Overcoming Barriers to Excellence

Overcoming Barriers to Excellence

PRESIDENT’S MESSAGE Overcoming Barriers to Excellence VICTORIA M. STEELMAN PhD, RN, CNOR, FAAN, AORN PRESIDENT I t has been 14 years since the Insti...

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t has been 14 years since the Institute of Medicine released its landmark report, To Err Is Human.1 In addition to the Institute of Medicine, other organizations (eg, Institute for Healthcare Improvement, National Quality Forum) and government agencies (eg, Centers for Medicare & Medicaid Services, Agency for Healthcare Research and Quality) are leading the way, promoting national initiatives to transform health care into a safer system. Many improvements have been made, including reductions in catheter-associated urinary tract infections,2,3 blood stream infections,4,5 and ventilator-associated pneumonia.6,7 Yet, for perioperative nursing, there is much work to be done. The Joint Commission reported that wrong-patient, wrong-procedure, and wrong-site surgeries, and retained foreign bodies after surgery were two of the top three sentinel events reported in 2013. Delay in treatment, which also can apply to the OR, was the most frequently reported sentinel event.8 Reports in the media personalize these experiences, increasing public demand for a safer health care system. Perioperative nurses should use techniques successfully used by high-reliability organizations (HROs) to realize the goals of achieving a safer health care system and overcome barriers to excellence. HIGH-RELIABILITY ORGANIZATIONS Transforming hospitals into HROs is one framework to improve the quality and safety of health

care. High reliability means delivering what is intended to be delivered 100% of the time. Highreliability methods have been used successfully by complex, high-risk industries, including aviation and nuclear power. Because of their demonstrated effectiveness and high safety records, the methods used by HROs have been increasingly adopted in health care as well. The Joint Commission and Agency for Healthcare Research and Quality recommend transforming hospitals into HROs.9,10 Hospitals that have become HROs have developed five characteristics.11 Sensitivity to Operations First, leaders and staff members are sensitive to operations, acutely aware of how processes and systems affect patient care and desired outcomes. Each employee pays close attention to what is working and what is not. These observations are used to identify risks and improve the processes and systems, instead of using workarounds. Reluctance to Simplify Second, in HROs, leaders and staff members are reluctant to accept simple explanations of problems or excuses (eg, inadequate training, communication failure). Instead, they recognize the complexity of the processes and systems and place problems within this context. By doing a “deep dive,” the underlying cause and contributing factors of problems can be explored, and acted on.


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Preoccupation With Failure Third, employees in HROs are preoccupied with failure. Every employee is vigilant, looking for ways that the systems and processes can break down. Near misses are reported and investigated, and corrective actions taken. Instead of blaming employees or patients, this work focuses on how to improve processes. Deference to Expertise Fourth, HROs defer to the expertise of frontline staff members who understand the complexity of processes and the tasks involved. Leaders listen to these individuals, regardless of seniority or hierarchy. Resilience Five, HROs are resilient. Leaders and staff members stay on course, relentlessly seeking out solutions to problems. They have specific, measurable goals and prioritize these goals. Report cards and 90-day action plans set the stage for meeting these goals. BARRIERS TO EXCELLENCE AND STRATEGIES FOR CHANGE Perioperative nurses see the barriers to achieving high reliability and excellence every day. Most of these barriers are based on perception. Some perceived barriers to excellence involve workflow and schedule changes, attitudes toward failures and mistakes, and the facility’s response to system’s issues. n

Workflow and schedule changes throughout a work shift are sometimes seen as uncontrollable: n How can I prepare for the changes in the schedule if I don’t know what they will be? n If we are efficient, will we be “rewarded” with another case? n Failures may be seen as inevitable and acceptable: mistakes happen, and people are imperfect. n Or, mistakes may be seen as the fault of an individual: if she were just more vigilant, she would not have left that sponge in the patient. 352 j AORN Journal


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There is also a common perception that reports of adverse events, near misses, and systems issues are not addressed: if the issue will not be addressed, then why take the time to report it?

