Address correspondence to Nancy M. Dixon, Ph.D., President, Common Knowledge Associates, 2857 Selma Lane, Dallas, TX 75234. Marjorie Shofer, B.S.N., M.B.A., Senior Program Analyst, is with the Office of Communications and Knowledge Transfer, Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, Washington, DC.
Struggling to Invent High-Reliability Organizations in Health Care Settings: Insights from the Field
Article first published online: 9 JUN 2006
Health Services Research
Volume 41, Issue 4p2, pages 1618–1632, August 2006
How to Cite
Dixon, N. M. and Shofer, M. (2006), Struggling to Invent High-Reliability Organizations in Health Care Settings: Insights from the Field. Health Services Research, 41: 1618–1632. doi: 10.1111/j.1475-6773.2006.00568.x
- Issue published online: 9 JUN 2006
- Article first published online: 9 JUN 2006
- Quality of care;
- patient safety;
- high reliability organization;
- knowledge transfer;
The Mission of the Agency for Healthcare Research and Quality (AHRQ) has been to support and conduct health services research and to disseminate those research findings. Recently the Agency has changed its mission to: “Improving the quality, safety, efficiency and effectiveness of health care for all Americans.” For agency personnel working with the topic of patient safety, that change has created a need to develop greater awareness of the current patient safety initiatives underway at leading health care systems in order to determine where AHRQ might best play a role in helping these systems more rapidly adopt new practices to improve patient safety.
In order to make that determination, AHRQ conducted a customer needs assessment of leaders in selected health care systems, asking them questions about their current implementation initiatives and their perceived needs for continued implementation of patient safety initiatives. Although not designed or conducted as a research study, the hour-long interviews produced rich insights into the implementation efforts of patient safety initiatives.
The senior leaders interviewed in each of the health care systems, described implementing patient safety initiatives on multiple fronts—in some systems as many as 15 initiatives were underway. As the number of initiatives attests, there was no lack of knowledge about what patient safety practices should be implemented (CPOE, rapid response teams, reduction in surgical site infections) rather the major struggle these health care systems faced was the “how to” of implementation. Most initiatives were only newly begun, so these leaders were not yet confident about what they had learned from these efforts or whether they could be sustained over time. These health care systems drew many of the ideas for initiatives from outside of health care, for example, the nuclear power industry or aviation. The executives expressed concern about a number of issues including: how patient safety initiatives should be sequenced, the lack of benchmarking data to measure their systems against and the pressing need for IT standardization.
The insights from this customer needs assessment revealed a wealth of implementation knowledge in the field and has led AHRQ to create an opportunity for leading edge health care systems to learn from each other via learning networks.