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High Reliability

Sensitivity to Operations

In this lesson on High Reliability Organizations (HRO) , we discuss the need for laboratories to treat "routine" tests as anything but routine. How does your laboratory handle the crush of data and detail in its daily operation - and still be sensitive to possible signs of failure?

High Reliability Organization Principle #3:
Sensitivity to Operations

February 2009
Sten Westgard, MS

In this lesson, we'll discuss the third in our series of High Reliability Organization principles: Sensitivity to Operations. Don't worry, this does not involve group therapy, nor does it necessarily involve some kind of surgery. Instead, it's a commitment to paying attention to the "sharp end" of work. This concept is found at the opposite end of the strategic view. Rather than focus on the traditional strategic planning "big picture," this principle describes a local, tactical "big picture" that concentrates on the many details of the daily routines. It's also been called "situational awareness", on-going real-time awareness, and in the US Navy, it's called "having the bubble":

"those who man the combat operations centers of US Navy Ships use the term 'having the bubble' to indicate that they have been able to construct and maintain the cognitive map that allows them to integrate such diverse inputs as combat status, information sensors and remote observation, and the real-time status and performance of the various weapons and systems into a single picture of the ship's overall situation and operation status."1

In other words, Sensitivity to Operations describes how high reliability occurs at the most basic process level, the high reliability that happens while actual work is being done. How does the organization balance routine work with reliability? Do workers pay attention to small signs of emerging problems? Do they keep the "big picture" in mind, and maintain communication with other workers, and ensure that as many people as possible are informed about the state of operations?

How does an organization maintain Sensitivity to Operations?

While it would be easy to place the burden of this concept squarely on the shoulders of workers, it's not enough to have skilled workers with good judgment. Heroic leadership, or heroic workership, is not the essence of Sensitivity to Operations. It may be more important for the staff to work as a team in specific ways:

  1. Insure frequent communication between and among workers
  2. Deepen people's "understanding of the interdependent workings of the complex system itself."2
  3. Make certain that empowered management is available to workers, to ensure a rapid response to developing problems.

Sensitivity to Operations is bigger than one person, because the system is always beyond the scope of an individual worker. Thus, the effective sensitivity emerges organically from a team of workers paying attention and exchanging information about the status of current work processes. It's a "big picture" because it encompasses information beyond any single individual perspective. This is the opposite of groupthink, where a like-minded set of individuals refuse to see things that differ than their shared mental model. Sensitivity to Operations on a team level creates a wide angle view of the real processes of the system, based on the actual details.

 

Maintaining Frequent Communication and Deepening understanding of the complexity of the system: Examples in Healthcare

We're going to address the first two points together, since the communication between workers is what is necessary to deepen their understanding of the system.

Healthcare is a workplace with extreme hierarchical differentiation and multiple decision-makers. Sadly, the doctors and nurses, just to mention one of the obvious differences, are not always on the same page. Take your garden variety office visit: how often is the story you tell the nurse about your condition get relayed accurately to the doctor? Usually you have to tell the story twice, right? The challenge to get different professionals to communicate effectively is daunting:

"As most teams in health care are comprised of four to six unique individuals, however, decisions are not always unanimous....[A]s different team members are trained separately in their respective professions...they have learned to communicate differently and have varying styles of conveying information depending on their role."3

A quick way to understand this is to think of the nurses on a patient floor. Does everyone know who the sickest patient is that day? Undoubtedly at least one nurse knows, but when the entire staff on the floor knows, that can help speed a response to a sudden crisis.

Sentara Health built its expectations about communication directly into several Behavior Based Expectations (BBEs) for their staff. There are only five BBEs, of which four are concerned with communication of operational detail:

  • Communicate clearly; use repeat-backs and clarifying questions;
  • Have a questioning attitude; stop actions when unsure about their safety.
  • Handoff effectively using a "5P" checklist to ensure that all elements of a successful transfer are followed: Patient/Project, Plan, Purpose, Problems, Precautions.
  • Never leave your wingman, which means using peer checking and peer coaching when appropriate.4

Here's another description of the communication needed to maintain Sensitivity to Operations:

"Closed loop communication and well developed shared situation awareness are key within this type of environment. Closed loop communication consists of the team's ability to exchange clear concise information, to acknowledge receipt of the information, and to confirm its correct understanding. When doctors prescribe medications for patients, it is critical that the nurse acknowledges that the request has been received [read-back] and the doctor verifies that the correct prescription is being obtained. Similarly, as a patient is transferred from one department to another (for example, from EMS to the emergency room), it is important that all of the necessary information (such as 'vitals') is transmitted and received accurately."5

Returning to Sentara as an example, they instituted daily check-in meetings to keep the entire staff aware of the most important problems and key details about what's happening that shift. One of the sample agendas included these items:

  • Issues in the past 12 hours.
  • Any pressing problems at present.
  • Any anticipated problems coming up.
  • Staffing issues.
  • Flow issues.
  • Facility issues.

