Safety and High Reliability in the Hospital Radiology Department

What is a high-reliability organization (HRO)? Quint Studer, founder and board chair at Studer Group, Inc., defines high-reliability organizations as “organizations with systems in place that make them exceptionally consistent in accomplishing their goals and avoiding potentially catastrophic errors.”1 The original HRO research focused on complex environments with a high probability of accidents (naval aircraft carriers, the air traffic control system, and nuclear power generation), so the guiding principles translate well to the radiology department, where the primary objective is to perform high-quality examinations and provide accurate interpretations in a timely fashion while keeping patients safe.

High reliability performance–or trustworthiness–is based on principles that define a strong safety culture. Derived from the Institute of Nuclear Power Operations (INPO), a culture of safety within healthcare is “an organization’s values and behaviors–modeled by its leaders and internalized by its members–that serve to make [patient] safety the overriding priority.”2

To create and sustain a meaningful culture of safety, everyone assumes responsibility for patient safety. Leaders make commitment to safety a top priority: An atmosphere of trust facilitating honest communication without fear of punitive action is critical. In turn, this cultivates a questioning attitude and healthy opportunities for staff development.

Decision-making is always focused on safety first, and associates value health care and view their role in serving patients a privilege. A strong emphasis on learning and process improvement pervades the organization, and policies and procedures are regularly reviewed and modified to reflect patient safety, a dynamic phenomenon under constant scrutiny to affect ongoing positive growth.2

Leading an HRO

Leaders within an HRO must approach the challenge with clarity and purpose and embrace the cultural transformation required to meet strategic imperatives. They model behavior that reflects commitment to safety for patients and associates; train the team; and rely on metrics such as the serious safety-event rate (SSER) to monitor harmful events.

The day begins with a safety huddle or safety check-in, a mechanism that encourages error, problem, and event reporting (the so-called holes in the Swiss cheese). This is a time to identify barriers that impede team members from performing effectively to prevent patient or associate harm. Leaders publicly acknowledge those who speak up in the interest of safety and applaud those who question classic dogma, engage in thought sharing and “think outside the box” to improve quality and patient safety.

Leaders hold themselves and the team accountable, creating an atmosphere of collegiality, teamwork, and collaboration in which everyone adopts the practices necessary to reduce human error. Leaders reinforce good habits, correct poor ones, and never punish honest mistakes. On the other hand, they demonstrate zero tolerance for reckless behavior. Ambassadors for a fair and just culture, they support “Red Rules”, hospital-wide mandates observed to ensure patient safety. All practitioners are expected to be in compliance and violation can result in serious disciplinary consequences. An example of a Red Rule is the “time out” before the commencement of any invasive procedure.

Truly modifying behaviors, attitudes, and performance among a heterogeneous group of individuals requires transformational change and the commitment to incremental stages of progress. The process can be slow, but ultimately quite rewarding. The leader plays a pivotal role in maintaining momentum and creating synergism among the team, so the importance he or she attaches to the initiative is critical.

Rather than view the process as a directive from hospital administration, an effective leader welcomes the challenge, champions the purpose and supports the efforts of others in order to sustain growth and development. A good leader seeks out the value each person on the team brings to the table and nurtures it. Individuals become genuinely engaged when they feel that what they do is worthwhile and substantive. People follow leaders who are authentic, demonstrate appreciation and generate an esprit de corps. This is the bedrock for better patient care, improved clinical outcomes and a functional work environment.

Five principles of HROs

Five recognized principles of HROs can be applied to radiology: preoccupation with failure; reluctance to simplify; sensitivity to operations; commitment to resilience; and deference to expertise.3

Preoccupation with failure. This implies identifying potential missteps that could lead to catastrophic safety occurrences. Proactive rather than reactive behavior is woven into the fabric of daily practice. It requires re-thinking seemingly minor issues as not mere standard deviations, but interrelated components of larger system failures.

Before starting a radiologic procedure, for example, technologists and/or nurses should assemble all materials that will be needed to complete the study. Supplies should be in the room and in multiples. This strong sense of personal ownership and being prepared will alleviate mistakes later. When staff is rushing in and out of the procedure room scrambling to locate equipment, contrast or syringes, the atmosphere grows chaotic and the radiologist distracted and oftentimes stressed—the perfect storm for making a mistake or worse, creating a sentinel event.

Near misses are potential process failures on which a functional team will reflect. Directing laser focus on the chain of events leading up to the near-hit is the perfect way to assess points along the continuum of care that warrant modification. Complacency in the status quo of mediocre systems must be replaced by aggressive troubleshooting and the need for constant improvement.

