Travel Buddies: Leaders Share Insights Along the High Reliability Journey

During our time in Telluride over the last eight years, preparing medical students and residents to handle the challenges that lie ahead–interpersonally, professionally and through patient care–we would make an annual hike up to the waterfall at Bear Creek mountain. The hike itself was an excellent environment to apply creative thinking to the material presented throughout the week. It also served as a physical metaphor for the professional challenges that the students will face once they graduate. A long hike like this that starts at 9000′ and rises to over 11,000′ is always safest with a buddy–and navigating the healthcare profession is no different–especially today.

Our hike is also a journey, not a race, taking almost four hours to complete. On the hike we talk about the similar “journey” healthcare is taking towards High Reliability. That’s why those like myself, leading change within healthcare systems, like my own MedStar Health, have focused our direction toward high reliability. We look to others who have already started down the road to high reliability for insight. Steve Muething MD and VP of Patient Safety at Cincinnati Children’s Hospital (CCH) has provided great insight through his online presentations, along with others who openly share their stories of transformation, such as Gary Kaplan at Virginia Mason Medical Center.

In 2010, Steve gave a talk on situational awareness at the 2010 Risky Business meeting. Risky Business is a non-profit collaborative between CCH, the Great Ormond Street Hospital for Children NHS Trust and others, and their goals are:

  • To think outside our “box” and share new ideas about managing risk and human factors from other high risk industries.
  • To understand why humans make mistakes, and how to mitigate and recover from them.
  • To learn how to manage and add value from critical incidents.
  • To learn from defining moments in other high risk industries.
  • To share ideas about leadership and teamwork from the highest achievers in sport, business, politics, the arts, exploration, space and medicine.
  • To hear about the experiences of well know whistleblowers when all else failed.
  • To learn more about the importance of appropriate regulation, when, by who and by how much.
  • To understand the role of the law and the media when things have gone wrong.
  • To share pragmatic examples of excellence in improvement and transformation at individual and organizational level.

Steve’s talk at this meeting focused on how his organization was reducing Serious Safety Events by raising situational awareness with the use of a tool that could predict and catch children likely to deteriorate at a time care providers could intervene and have a chance at changing the outcome. He describes three levels of situational awareness and where they occur:

  1. At the bedside level: Where less experienced healthcare providers are caring for patients.
  2. At the microsystem level: Where more experienced providers are in charge and understand the need to act on data received.
  3. At the organizational level: Where hot spots in the hospital are known, and the ability to provide additional resources to be successful is available.

And he shared the five risk factors CCH identified, at least one of which they found to be present every time a child deteriorated:

  1. Elevated PEWS (Pediatric Early Warning Score)
  2. High risk drug or therapy
  3. Family expressed concern
  4. Communication breakdown
  5. Patient is a “watcher”–the gut says “something is happening”

To catch a child before they coded or needed to transfer to the PICU, each level of patient care was required to report up a level on each of these five risk factors every four hours, even if the answer was to report no concerns. They took the “let me know if there is a problem” mentality out of the equation, and simply made it policy to anticipate and catch a problem by being aware around the clock. He also shared insight from his visit to an aircraft carrier, and the resulting knowledge that taught him just how similar his hospital was to that environment. I encourage you to watch the video and share your thoughts.

For those embarking on their own high reliability journey, I welcome the trial and error discussion here–a place where those of us traveling the same road can share what is working, what presents challenges and who has found some answers we can all apply. We can both teach and learn together, as we each do our part to improve the system in which we have dedicated our lives to serve our patients.

2 Comments on “Travel Buddies: Leaders Share Insights Along the High Reliability Journey”

  1. Jason Newland says:

    Hi David,
    Another outstanding post. We have been trying to learn from Steve and Cincinnati Childrens and our now a part of the Ohio Collaborative for Solutions for Patient Safety. In this journey we are trying to create high reliability organizations. Yesterday, we started a daily safety update that occurs at 9:10 everyday and lasts 20 minutes. The hope is to know at an organizational levels the hot spots and to try to predict problems and mitigate them before they occur. As part of this network all of the 33 hospitals are dedicated to starting these daily safety briefs or updates.

    I will say the momentum and the excitement in our organization around doing this has been amazing. Will it reduce harms? It has to as we know communication and knowledge is power.

    Thanks again for a great post. I will be sharing it with many.

    • Jason,
      Thanks for sharing that story. People got excited when we start work like you described. The power is always in sustaining the momentum and excitement. Celebrating small wins and good catches on a regular basis helps do that.

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