the healthcare industry is not where it should be when it comes to being a high reliability industry [29].
Under this transition, the current White House administration is embracing a vision for the future of the healthcare industry and in particular the Medicare program by committing to clear goals and a timeline for shifting Medicare payments from volume-to-value. It is predicted the new administration in the White House after the 2016 election will continue this commitment. In this environment, medical providers need a reliable strategy to transcend traditional cost reduction approaches and responds to new payment models. If providers can improve and sustain patient outcomes, they can sustain or grow their market share. If they can improve the efficiency and reliability of providing excellent medical care, they will enter any contracting discussion from a position of competitive strength [19]. Those providers who improve value will be the most competitive. Clinics, physician-based practices, and integrated health systems that fail to enhance value proposition, no matter how prestigious and influential they seem today, are likely to encounter growing competitive pressure and challenges [24].
To leverage this impactful change and to manage its requirements, healthcare providers should embrace HRO model [11]. It is believed healthcare organizations and their leaders need to do more to change the status quo and to become high reliable organizations and to learn best practices from other industries that have achieved consistent reliability and performance results. The airline industry has worked tirelessly on these problems (delays, over-processing, redundant work, poor inventory management, inefficient transport, cost overruns, overproduction, and defects that cause harm and re-work) for decades. Although its operations and flow patterns are significantly less complex than healthcare, it has mastered basic elements where healthcare industry can learn from to give it a jump-start on mastering and managing a difficult but necessary components of operational design that will lead to reliable and improved outcomes at lower costs. i.e., value-based proposition [25].
The case calling for the healthcare industry to embrace HRO model and innovation is starting to pay off in meaningful and incremental successes. These successes in recent years affirm the establishment of the relationships between Weick and Sutcliffe’s HRO principles and desired clinical and business behaviors of healthcare providers. Some of these practices and examples about the HRO principles are presented below in (Table 2).
HRO Guiding Principles |
Corresponding Behavior of |
Examples in Healthcare |
Preoccupations with failure |
Attitude |
RNs and other clinical care |
Reluctance to simplify |
Metacognitive skills |
Attending residents and fellows |
Sensitivity to operations |
Systems-based value proposition and practices |
Outgoing RN shift teams |
Commitment to organization resilience |
Leadership and team focus on competency skills |
Nurse team leader monitors a |
Deference to qualified and relevant expertise |
Emotional intelligence; advocacy, accountability, and assertion |
Nurses more than ever before |
By focusing on bedside shift reports and improving communication with patients, providers, among other things, nurses at seven Washington state hospitals and clinics were able to make a significant impact in the work they do. The American Association of Critical-Care Nurses recently reported the result from its Clinical Scene Investigator Academy, a 16-month, team-based program to encourage RNs as leaders and change champions in their clinics. Among the success, those involved in the program were able to decrease medication errors, eliminate patient’s falls, and increase patient mobility, with a projected cost saving of almost $570, 0000.
For HRO model to deliver the desired performance results healthcare systems and clinics must have in place capable and robust IT structures to facilitate clinical data exchanges between providers and other stakeholders [9]. These days the diversity of information systems in healthcare delivery setting presents challenges to patient data sharing. Interoperability among disparate vendor applications remains one of the most significant roadblocks to providing continuity of care across the clinical setting [28]. These roadblocks are driven by many complex issues including the lack of clinical IT standards, high integration costs for physician practices and other non-acute services, and lack of electronic health record automaton in nursing homes and urgent care centers. The American Hospital Association (AHA) Report: “Why Interoperability matters, 2015,” indicates increasing number of integrated health systems starting to set up standards to share information for care coordination with nonaffiliated ambulatory providers. Many of these health systems are HRO adopters and in their pursuit of information sharing, they have implemented systematic protocols and standards to facilitate clinical data exchange.
UPMC, the well-known Pittsburgh-based healthcare network, is committed to HRO model as it leverages its investments to improve patient outcomes, increase efficiency, reliability, and quality, and to reduce healthcare costs. The commitment to HRO model is a mission-critical innovation and it is expected to shape behaviors for the rising risk population. UPMC is expected to go live soon with a substantial enhancement to its telehealth program. UPMC will deploy a comprehensive cloud-based platform to facilitate virtual care visits to those with chronic diseases.
The Advocate Healthcare, faith-based, the not-for-profit health system based in Downers Grove, Illinois, has operated as a value-based medical care organization for several years. This integrated system is moving from fee-for-service revenue models to value-based reimbursement and leading Advocate toward adopting sophisticated clinical data exchanges and analytics systems to quantify quality measures and track process improvement. The Advocate had a big problem with siloed and fragmented data spread across many EHR systems that did not integrate well together. With the goal of becoming a high reliable organization, Advocate was motivated to improve patient care and control costs and decided to invest in partnership with a national healthcare information technology vendor and set up a cloud-based analytics platform to integrate data from all the EHRs within Advocate’s existing information technology infrastructure.