Reluctance to oversimplify. Radiology is a specialty grounded in extreme complexity. The expansive formulary of exams, procedures and protocols, imaging modalities, subspecialties, disease entities, reporting structures, and IT interoperability are just a few of the components that comprise an imaging department. Ascribing an easy solution to integrated process breakdown is not always appropriate. HROs resist the urge to “fix” problems with broad, rational excuses. Leaders in HROs scratch past the surface issues and dig deep to find the real cause for error.

The new healthcare reality of doing more with less has prompted aggressive cost containment throughout radiology departments now faced with the difficult task of downsizing. Although decreased numbers of employees can lead to real problems in efficiency, workflow, and patient satisfaction, many organizations are recognizing that eliminating redundant processes can be beneficial. For example, the intuitive or superficial explanation for why workers today are stressed and feel rushed is that fewer associates are performing the same workload as before. Although technically the mathematics of this is true, a more profound explanation for the harried atmosphere created by the re-tooled workforce warrants further investigation. One of the real reasons employees may experience anxiety and frustration is poor or misguided management.

In today’s world, managers, especially front-line managers, must negotiate uncharted waters with their team and coach them through transition. They must anticipate new types of problems brought on by leaner resources, cross-training and re-training. Those employees who adapt easily, multi-task and problem solve should be placed in positions that exploit those talents. Individuals with different skills should be matched with new roles that are a better fit. Educating the staff in how to worker better (not just faster) is the first step in assuaging resentment and feelings of inadequacy. Equipping co-workers with the tools to succeed facilitates the best outcomes, promotes healthy engagement, and defends against low morale.

Sensitivity to operations. Radiology departments are filled with policy and procedure manuals either housed in the faithful oversized three-ringed binder or accessible online. What is recorded, however, and what actually happens in real life are not always in sync. Leaders in HROs appreciate this phenomenon as an occupational hazard and opportunity for improvement. They accept responsibility for identifying to what extent discordance occurs by creating a plan of action for ameliorating obstacles. In addition to physically walking around to learn more—a traditional albeit effective way of understanding what staff actually do on a daily basis—computer-generated analytics tools are available that can be programmed to troubleshoot and assess care delivery during an exam or procedure.

For example, at Advocate Lutheran General Hospital, we utilize an informatics platform that can analyze IV contrast documentation accuracy across multiple systems (e.g., manual captures in RIS and PACs versus automated injector apparatus recording). The following scenarios (see figure) demonstrate how discrepancies in contrast documentation can occur (how much contrast was actually loaded into the injector and what volumes were recorded in RIS and PACs). In the first case (pulmonary embolism CT angiography), 71.49 cc were loaded into the injector (70.14 cc delivered). The technologist wrote 200 cc in RIS. This translates into close to a 130 cc variance. Later, 51 cc was manually recorded into PACs – a variance of about 19 cc.

In the second case (CT chest/abdomen/pelvis), a total of 150.55 cc were loaded into the injector (149.75 cc delivered). Manual documentation in RIS was 97 cc or a variance of 52.75 cc. In PACs, 97 cc were recorded or a variance of 52.75 cc.

This simple exercise underscores the importance of performing regular internal audits to recognize what is mandated as policy and procedure versus what actually transpires. Presenting anonymous objective data to staff in a supportive environment uncovers potentially serious errors, reinforcing culture-of-safety behaviors when administrating iodinated contrast: meticulous documentation, attention to detail, and accuracy.

Mistakes happen

Maintaining and exercising flexibility when errors occur is integral to an HRO. Whether it’s a HIPAA violation from a security breach or scanning the wrong patient, mistakes happen. A functional and successful organization has mechanisms in place to contain and limit the damage. No one person is ever solely responsible for an error. A lattice of multiple linked events facilitates or predisposes the final act that leads to potential harm. “Human error is not the cause of failure, but a symptom of failure. It should be the starting point for investigation, not the conclusion,” advises Healthcare Performance Improvement, LLC, Virginia Beach, Va., a healthcare consulting group that leverages the best practices of HROs.4

A safety event compels the organization to act swiftly in the short-term, but built-in system redundancies allow HROs to adapt appropriately to change. Once imminent or immediate danger has been neutralized, longer-term process analysis can begin. This is an opportunity to ask: Is the right process in place? Have the expectations within the accountability infrastructure been clearly defined and communicated? Have the right people been assigned for the process to work?