Sentara keeps the check-in time consistent and never cancels the meeting. It's a "stand-up" meeting to keep it short and focused.6

Christiana Care created a similar program on a slightly higher level:

"To keep all staff members informed of patient safety issues, Christiana elects a "Patient Safety Mentor" from each medical unit who is responsible for attending bimonthly meetings. During these meetings, mentors report on their unit's measurement of the national patient safety goals and communicate back to their individual units the issues discussed at the meeting. Committee members have the opportunity to share stories of recent patient safety events and hear strategies for improvement from other members. To ensure that all the information discussed at the meetings gets communicated to each member's medical unit, all the meeting information is placed in a public system. These meetings serve as a way for staff members from different medical units to build awareness of the kinds of patient safety issues occurring throughout the hospital. The meetings also help to detect patterns in events related to patient safety."7

Maintaining Frequent Communication and Deepening understanding of the complexity of the system:
Examples from the Laboratory.

In one aspect, laboratories are extremely aware of their operations. They generate a tremendous volume of results and metrics and data about performance, probably far more than they can actually analyze on that particular day. Labs are monitoring TAT, QC, critical tests, etc. Not only is the laboratory doing a lot of the monitoring of the details of daily work, there is a professional focus on the processes.

However, this strength in gathering data can be a weakness from another perspective. A laboratory can easily drown in all the data, so the real test is if the staff can identify the most important details of the day. For example, which out-of-control events are important? Is there a regular meeting for different laboratory shifts? Are staff techs aware of the most troublesome method in the lab that day? What's the "sickest" method in the laboratory? Is the staff aware of which instruments have deteriorating - but not yet deficient - performance? Can the staff identify which instruments have been recently calibrated, upgraded, or had significant maintenance? Is there awareness when new control lots have been introduced? Is the staff aware of methods that are generating more clinician concern than normal? Does the staff know which test has gotten the most number of complaints from clinicians?

From a simple technical perspective, the laboratory starts with statistical quality control results. The next step toward better sensitivity would be to design those QC procedures to detect medically important errors - while avoiding false rejections. Further sensitivity could be developed through the addition of non-statistical QC checks like patient data QC, or perhaps delta checks, etc. "Warning rules" could also be added, so that drifts could be detected before they develop into full-fledged "out-of-control" events. But beyond the gathering of this data, the laboratory needs an effective way to communicate it throughout the laboratory and even, when necessary, further up the chaoin of command. Making sure that laboratory staff understand the difference between a rejection rule and a warning rule, for example, is crucial for the proper interpretation of these signals.

Clearly, all kinds of information could be useful to the entire laboratory. Informations systems that can display the QC results on a network, or remotely, might help communicate the information beyond the instrument itself. Some labs have adopted electronic boards that give a "real time" display of the testing processes. Each laboratory needs to decide what is most important and how to communicate that between the workers.

Making empowered management available to workers: Healthcare examples

It's not enough for workers to know what's going on with the system. They have to be able to act upon that information. If the front-line staff is powerless to fix or prevent an emerging threat, and management is not available, there's not much point to being informed. Keeping the management involved is important.

Within the healthcare hierarchy, as noted earlier, the connection of upper levels of management to the front line of work can seem tenuous. How many patients actually see an executive during their encounter with the system? How many executives are available to make changes and impact patient care on any given day?

Picking up the Sentara Leigh example, they took actions to place their management closer to the real work of the organiization.

"Sentara Leigh also realized the need for hospital executives and leaders to directly observe and communicate with staff providing direct patient care. Such opportunities would allow leaders to identify issues they needed to address. Of equal importance was the need to reflect the significance they placed on direct patient care and on understanding and supporting the staff who provide it. To address this need they implemented "executive walkarounds."

