Program Teaches UHN Leaders How to Put High Reliability Theory into Practice

Added on Dec 20, 2018

Program Teaches UHN Leaders How to Put High Reliability Theory into Practice
By Audrey Doyle

A multimodal training program that combines simulation, videos and a quiz show-style game with traditional education techniques has helped University Health Network (UHN) reinforce leaders’ understanding of how High Reliability leadership methods drive culture change and advance patient and staff safety.

Comprising seven 2- to 3-hour training modules, the mandatory program, called “Making Reliability a Reality,” is a key component of UHN’s Caring Safely patient and workplace safety initiative. The goal of the program is to teach clinical and nonclinical leaders throughout UHN how to consistently and confidently embed the concepts of safety and High Reliability into their daily interactions with staff.

Since the training was launched in 2017, Toronto-based UHN has achieved quantifiable improvements in a number of key safety measures, according to Ivanka Hanley, senior education specialist. Of note, she said, incident reporting has increased 20%, indicating that staff members feel more empowered to report the occurrence of near-miss, precursor and Serious Safety Events (SSEs). Additionally, at least 14 unit or site “record bests” have been achieved for number of days with zero hospital-acquired conditions (HACs). 

These improvements wouldn’t have been accomplished, however, had the team not acted on leaders’ feedback and made some changes to the final module in the program. “Partway through the program, some leaders were still struggling to apply some of the principles we’d been teaching,” said Hanley. “So we reconsidered how to round out the program, and the changes we made, coupled with the other UHN safety initiatives, have had a positive impact on our safety scores.” 

Building on a Foundation of Safety

According to Hanley, UHN has been implementing strategies to reduce harm and improve patient and staff safety for several years. For instance, the health care and medical research organization has a host of structured safety programs in place, and it continuously monitors for the occurrence of HACs, SSEs and never events. In addition, UHN has a Safety and Quality Committee that has been advising its Board of Trustees on their governance responsibilities for reviewing, ensuring and continuously improving safety and quality of care in all four of its hospitals since the early 2000s.

In 2015, UHN built on this foundation of safety with the launch of the Caring Safely initiative. Developed with assistance from Press Ganey HPI safety consultants, Caring Safely is based on the concept that preventable harm can be mitigated or eliminated through culture transformation and the consistent application of proven safety standards and High Reliability best practices.

According to Brenda Perkins-Meingast, UHN’s Practice-Based Education director and Caring Safely Education lead, UHN developed the “Making Reliability a Reality” training program in 2016 to reinforce the High Reliability leadership methods embedded in Caring Safely. 

“We created the education program because we wanted everyone at the manager level and above—whether they’re in a clinical or a nonclinical position—to be accountable for practicing safety behaviors themselves,” said Perkins-Meingast, who, along with Hanley, presented a session on the program at the 2018 Press Ganey National Client and Executive Leadership Conferences in Orlando last month. “We wanted our leaders to lead with safety so they’d have a positive influence on the safety behavior of their teams.”

To this end, each of the “Making Reliability a Reality” training modules is designed to teach leaders how to use Press Ganey HPI’s evidence-based leadership methods, safety behaviors and error prevention tools to promote a culture of safety and High Reliability within their units and departments. The modules were developed by Perkins-Meingast, Hanley and Shawna Fraser, education coordinator, in collaboration with Press Ganey and content experts at UHN, and were initially delivered to UHN’s approximately 700 leaders over the course of seven months beginning in February 2017. Today, when new leaders join the organization, they’re required to complete the training as part of their orientation, according to Perkins-Meingast. 

Module 1 covers the five best practices of High Reliability Organizations (HROs): Preoccupation with Failure, Reluctance to Simplify, Sensitivity to Operations, Deference to Expertise and Commitment to Resilience. Leaders also learn the importance of committing to a goal of Zero Harm, establishing a positive safety culture and instituting a robust process improvement culture.

Module 2 teaches safety behaviors and error prevention tools, such as Pay Attention to Detail Using STAR (Stop, Think, Act, Review); Speak Up for Safety Using ARCC (Ask a question, Request a change, voice a Concern, invoke the Chain of command); Have a Questioning Attitude Using Question & Confirm; and Communicate Clearly Using 3-Way Repeat-Back, Clarifying Questions, Phonetic & Numeric Clarifications, and SBAR (Situation, Background, Assessment, Recommendation).

“This module also teaches the Partner for Accountability safety behavior and the error prevention tools of Cross-Check, where we work as a team to check each other’s work to prevent errors, and 5-to-1 Feedback, where we provide five encouraging comments for every one corrective comment,” said Hanley.

