High Reliability Strategy Advances “The Sharp Experience”

Added on May 18, 2017

High Reliability Strategy Advances “The Sharp Experience”
By Audrey Doyle
From Industry Edge May 2017

In 2001, Sharp HealthCare launched an initiative known as The Sharp Experience, with the goal of transforming the health care experience and becoming the best place to work, the best place to practice medicine and the best place to receive care—and ultimately becoming the best health care system in the universe.

Over the past 16 years, Sharp has continually enhanced The Sharp Experience, integrating the tenets of Planetree, Malcolm Baldrige Performance Excellence Program criteria, Magnet Recognition Program components and others, resulting in measurable advances in employee, physician and patient experience. In 2014, Sharp committed to placing a stronger focus on its culture of safety by incorporating the discipline of High Reliability into The Sharp Experience. The ultimate goals of this effort are to achieve zero defects and zero harm to employees, physicians, patients and families.

“Our High Reliability initiative continues our cultural transformation at every level of the organization,” said Patty Atkins, RN, Sharp’s vice president of Quality, Patient Safety and Lean Six Sigma. “Although we’re still at the beginning of this work, we’ve seen reductions in harm that are putting us on track to accomplish our safety and reliability objectives.”

Creating an Experience

Headquartered in San Diego, Sharp HealthCare is a nonprofit, integrated, regional health care delivery system comprising four acute care hospitals, three specialty hospitals, two affiliated medical groups and a health plan subsidiary. The organization operates 2,100 beds, and has approximately 2,600 affiliated physicians and more than 18,000 employees.

Sharp’s High Reliability initiative isn’t a standalone approach. Rather, it has been engrained in The Sharp Experience, which Atkins described as “a commitment we made years ago to deliver an exceptional health care experience, and truly the foundation for everything we do today.” As she explained, when The Sharp Experience was conceived the organization had a longstanding reputation for being a good place to work and providing a good health care experience for team members, patients and families. “But as our CEO, Mike Murphy, shared at the beginning of our journey, we didn’t want to be a good health care system, we wanted to be a great health care system. We wanted to differentiate ourselves from other organizations, in San Diego and beyond.”

Inspired by the books Good to Great by Jim Collins and The Experience Economy by B. Joseph Pine and James Gilmore, the leadership team determined that the best way to take Sharp from “good to great” was to transform the health care experience for employees, physicians, patients and their families. “We called the initiative The Sharp Experience and made a commitment to support our vision through memorable health care experiences for everyone,” said Atkins.

As part of The Sharp Experience, 26 “model developers” created a structure to align all of Sharp’s strategies under six “Pillars of Excellence”: Quality, Service, People, Finance, Growth and Community. “The success of The Sharp Experience lies in the people of Sharp being the architects of change,” said Lynn Skoczelas, Chief Experience Officer. In 2002, the standards action team, one of eight action teams comprising employees from across disciplines at all levels, created the 12 behavior standards that define the culture and have become part of every employee’s annual performance evaluation. Those behavior standards encompass such areas as compassion, reward and recognition, courteous communication, teamwork, service excellence, and privacy and confidentiality. In addition to the behavior standards, five “must-haves” were established to quickly set the tone for behavior expectations.

Efforts to advance the care experience included building strong connections with patients through collaborative health programs and multicultural services, and encouraging and supporting a culture of transparency between leaders and staff. “Also, leaders started rounding on patients regularly, and we started surveying patients about their care experiences and conducting research studies to identify areas for improvement,” said Atkins.

In 2003, Sharp partnered with General Electric’s health care division to deploy a systemwide Lean Six Sigma program. Since that time, Lean Six Sigma project teams have focused on preventing medical errors, decreasing mortality rates, reducing lengths of stay and improving quality and patient safety. The health system also began offering courses and training sessions through The Sharp University, a newly developed, in-house corporate education program designed to instruct and develop leaders in advancing the Sharp Experience vision.

Advancing the Experience with High Reliability

According to Atkins, these commitments to purposeful experience design, leadership development and process improvement delivered several positive outcomes, including an increase in employee, physician and patient satisfaction, a decrease in employee turnover, an increase in market share over each of the past 16 years, and increases in net revenue, bond ratings and philanthropic support. In addition, in 2007 Sharp received a Malcolm Baldrige National Quality Award for demonstrating quality and performance excellence in health care.

But while these efforts had driven advances in patient and employee experience, “the areas of quality and safety—which are rooted in organizational culture—were not yet at industry-leading levels, especially in regard to patient safety and mortality rates,” said Atkins.

“We looked at other organizations that were quality and safety leaders and learned that several had adopted the principles of High Reliability,” added Sharp University director Amy Kosifas. “As we grew in our knowledge of High Reliability, we recognized the value of the principles, but realized that for them to work at Sharp, we had to integrate them into our existing successful structures.”

According to Kosifas, this required aligning the health system’s core values and Pillars of Excellence with the principles of High Reliability: Preoccupation with Failure, Reluctance to Simplify, Sensitivity to Operations, Commitment to Resilience and Deference to Expertise. To do this, leaders made safety an explicit core value, and added Safety, which previously was a subset of the Quality pillar, as a seventh Pillar of Excellence.