"Each day at 8:00 a.m., a group of hospital executives meets and walks through the hospital observing patient care and informally talking with staff along the way. Participants in these walkarounds observe, ask questions, and note issues raised by staff, which they address after the walkaround ends. Consistency, approachability, and responsiveness to concerns that staff raise have enabled Sentara Leigh to break down communication barriers between leadership and staff that exist in many other hospitals.8

 

These "executive walkrounds" have been discussed in the literature - and have even been trademarked:

"Thematic issues come up continuously in varying ways during the WalkRoundsTM. Problems of the magnitude of the shortage of nurses and pharmacists usually require large-scale efforts beyond the local facility’s resources. An executive who hears about this kind of issue during rounds—often over and over again every week—should respond by reminding other rounds participants of the limitations facing the system, seek out ideas for improvement, and discuss efforts that are under way to address them.

"BWH’s [Brigham Young Hospital] experience suggests that participating in WalkRoundsTM helps executives witness the effects of budgetary decisions on actual operations. The concept of latent factors, in which decisions made at the “blunt,”or administrative, end of care may lead to events of harm to patients, becomes more real for them. Seeing the direct effects of actions, as opposed to discussing them in the abstract, can constitute a powerful inducement to change."9

WalkRounds are not actually not a novel concept - Hewlett and Packard called it Management by Walking Around and Honda called it the 3 Gs (Genba, Genbutsu, and Genjitsu, which means roughly “actual place”, “actual thing”, and “actual situation”). Getting management back in touch with daily operations is always a good idea. The more management sees the daily problems, the more likely they are able to - and willing to - fix them.

Making empowered management available to workers: Laboratory Examples

Here we encounter a real challenge for the laboratory. Does the medical director actually understand the quality control processes of their laboratory? Unfortunately, some of today's laboratory directors are directors in name only, or directors who tend only to the pathology side, and leave the technical details of the other testing areas to a subordinate. This was one of the contributing factors to the Maryland General Scandal. But Maryland General wasn't the only laboratory with a leadership problem.

Revisiting the Maryland General problem is instructive. The problems there were well-known by the laboratory technicians, but management refused to act. Indeed, the upper levels intimidated lab workers for complaining about poorly functioning instruments and quality practices. For a laboratory to rise to the level of high reliability, there must be management support and involvement. Every laboratory technologist has to have the confidence and support to stop a dangerous testing process, hold back a run, or call a time-out before specimens get loaded.

One of the obstacles to managerial support is simple ignorance. Laboratory processes are intensely technical and administrators above the bench level often lack a real understanding of how much effort and focus is required to properly manage them. Administrators sometimes fail to appreciate the detail and demands of the testing processes. Clinicians often do not comprehend the uncertainty of the test results. When Point-of-Care devices get introduced to non-laboratorians, there is inevitably a chorus of complaints about the quality control procedures; non-laboratory professionals simply assume that testing processes don't need as much quality control as they actually do.

Here is where a broader effort is needed. Not only does the laboratory need to educate the managers and higher level officers in the organization on the scope of the challenges, there also needs to be an effort to raise the profile of the profession and promote the mission. One of the reasons the laboratory is often under-resourced is because it is under-appreciated. Laboratory technicians do not enjoy the same heroic status as doctors or nurses - there are no prime-time television shows dedicated to the careers and personal lives of laboratory professionals.

Labs are Vital, COLA's Laboratorians: Saving Lives One Test at a Time, and CAP's Every number is a Life, are just three of a growing number of programs dedicated to increasing awareness about the importance of the laboratory in healthcare. These efforts are not going to make huge improvements overnight, but on a longer time scale, they will help the laboratory get the respect and attention it needs from administrators and management.

 

Threats to Sensitivity to Operations.

The description of how this HRO principle works is distressingly "soft", in that there are not a lot of numbers or concrete calculations to act upon. It may be easier to understand this principle by describing the "Insensitivities" to Operations that can develop and try to avoid those practices.

Threat #1: Valuing some kind of information above others.

Engineering cultures typically prefer "hard" data over qualitative data. Numbers over gut feelings. Objective, formal knowledge is valued more than experiential learning. The worker who makes an "on-the-spot" interpretation of a process may not conform to the models, rules, and procedures that the organization has created. But above all, the HRO values the right choice, not the choice that should be right according to the rules and equations.

In the laboratory, quality control provides a vast supply of hard numbers. However, the basis for those numbers might be corrupted (by artificially-widened limits or improperly-adopted ranges). A bench-level worker's intuition may become more important; if they can sense an instrument is beginning to degrade in performance, that's a signal that should be acted upon. If a tech thinks that the method is going bad, don't feel obligated to stick to the QC numbers.

Threat #2: Mindless routine

Remember, there are two definitions of routine. The first definition of routine is a regular, automatic activity. The second definition is a trivial, unimportant, or safe activity. A "routine test" is a test we don't have to worry about.