Module 3 discusses how daily safety huddles and visual boards can be used to find and fix problems, and Module 4 teaches the importance of building and reinforcing a culture of accountability in patient safety.

In Module 5, cause analysis is the focus. “It’s especially important for leaders to know how to perform a cause analysis so they can better understand why a safety event occurred and how to prevent it from recurring,” said Perkins-Meingast, stressing that the goal of such analyses is not to penalize individuals or call out their wrongdoings, but to identify process and system issues. In this module, leaders also learn about corrective action plans, including ways to identify solutions that directly address root causes, and ensuring that the actions are SMART (Specific, Measurable, Actions-oriented, Realistic and Time-constrained) and that they incorporate HRO behavior.

Module 6 emphasizes the concept of a fair and just culture by teaching leaders the difference between human error, behavioral choices and system weaknesses as the cause of safety events, with the goal of increasing the reporting of near-miss and precursor safety events, decreasing the number of SSEs, and decreasing the anonymous reporting of safety events systemwide. 

Adjusting the Program to Enhance Learning

Module 7, the final module in the training program, was going to focus on additional High Reliability leadership methods. But the team decided to make some modifications to ensure a complete understanding of the principles they’d already covered.

“At the beginning of each new module, we were asking the group if they were using the behaviors and tools we’d previously covered,” said Perkins-Meingast. At first the responses were positive, she said, but over time, it became clear that for some of the leaders, additional reinforcement was necessary. According to Perkins-Meingast, starting each meeting with a safety story, rounding to influence, cause solving using individual and system failure mode taxonomies, and the concepts underlying a fair and just culture were challenging for these leaders to embed into their daily practice.

“In addition to this, these leaders were looking at each training module as a standalone concept or method or tool, and didn’t appreciate how all the modules fit together,” added Hanley. “We knew we needed to circle back and come up with a way to use Module 7 to reinforce what we’d been covering throughout the program.”

To optimize the adoption of concepts from the previous modules, the team devoted Module 7 to tying together all the behaviors and tools covered in Modules 1 through 6. And to further engage the leaders in the learning process, they decided to make the experience more interactive.

To achieve this goal, three short videos were created, each one demonstrating through simulated role-play a different leadership method: unit huddles, storytelling, or rounding to influence. Each video is followed by an interactive team activity designed to spark discussion around the topic being presented.

“For example, we taped a huddle that purposely went awry—it didn’t start on time, they didn’t use the visual board, people were disengaged, and they didn’t take problem solving offline. Then we divided the leaders into teams and asked, ‘What was missing? What went well? What will you do differently when you conduct your own huddle tomorrow?’” explained Perkins-Meingast. “They were able to see what methods worked and how they apply to their own huddles.” 

Adding Gaming Simulation Techniques

Perkins-Meingast and Hanley also implemented a game based on the popular quiz show Jeopardy! As Hanley explained, leaders break into teams of five, and each team chooses a category—Safety Behaviors, Error Prevention Tools, Just Culture, Individual and System Failure Modes, or Serious Safety Event Classification. The team members are presented with a clue in the form of an answer, and on a whiteboard they write their agreed-upon response, phrased in the form of a question. Then all the responses are discussed as a group to ensure comprehension. “This turned out to be a fun and effective way to refresh leaders’ memory about what we covered in the other modules,” said Hanley.

The final component of Module 7 is a simulation in which participants act out a Serious Safety Event that actually occurred at one of UHN’s hospitals. The event involved a patient who died as a result of a failure to recognize and respond to patient deterioration and escalate care. “When the leaders watched the simulation, it elicited a real emotional response. Many were in tears,” Perkins-Meingast said.

“Through the simulation, leaders learned that events like this—where people don’t communicate clearly, or they second-guess themselves, or they don’t question and confirm, or the culture doesn’t support speaking up—happen far too frequently,” she continued. “They also learned that error prevention tools and techniques like SBAR and Question & Confirm could have prevented this particular event from happening, and that understanding the root cause and applying the appropriate solutions can prevent it from happening again.”

To ensure that they continue to build capacity in High Reliability among leaders, the team has collaborated with engineers in the Healthcare Human Factors group at UHN, along with simulation experts at UHN’s Michener Institute of Education, to create additional educational courses that they expect to begin delivering in early 2019.

“The courses focus on how people’s behavior is influenced by their environment, and they support a deeper look into identifying the right cause so the correct solution beyond a superficial fix can be put in place,” Perkins-Meingast said.

“Leaders play a vital role in developing a safety culture,” she concluded. “By ensuring that our leaders understand High Reliability leadership methods and are embedding them into their daily practice, we’re making reliability a reality for our patients and staff.”