Leaders of Hartford HealthCare system formed a crossfunctional team. These teams included nurses, physicians, case managers, social workers, clinical trainers, business executives and informational technologists from across the organization. The team main task was to ensure the new clinical decision support system tracks and evaluates existing clinical and patient care workflows. Adopting this strategy have allowed Hartford HealthCare to reap many strategic benefits ranging from improved discharge planning achieving and improving population health management outcomes. This high reliability organization component implemented at this system has served as the catalyst for a cultural shift that resulted in an improved, streamlined care transition process and less variation across the system. These benefits will be the underpinning of high reliability organization’s success in managing population health needs, improving outcomes, and controlling overall healthcare costs [2].
HRO model adoption not only creates an opportunity for innovation in technology, data analytics, and IT infrastructure but also promotes innovation opportunities in many other areas of the healthcare delivery ecosystem [25]. In recent years, increasing number of outpatient facilities has embraced Lean design to improve patient throughput. Porter and Lee delineate nowadays in an ambulatory care setting, what it was done in the outpatient arena is what it used to be done 10 years ago in an inpatient setting [24]. As ambulatory care has flourished, the U.S. healthcare market has focused increasingly on efficiency and the patient experience. Health systems implementing HRO model are building ambulatory care facilities throughout their communities, rather than just on the main hospital campus—as patient convenience and a healthcare organization’s visibility in the community are now key factors in choosing preferred ambulatory care sites [29]. Off-site ambulatory facilities also can make health and wellness services more accessible to patients, improve the reliability of patient care delivery, and increase patient satisfaction. Children’s Hospital of Philadelphia has built ambulatory clinics off the main campus to improve the patient care experience and takes away patients’ anxiety of going to the main hospital campus.
While many healthcare systems have pursued a strategy of providing community-based care in a more accessible, convenient and less intimidating environment, implementing HRO model has also provided health systems, clinics, and physician practices the opportunity to focus on facility design and patient care experience [7]. These organizations conduct extensive research to listen to patients and customers and understand how they interact with and perceive healthcare spaces, how healthcare providers apply treatments, therapies, and procedures, and how to standardize clinical spaces within buildings and across their institutions in different site locations and settings. The reason is, these systems are now having their staff travel from location to location. Therefore, a standardized clinic module can support a variety of specialties and is easy for people who work at multiple sites to navigate [17]. Many clinic rooms are now designed for efficient and comfortable care. They are built both for exams and consultations, so patients and physicians do not have to move to another room for a consult.
As payment shifts to value-based models, increasing number of healthcare organizations will pursue lower-cost settings more aggressively than before while employing creative approaches to distributing and delivering medical care [22]. Every healthcare system attempting to start a new medical facility should utilize Lean methodology [7]. Not only does the process help organizations design efficient operational workflows and the necessary auxiliary facilities to support them, but it also stresses continuous improvement and support of HRO model [27]. The St. Louis Children’s Specialty Care Center is one of the only of few stand-alone, comprehensive outpatient facilities in U.S. focused exclusively on patients up to the age of 21 and it is 12 miles from the main St. Louis Children’s Hospital campus in a suburban area. This center is an example of how HRO model can fosters innovation to provide comprehensive community-based care in a more accessible, convenient, and more welcoming environment.
The HRO model implementation impact is reaching beyond the basic clinical care setting to medical insurance payers integrated across the entire continuum of medical care. The Accountable Care Organization transformation in recent year has given these insurance payers the opportunity to work directly and collaboratively with hospitals and physician practices in each community. This collaborative effort critical in supporting practice transformation from a reactive model of patient care to a proactively accountable care, analyzing population data to measure, monitor, and manage the healthcare of patients and present results and outcomes to these organizations [9]. United Healthcare Accountable Care Practice consultants and teams work collaboratively and directly with various healthcare systems and physician practices to improve access to medical care. They use practice level population data to analyze overall capacity/demand for appointment and visits patterns by practice clinic site and assist the practice leadership to implement process improvement to reach mutual goals and improve patient access. These teams help hospitals reduce inappropriate ER use by using the hospital’s Admission, Discharge, and Transfer (ADT) and daily ER data to analyze trends and outliers and work with all community partners to implement proactive strategies to address issues, and measure impact using Rapid Cycle Improvement, PDCA (Plan-Do-Check-Act) approach.