For HROs, Sensitivity to Operations means taking the routine out of routine. Workers need to act "mindfully." They can't blindly apply the routines and rules without adjusting them to the particular circumstances of the moment. While command-and-control management likes to act as if workers can be programmed like automatons, the reality is that we want and need workers to use their heads. If a routine needs to be adjusted because of a peculiar set of conditions, we need to empower our workers to do that. We also need them to pay attention while they're performing those routines, to pick up subtle signals of emerging problems.

"Mindfulness" is the opposite of compliance. Compliance asserts adherence to a rule. Mindfulness is the triumph of reality over procedure.

Threat #3: Overestimation of Safety.

Paradoxically, organizations often learn the wrong lesson from a close call. Instead of seeing danger in the guise of safety, they see safety in the guise of danger. After a near-miss, they breathe a sigh of relief, and continue onward, thinking that they are safer than they really are.

With NASA, increasing burn marks on the rocket O-rings convinced them that the O-rings were robust and could tolerate ever greater demands. Likewise, mounting evidence of larger and larger foam strikes led management to believe that they did not have to worry. Both decisions concluded that earlier near-accidents were proof that the system was safe. In both cases, managers were catastrophically mistaken.

With Laboratory QC, QC seems to be a victim of its own success. The ability of statistical QC to detect errors has been so successful that laboratories have become complacent. Labs now believe that errors don't occur very often and thus, they should be able to do less QC. That's like removing the number of smoke detectors from your building every year that you don't have a fire. That works until it doesn't, and then it's a disaster.

"HROs worry about the blind spots that are associated with safe interpretations of a near miss. the principle of sensitivity to operations is a guideline that can offset some of this blindness if it is translated into practices that focus on actual work rather than intentions, define actual work by its relationships rather than its parts, and treat routine work as anything but automatic."10

Conclusion

Sensitivity to Operations is a way of articulating the commitment to the do the routine work of the organization well. High Reliability requires both top management engagement and worker commitment. Workers must be willing to pay attention to details, communicate them both vertically and horizontally. Management must enable workers to do both of those tasks - and provide the authority to take action upon when threats are revealed.

References

1. Rochlin G.I. , 1997: Trapped in the Net. Princeton University Press, Princeton, NJ, p. 109 as quoted in Karl Weick , "Making Sense of Blurred Images: Mindful Organizing in Mission STS-107", in Organization at the Limit, eds. William H. Starbuck & Moshe Farjoun, Blackwell Publishing, (Malden, MA) pp.170-171.

2. Karl E. Weick and Kathleen M. Sutcliffe, Managing the Unexpected, Second Edition, Wiley, San Francisco, CA, 2007, p.59.

3. David P. Baker, Rachel Day, Eduardo Salas, "Teamwork as an Essential Component of High-Reliability Organizations", HSR: Health Services Research 41:4, Part II (August 2006).

4. Case Study: Accelerating Patient Safety Improvement by Strengthening the Culture of Safety - Sentara Norfolk General Hospital, September 26, 2008 Committed to Safety: Ten Case Studies on Reducing Harm to Patients by Douglas McCarthy and David Blumenthal, M.D. http://www.commonwealthfund.org/innovations/innovations_show.htm?doc_id=707602 Accessed February 10, 2009

5. K.A. Wilson, C.S.Burke, H.A. Priest, E. Salas, "Promoting health care safety through training high reliability teams", Qual Saf Health Care 2005;14:304.

6. Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. AHRQ Publication No. 08-0022, April 2008, Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/hroadvice/. Appendix A http://www.ahrq.gov/qual/hroadvice/hroadviceapa.htm#sensitivity Accessed February 10, 2009.

7. Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. AHRQ Publication No. 08-0022, April 2008, Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/hroadvice/. Appendix F http://www.ahrq.gov/qual/hroadvice/hroadviceapf.htm#sensitivity Accessed February 10, 2009.

8. Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. AHRQ Publication No. 08-0022, April 2008, Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/hroadvice/. Appendix A http://www.ahrq.gov/qual/hroadvice/hroadviceapa.htm#sensitivity Accessed February 10, 2009.

9. Allan Frankel, MD, Erin Graydon-Baker, Camilla Neppl, Terri Simmonds, RN, Michael Gustafson, MD, MBA, Tejal K. Gandhi, MD, MPH, Patient Safety Leadership WalkRoundsTM, Joint Commission Journal on Quality and Safety, January 2003, Vol 29, No.1: 16-26.

10. Weick and Sutcliffe, op. cit. p.62