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Creating High Reliability in Health Care Organizations

Authors

  • Peter J. Pronovost,

    1. Departments of Anesthesiology & Critical Care Medicine, Surgery, and Health Policy & Management, The Johns Hopkins University, 1901 Thames Street, 2nd floor, Baltimore, MD 21231,
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    • Address correspondence to Peter J. Pronovost, M.D., Ph.D., Departments of Anesthesiology & Critical Care Medicine, Surgery, and Health Policy & Management, The Johns Hopkins University, 1901 Thames Street, 2nd floor, Baltimore, MD 21231. Sean M. Berenholtz, M.D., M.H.S., David A. Thompson, D.NSc., M.S., and Lisa H. Lubomski, Ph.D., are with the Department of Anesthesiology & Critical Care Medicine, The Johns Hopkins University, Baltimore, MD. Christine A. Goeschel, R.N., M.P.A., M.P.S., is with the MHA Keystone Center for Patient Safety & Quality, Lansing, MI. Dale M. Needham, M.D., Ph.D., is with The Johns Hopkins University, Baltimore, MD. J. Bryan Sexton, Ph.D., is with the Departments of Anesthesiology & Critical Care Medicine and Health Policy & Management, The Johns Hopkins University, Baltimore, MD. Jill A. Marsteller, Ph.D., M.P.P., is with the Johns Hopkins Bloomberg School of Public Health, Department of Health Policy & Management, Baltimore, MD. Martin A. Makary, M.D., M.P.H., is with The Johns Hopkins Bayview Medical Center; Department of Surgery A5 Center, Baltimore, MD. Elizabeth A. Hunt, M.D., M.P.H., is with the Johns Hopkins University, Department of Anesthesiology & Critical Care Medicine, Baltimore, MD.

  • Sean M. Berenholtz,

    1. Department of Anesthesiology & Critical Care Medicine, The Johns Hopkins University, Baltimore, MD,
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  • Christine A. Goeschel,

    1. MHA Keystone Center for Patient Safety & Quality, Lansing, MI,
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  • Dale M. Needham,

    1. The Johns Hopkins University, Baltimore, MD,
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  • J. Bryan Sexton,

    1. Departments of Anesthesiology & Critical Care Medicine and Health Policy & Management, The Johns Hopkins University, Baltimore, MD,
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  • David A. Thompson,

    1. Department of Anesthesiology & Critical Care Medicine, The Johns Hopkins University, Baltimore, MD,
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  • Lisa H. Lubomski,

    1. Department of Anesthesiology & Critical Care Medicine, The Johns Hopkins University, Baltimore, MD,
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  • Jill A. Marsteller,

    1. Johns Hopkins Bloomberg School of Public Health, Department of Health Policy & Management, Baltimore, MD,
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  • Martin A. Makary,

    1. Johns Hopkins Bayview Medical Center; Department of Surgery A5 Center, Baltimore, MD, and
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  • Elizabeth Hunt

    1. Johns Hopkins University, Department of Anesthesiology & Critical Care Medicine, Baltimore, MD.
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Abstract

Objective. The objective of this paper was to present a comprehensive approach to help health care organizations reliably deliver effective interventions.

Context. Reliability in healthcare translates into using valid rate-based measures. Yet high reliability organizations have proven that the context in which care is delivered, called organizational culture, also has important influences on patient safety.

Model for Improvement. Our model to improve reliability, which also includes interventions to improve culture, focuses on valid rate-based measures. This model includes (1) identifying evidence-based interventions that improve the outcome, (2) selecting interventions with the most impact on outcomes and converting to behaviors, (3) developing measures to evaluate reliability, (4) measuring baseline performance, and (5) ensuring patients receive the evidence-based interventions. The comprehensive unit-based safety program (CUSP) is used to improve culture and guide organizations in learning from mistakes that are important, but cannot be measured as rates.

Conclusions. We present how this model was used in over 100 intensive care units in Michigan to improve culture and eliminate catheter-related blood stream infections—both were accomplished. Our model differs from existing models in that it incorporates efforts to improve a vital component for system redesign—culture, it targets 3 important groups—senior leaders, team leaders, and front line staff, and facilitates change management—engage, educate, execute, and evaluate for planned interventions.

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