These teams engage and coordinate with hospitals’ clinical care teams to reduce avoidable admissions and readmissions by tracking and managing medical care transitions of all discharges and ensure follow-up with Primary Care Physicians (PCPs) and or specialists within seven days. These teams use predictive modeling analysis of practice population to improve the medical care of high-risk patients and assist practices in identifying cohorts of high-risk health home patients for focused and enhanced improvement initiatives.
Also, United Healthcare clinical teams and consultants support various healthcare systems and practices in implementing process improvements to assist the practice in becoming a certified Patient Centered Medical Home (PCMH). This is another valuable HRO approach leveraged where United Healthcare engages with many health systems by assisting them in creating workflows to optimize care delivery, introducing best practices improvements, and evaluating outcomes using rapid cycle improvement PDCA method.
The National Patient Safety Foundation’s recent report, “Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after “To Err Is Human,“ proposed greater oversight, communication, funding, and support to help improve patient safety and the reliability of patient care delivery models. Integrated health systems and clinics can make substantial progress toward high reliability organization model by undertaking several specific organizational change initiatives. The leaders of these organizations must continually challenge and improve upon themselves and how they respond to reliability and performance concerns. This improvement will ultimately drive a shared sense of resilience throughout the organization [27].
Health systems and clinics employee large numbers of staff and utilize expensive physical resources. Providing this type of feedback to staff and for them to function as an HRO, they need responsive clinical and business systems in place and a mindset to allow multiple stakeholders to receive and respond to relevant feedback, rather than being overwhelmed by information [13].
The Kotter’s 8-Step Process for Leading Change presented in (Table 3) serves an effective conduit for leaders and organizations trying to transform or execute their strategies [18]. Both the initial Leading Change 8-Step Process (1996) and Accelerate 8-Step Process (2014) models can serve the needs of the healthcare industry to facilitate and implement HRO model. By applying the Kotter’s 8-step
Process, healthcare leaders and organizations should gain unprecedented decision-making authority and leverage, the risks of doing so, and the rewards of an exponentially more efficient and more resilient organization.
Leading Changes 8-Step Process (1996) |
Accelerate 8-Step Process (2014) |
Respond to or affect episodic change in |
Run the steps concurrently and |
Drive change with a small, powerful core group |
Form a large volunteer army from up, down |
Function within a traditional hierarchy |
Function in a network flexibly and agilely |
Focus on doing one new thing very well in a linear fashion over time |
Constantly seek opportunities, identify |
Integrated health systems can leverage data analytics to make significant improvements in clinical and business outcomes [25]. Recent findings have indicated the rapid growth of predictive analytics enables health systems and clinics to spot trends from avoidable patient readmissions to staffing and physical resources needs. Predictive analytics enabled the Robert Wood Johnson University Hospital (RWJUH) and its many clinics in 2016 to save $10 million using workforce analytics by addressing staff issues and increasing employee engagement. Also, RWJUH has also increased employee engagement and reduced staffing issues without layoffs. This health system needed and used clinical and business data to help in many areas such as improving operations, making evidence-based decisions and taking the most appropriate action, and eventually implementing an effective HRO model.
Also of an added value for healthcare organizations attempting to implement HRO is to consider the Baldrige Criteria for Performance Excellence, Core Values and Concepts, and Guidelines for evaluating an organization’s processes and results (www.nist.gov/baldrige/ ). The recent updated Baldrige Criteria Program features a renewed focus on managing all of the components of the organization as a unified whole; managing change; and dealing with data analytics, data integrity, and cyber security. The ratio of the Baldrige Program’s benefits for the U.S. economy to its costs is estimated at 820 to 1. Many healthcare organizations that employ the Baldrige Criteria outperform their non-Baldrige peer systems by achieving faster 5-year performance improvement than peers. Whether used as guidance in establishing an integrated performance management system or for self-assessing progress or benchmark purposes the Baldrige Criteria Program is about helping healthcare organizations, no matter what size or type, innovate, improve, and become Reliable [23].
In this case study, we learned that implementing evidence-based HRO model has many strategic and tactical benefits and it could serve as a successful model for healthcare systems transformation and innovation across the country. The roads to success in HROs depend on dedicated and relentless leadership that puts quality, safety, and excellence as the central focus of strategic success. Health systems like Intermountain, UPMC, Cleveland Clinic, RWJUH, and others have revamped clinical and business operations throughout the care delivery ecosystem. Empirical research and lessons learned from the practitioner setting have shown HRO model is beginning to provide insight into the context of medical care to influence reliability [29]. This insight has been instrumental for healthcare organizations to tie organizational results back to their purpose and worthwhile work; these organizations more than ever before are inspired to achieve great results and become highly reliable.
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