Threats to safety that put patients and associates at risk for harm can be divided into individual behaviors, team behaviors, and work conditions. Individual behaviors include rushing around being distracted, deliberately keeping quiet when something isn’t safe, disobeying the rules, and focusing on “getting it done” rather than concentrating on doing it correctly. Team behaviors include handing off incomplete information, not working together as a team, retreating into “silence or violence” as a way to abort dialogue, communicating ineffectively, and fearing to speak up to authority. Work conditions define an environment in which there are too many things to do (either perceived or real), it’s difficult to get answers to questions, people don’t have the knowledge to do the job, the focus is always on putting out fires, and the demand is there to do more with less.4

Recognizing that an amalgam of disruptive behaviors and suboptimal work conditions can lead to a safety event is an important step in preventing harm. One way to monitor the environment in a radiology department is to regularly recruit feedback from staff and continuously identify emerging problems before they bloom into serious issues. Staff support through education (on-line tutorials, lectures, webinars), coaching (informal one-on-one discussions, group workshops) and skills development (simulation lab experience, off-campus retreats) help ensure organizational resilience.

Deference to local expertise. The final tent pole in establishing a culture of safety in a high-reliability environment relates to the concept of power distance derived from Geert Hofestede.5 As seen by subordinates, perceived hierarchal distance—not necessarily the real difference—can serve as an impediment to quality improvement. Ignoring or minimizing the value of frontline workers in providing useful feedback about process improvement is short sighted and inefficient. In the highly hierarchal system of healthcare, however, executive leadership determines strategy and people in the field carry out the day-to-day maneuvers. This large distance is characterized by autocratic and paternalistic governance in which formal, high-ranking positions hold the power; a small distance includes consultative and democratic relations; individuals relate as equals regardless of formal positions.

In order to establish a culture of safety in an environment of trustworthiness, the dynamics of the power- distance paradigm must be recognized and openly discussed. While an adroit leader understands that a first-year radiology resident holds a more advanced degree and is higher ranked than a veteran ultrasound technologist, he or she also recognizes that the technologist naturally brings more value to the team. Leaders in tune with and sensitive to the normal ebb and flow of shifting roles over time and relative to the task at hand respond accordingly. Deferring to the expertise of the most qualified individual in the group regardless of title not only demonstrates trust and respect, but is in the best interest of patient care.

Leaders struggle with how to get started in establishing and maintaining a safe and trustworthy imaging environment. Intuitively we understand the significance and appreciate the call to action. Identifying the nuts and bolts of how to pull all the puzzle pieces together in a timely fashion without disrupting work flow is what differentiates those who can take control and make a difference from those who can’t—or won’t.

The new reality is one in which many radiologists are working longer and transitioning later in an effort to achieve retirement financial security. The idea of spearheading a large-scale initiative—regardless of governmental mandates—can seem overwhelming and a task better suited for their younger, more energetic colleagues. Junior radiologists, on the other hand, lack interest in this regard and instead are preoccupied with making partner, juggling work life balance, or tallying RVUs as employed physicians.

The fact is, the best way to affect meaningful change in today’s fast paced world of technologic innovation is to form a coalition of engaged individuals, each possessing a unique set of skills and fund of knowledge. Measures to improve quality and enhance patient safety must be objective and reliable. Outcomes determine best practices and must be in alignment with the strategic imperative of the organization. Data-driven performance and accountability define a quality improvement project (QIP), which provides the framework to implement, track, monitor, and optimize policies, procedures and processes (see sidebar).

We have been successful in implementing advanced technologies in our CT department at Advocate Lutheran General Hospital based on the QIP approach. In 2011 we piloted an innovative CT computer-assisted, weight-based software in the administration of IV contrast for CT studies. We were able to maintain high image quality while decreasing contrast volume and waste. Through a multi-pronged educational initiative, technologists demonstrated 100% compliance in utilizing the new imaging algorithm in just a few short weeks. Earlier this year, we installed a dose analytics tool to track, monitor and decrease CT ionizing radiation. Through study review, protocol optimization, and a comprehensive interactive staff assessment and education program, CTDIvol values for several commonly performed CT studies decreased.

References

1. Gamble, M. 5 traits of High Reliability Organizations: How to hardwire each in your organization. Becker’s Hospital Review. April 29, 2013. Accessed September 22, 2014: http://www.beckershospitalreview.com/hospital-management-administration/5-traits-of-high-reliability-organizations-how-to-hardwire-each-in-your-organization.html
2. Institute of Nuclear Power Operations. Principles for a strong nuclear safety culture. http://www.nrc.gov/about-nrc/regulatory/enforcement/INPO_PrinciplesSafetyCulture.pdf. Published November 2004. Accessed September 22, 2014.
3. Weick KE, Sutcliff KM. Managing the unexpected: Assuring high performance in an age of complexity. San Francisco, CA: Jossey-Bass; 2001.
4. Healthcare Performance Improvement, LLC. High Reliability Series for Advocate Health Care. Downers Grove, IL; 2014.
5. Hofstede, Geert (2001). Culture’s Consequences: comparing values, behaviors, institutions, and organizations across nations (2nd ed.). Thousand Oaks, CA: Sage Publications.