Five Steps to Improve Your Decision-Making Processes and Become a High Reliability Organization

Ways to improve ineffective policies and broken processes.

Ways to improve ineffective policies and broken processes.

Despite increased emphasis on patient outcomes and safety, medical errors in hospitals and clinics are a leading cause of death in the United States, resulting in approximately 100,000 deaths each year. To prevent these errors, healthcare organizations need to establish a safety culture that focuses on improving processes by viewing medical errors as challenges that must be overcome.

High reliability organizations (HROs) are organizations that successfully avoid catastrophe, despite a high level of operational risk and complexity. Typically, even minor errors in these organizations can result in disastrous consequences and heavy cost to human life. Think nuclear power plants or air traffic control systems. Healthcare organizations—where mistakes can result in serious, if not fatal, consequences—need to learn from their mistakes and improve ineffective policies and broken processes. In addition to examining mistakes that caused patient harm, clinicians also need to focus on near misses, identifying faulty processes and/or situations that could potentially cause harm in the future. With the shift to value-based reimbursement, improving care quality and clinical outcomes is essential.

Better decision-making improves care quality. Improving your clinical evidence-based decision-making is one important step healthcare organizations can take toward high reliability. To do this, you need to engage clinical staff in decision-making regarding products, technology, and patient care protocols. You’ll also need an appropriate combination of supporting technologies, evidence sources, and team collaboration.

With the COVID-19 pandemic, physicians are leaving private practice to be employed by healthcare organizations. Historically, there has been a big disconnect between administrators’ and physicians’ perceptions of physicians’ experiences. Administrators thought physicians were involved in decision-making, but physicians didn’t always agree. To have buy-in and be engaged, employed physicians need to feel they are part of the clinical team making decisions that impact patient care delivery. They also need to understand the organization’s decision-making process. If an organization’s decisions aren’t solid, physicians may be skeptical of the organization and become disengaged. Disengaged physicians are less productive and more likely to leave for greener pastures.

RELATED WHITE PAPER: Toward A High Reliability Organization

Follow these five steps to help your organization improve its decision-making and become an HRO:

  1. Include physicians and other front-line clinical staff in decision-making. Healthcare HROs focus on improving clinical processes and operations. Every voice matters. Physicians and other frontline clinical staff are in the best position to spot potential failures and identify areas for improvement, so they should be included in your team that evaluates new product requests. Clinical staff should help evaluate new technologies and services through an automated workflow tool and standardize the environment, equipment, and procedures.
  2. Use unbiased clinical evidence to make objective purchasing decisions. HROs defer to expertise; they rely on experts—not authority figures—to make decisions. Physicians and other clinical experts, more than hospital administrators, are needed to evaluate new product requests and respond to patient safety issues. Your decision-making team should consider the clinical evidence and safety data for new products, instead of making purchasing decisions based solely on cost or subjective opinions. Clinical evidence reveals the effectiveness (or lack thereof) of a device or technology, which has a direct impact upon patient satisfaction, readmission rates, and measurable improvements in care.
  3. Standardize your clinical processes using checklists and scorecards. HROs are preoccupied with failure, immediately and completely addressing any human, technical, or process failure—no matter how small. Hospital staff identify, troubleshoot, and build new processes around potential process breakdowns before they become systemic, eliminating the bad decisions that result in high-risk or unforeseen patient care scenarios. By standardizing clinical practices and the utilization of products (based on clinical evidence), you can simplify new product decision-making; improve clinical outcomes; prevent patient safety issues; decrease hospital readmissions; and eliminate waste (e.g., ineffective products or procedures). Assume that you will need to modify your processes when they fail.
    Standardizing the healthcare environment promotes a culture of safety and high reliability. For example, standardizing the equipment used in the operating room (and its location) makes it quicker for providers to find the necessary equipment and supplies. When everything is in its place, providers can take care of patients without being distracted as they search for what they need. Patient safety and care quality aren’t compromised by unexpected distractions. For example, by using only two orthopedic trays, instead of eight trays, you reduce waste (purchasing unnecessary equipment) and the amount of equipment (including unused equipment) you need to sterilize.
  4. Use data to improve your processes. If a patient has a negative outcome, it could be due to a variety of problems: environmental, staffing, process, or some other cause. For this reason, HROs are reluctant to simplify. They reject simple diagnoses of problems, instead conducting root cause analyses. To challenge long-standing beliefs about why problems occur, healthcare HRO leaders must examine clinical outcome data, benchmarks, and other performance data. The NIH’s Comprehensive Safe Start, for example, reflects a reluctance to simplify, and can be used to examine and improve every step in the care process. You should review new medical technologies six to twelve months after implementation to answer these questions: Was the length of stay correct? Was the support staff number appropriate? Are the patients in the appropriate status post-procedure? What impact has the procedure had on patient satisfaction and outcomes? If your performance data tells you a process isn’t working, it’s time to correct that process.
  5. Standardize your decision-making processes. HROs are committed to resilience. They recover quickly by anticipating trouble spots and improvising when the unexpected occurs. They prepare for emergencies, identify errors that need to be corrected, and develop innovative, cross-departmental solutions that extend beyond the four walls of the operating room. When you have a standardized, transparent decision-making process based on data (e.g., clinical evidence, financial, and safety data) and clinical experience, with everyone having an equal voice, stakeholders understand how and why new product decisions are being made. With this understanding, they become more engaged and open to modifying processes. Workflow software standardizes the decision-making process and makes it transparent.

There is no “one size fits all” approach to quality improvement and becoming an HRO. But deciding to adopt the cultural changes to drive the decision-making necessary to facilitate higher-quality care is a necessary first step. Actually accomplishing that goal proves to be difficult. TractManager is here to help. For more information on taking the next steps, read our new white paper titled “Toward A High Reliability Organization.”


Mark S. Kestner, MD, MBA

Chief Medical Officer

Mark is a surgeon with deep leadership experience in military, university, integrated delivery, and especially community-based healthcare systems.


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