These perceptions lead to complacency and lack of initiative to implement or even participate in changes to improve patient care or the workplace. These barriers may seem overwhelming. But, strategies developed by HROs can overcome these barriers and the resulting complacency. Three simple strategies used by HROs are huddles, action boards, and daily progress reports. Huddles One strategy that can be used effectively to promote high reliability is the use of huddles.12 The preprocedural briefing is one type of huddle, focusing on care of an individual patient. This provides an opportunity for everyone to prepare for potential changes that might occur during the procedure. For example, sharing the anticipation that mesh might be needed during a hernia repair allows the circulating nurse time to order the mesh and prevent a delay during surgery. Likewise, knowing that blood may be needed but none has been ordered allows the circulating nurse to anticipate and obtain the blood in a timely manner. Sharing success stories about prevented delays with surgeons enhances collaboration. Another type of huddle is at the unit level, focusing on the overall flow of the day. Key clinical leaders convene and discuss potential challenges, such as delays and add-ons, and develop a plan for addressing these challenges. This type of huddle is a stand-up meeting, is less than four minutes long, and is held at specific times every day (eg, 7 AM, 1 PM). It is important that it happens at the same time each day to use the time efficiently and to promote expectations of punctuality and attendance. The team composition depends on the facility but often includes the manager or charge nurse and the anesthesia director. In a large hospital, the team also might include clinical coordinators or the medical director.

PRESIDENT’S MESSAGE Unit level huddles have distinct benefits. They harvest the daily learning that is needed for decision making. They also provide a time and place to discuss events that occur. Huddles provide structure for a culture of transparency and a safe mechanism for open communication. They provide a culture that promotes recovery from adverse events and inclusiveness in decision making. Huddles also enhance interpersonal relationships to continually improve teamwork.12 Consider the following scenario as an example. During the 7 AM huddle, the charge nurse reports that there is a patient in the emergency department with an open fracture. Discussing this, the team develops a shared mental model of how the potential surgery can be worked into the flow of the day. The charge nurse alerts the staff in Room 1 that they may be receiving the patient after their first surgery is completed. By discussing alternative views on how and where to work the surgery in up front, the team avoids rework that might occur without a shared mental model. Action Boards Another strategy used by some high-reliability ORs is posting action boards in the hallway or lounge. Staff members or physicians post an issue on a red “defect” board. The note identifies a defect that needs to be addressed and is signed by the person posting the note. For example, an issue identified during a postoperative debriefing might be laparoscopic instrument trays that are missing a specific instrument. The RN circulator could post this on the defect board. Next, a staff member would accept the responsibility for addressing the defect. In this case, it might be a staff member in general surgery or an assistant manager. This person would move the note to a yellow “in process” board, and identify himself or herself on the note as the person accepting responsibility. After the issue has been resolved, the note would be moved to the green “resolved” board. Over time, the number of notes that have been moved to the green board increases.


The use of action boards overcomes the perception that nothing is done when issues are reported and overcomes complacency. As more and more defects move to the green board, team members take pride in their contributions and buy into the change in culture. Physicians see that issues are addressed and are more likely to engage in initiatives. Daily Progress Reports Daily reports about progress on safety issues also overcome complacency. For example, staff members can be complacent about using precautions to prevent sharps injuries and slip into unsafe handto-hand passing techniques. Posting the number of days since a sharps injury reminds everyone that these injuries can occur and diminishes the complacency that can so easily develop. Posting the number of days since a back injury reminds staff members to use mechanical lifting devices. When the posting shows “0” or “1,” it inspires discussion among staff members and a heightened vigilance. One hospital had a problem with instruments being sent to sterile reprocessing in a manner that made cleaning difficult. Posting the number of days since this occurred recognized the efforts of staff members and gave them a sense of pride in doing the right thing. Daily progress reports are also an ideal way to communicate the importance and progress made toward addressing patient safety issues. For example, posting the number of days since a missed intraoperative antibiotic redosing reminds everyone of the importance of this infection prevention measure. If focusing on prevention of pressure injuries is a priority for a hospital, then posting the number of days since the last OR-acquired pressure injury reminds staff members to be vigilant in prevention. These reports are also an effective strategy for communicating with surgeons and anesthesia professionals that an issue is high priority and is being addressed. Daily progress reports do not necessarily need to be added to the workload of one individual, such