Sharp also formed a High Reliability steering committee to lead strategy development, and systemwide action teams to define and develop actions to address perceived gaps.

To shine a light on what was driving Sharp’s safety outcomes, HPI/Press Ganey analyzed two years’ worth of patient safety and employee injury events and interviewed hundreds of people from across the organization. “The results were a big wake-up call,” said Atkins. Before partnering with HPI/Press Ganey, Sharp was conducting process-focused root cause analyses, primarily on sentinel events such as wrong-site surgeries, specimen labeling errors and foreign objects left in patients. “We weren’t looking at factors related to culture or leadership accountability, at common causes or at events that caused moderate to temporary harm,” she said.

Sharp also realized the value that High Reliability could bring to cases of employee harm, such as back injuries from handling patients, slips and falls on wet floors, and repeated falls on sidewalks that were noted as problematic but weren’t fixed, according to Atkins. “Embracing a High Reliability mindset also has a positive impact on personal safety,” she noted.

According to Atkins, HPI/Press Ganey’s analyses revealed that there were opportunities to improve critical thinking, paying attention to the task at hand and complying with known policies and procedures. In addition, in some parts of the organization staff members reported being hesitant to speak up about safety issues, even when they thought there was a risk of harm.

To address these concerns, 30 model developers were selected from across the health system to develop and champion a High Reliability model comprising strategies that everyone could adopt to also make Sharp the safest place to work, practice medicine and receive care, according to Atkins. Working with HPI/Press Ganey, the model developers created a model whose commitment is focused on “doing right every time” and includes the following key objectives:

  • Founded on The Sharp Experience
  • Committed to Zero Defects, Zero Harm
  • Promoting Mutual Respect and Teamwork
  • Creating a Culture of Safety
  • Continuously Improving Our Processes
  • Engaging Patients, Physicians and Employees

To guide the organization in meeting these objectives, the model developers and HPI/Press Ganey established two sets of High Reliability skills: a set of 13 skills for leaders to practice and a set of 14 skills for all employees to practice.

The leader skills are organized under three daily commitments: Set and lead a high-reliability mindset; Build skills and accountability; and Learn and improve as a team. Examples include starting meetings with a reflection or story, making it safe for people to speak up and applying Just Culture principles to processes and people. The skills for all employees are organized under five daily commitments: Pay attention to detail; Communicate clearly; Use critical thinking; Speak up for safety and reliability; and Learn and improve as a team. Examples include such techniques as STAR (Stop, Think, Act, Review), SBAR (Situation, Background, Assessment, Recommendation), cross-monitoring, closed-loop communication and Validate and Verify.

In addition to developing these sets of skills, Sharp aligned its 12 Sharp Experience behavior standards more closely with High Reliability principles by modifying the list to include the behavior of mutual respect and renaming the standard of “Think Safe, Be Safe” to “Zero Harm”.

Once the High Reliability skills had been identified, Sharp developed a curriculum and began conducting mandatory training sessions focusing on High Reliability skills and behaviors. To stress that these skills and behaviors apply to everybody and across all of the Sharp Pillars of Excellence, Sharp’s definition of High Reliability—“Performing as intended, consistently, over time”—is purposely generic, and each training class comprises people from across the organization. “For example, a class we taught recently included ED nurses, security personnel, a financial analyst, and front desk, corporate office and administrative staff, and each person was able to apply the High Reliability skills to the job they perform,” Atkins said, adding, “That’s the beauty of the High Reliability concept. The skills are universal.”

As of press time, Sharp had trained all its leaders in the High Reliability leader skills and nearly 9,000 of its employees in the High Reliability skills for all; the organization plans to train the remaining 9,000 employees by December. Physician education has begun as well, but because the state of California prohibits hospitals from directly employing physicians (with limited exceptions), Sharp can’t mandate that they participate in the training. However, Kosifas noted that Sharp’s independent physician association and the larger of its two group practices have made a commitment to train their physicians in High Reliability.

Atkins said that Sharp’s employee safety outcomes have improved since its High Reliability journey began, offering as an example the system’s decrease in employee total case incident rate from 8.7 in 2014 to 6.6 in Q2 2017 (the target is 5.6). She stated that wrong-site surgery, mortality and hospital-acquired infection rates also have improved, and added that California’s Hospital Quality Institute (HQI) acknowledged the organization’s progress when it named Sharp as a 2016 HQI Vanguard Award finalist for its achievements in patient safety, quality improvement and experience.

With further reinforcement of High Reliability principles and behaviors, Atkins and Kosifas expect patient safety outcomes will continue to improve. “It’s hard to change people’s mindsets; that’s where behaviors are rooted,” Atkins said. “But I’m confident that, by making High Reliability part of The Sharp Experience, we’re changing their mindsets around safety.”

“This has been a huge effort and it will require continued support systemwide,” Kosifas concluded. “But creating a safer and more reliable experience for patients and employees makes that effort worthwhile.”