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as the manager. These updates often can be more effective when delegated to staff members who have passion for the issues. They can “own” the report and update it as part of their routine assignments. SUMMARY The safety and quality of health care is at the forefront of attention from professional organizations, federal agencies, and the public. Our unified goal is ensuring that patients receive the right care at the right time, every time, with “zero harm.” Many improvements have been made during the past 10 years, and success is apparent. Yet, our pursuit of excellence continues. Barriers to achieving high reliability are well known to perioperative nurses. Overcoming these barriers requires active engagement on the part of all of us. Three strategies used by HROs have been discussed here. I encourage perioperative nurses to share their successes on ORNurseLinkTM at http:// www.ornurselink.org. These stories are inspirational to all of us and keep us on track on our pursuit of excellence. Additional resources about HROs are available here: n

Hines S, Luna K, Lofthus J, et al. Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. (Prepared by the Lewin Group under Contract No. 290-04-0011.) AHRQ Publication No. 08-0022. Rockville, MD: Agency for Healthcare Research and Quality; 2008. http://www.ahrq.gov/professionals/quality -patient-safety/quality-resources/tools/hroadvice/ hroadvice1.html. Accessed July 9, 2014. n The Joint Commission. Joint Commission Center for Transforming Healthcare, SCHA collaborate on high-reliability program. Bull Am Coll Surg. 2013;98(4):65. Editor’s note: ORNurseLink is a trademark of AORN, Denver, CO. References 1. Kohn LT, Corrigan J, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000:287.

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PRESIDENT’S MESSAGE 2. Fakih MG, Watson SR, Greene MT, et al. Reducing inappropriate urinary catheter use: a statewide effort. Arch Intern Med. 2012;172(3):255-260. 3. Saint S, Greene MT, Kowalski CP, Watson SR, Hofer TP, Krein SL. Preventing catheter-associated urinary tract infection in the United States: a national comparative study. JAMA Intern Med. 2013;173(10):874-879. 4. Bion J, Richardson A, Hibbert P, et al. “Matching Michigan”: a 2-year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in England. BMJ Qual Saf. 2013;22(2):110-123. 5. Hong AL, Sawyer MD, Shore A, et al. Decreasing central-line-associated bloodstream infections in Connecticut intensive care units. J Healthc Qual. 2013; 35(5):78-87. 6. Eom JS, Lee MS, Chun HK, et al. The impact of a ventilator bundle on preventing ventilator-associated pneumonia: a multicenter study. Am J Infect Control. 2014;42(1):34-37. 7. Lim KP, Kuo SW, Ko WJ, et al. Efficacy of ventilatorassociated pneumonia care bundle for prevention of ventilator-associated pneumonia in the surgical intensive care units of a medical center [published online ahead of print October 30, 2013]. J Microbiol Immunol Infect. 8. The Joint Commission. Summary data of sentinel events reviewed by The Joint Commission. http://www.joint commission.org/assets/1/18/2004_to_2Q_2013_SE_ Stats_-_Summary.pdf. Updated March 25, 2014. Accessed July 9, 2014. 9. Hines S, Luna K, Lofthus J, et al. Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. (Prepared by the Lewin Group under Contract No. 290-04-0011.) AHRQ Publication No. 08-0022. Rockville, MD: Agency for Healthcare Research and Quality; 2008. http://www.ahrq.gov/professionals/quality -patient-safety/quality-resources/tools/hroadvice/hroadvice1 .html. Accessed July 9, 2014. 10. Joint Commission Center for Transforming Healthcare, SCHA collaborate on high-reliability program. Bull Am Coll Surg. 2013;98(4):65. 11. Weick KE, Sutcliffe KM. Managing the Unexpected: Resilient Performance in an Age of Uncertainty. San Francisco, CA: Jossey-Bass; 2007:1761-1765. 12. Provost SM, Lanham HJ, Leykum LK, McDaniel RR Jr, Pugh J. Health care huddles: managing complexity to achieve high reliability [published online ahead of print February 28, 2014]. Health Care Manage Rev.

Victoria M. Steelman, PhD, RN, CNOR, FAAN, is the AORN President and an assistant professor at The University of Iowa College of Nursing, Iowa City. Dr Steelman has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.