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10 steps to becoming a high-reliability hospital from Truman Medical Center


March 18, 2021

By Brian Ward

In 2016, Truman VA Medical Center in Columbia, Missouri took part in a three-year project to become a high-reliability hospital (HRH). By the end of the study, Truman reported that its patient outcomes had improved, low-harm errors were being reported more often, and that quality improvement education had become self-sustaining within the facility. The HRH model was developed by the Veterans Health Administration’s National Center for Patient Safety (NCPS) and its process is open for all facilities to adopt.

The full study, “A High-Reliability Organization Framework for Health Care: A Multiyear Implementation Strategy and Associated Outcomes,” was published in the Journal of Patient Safety. In March, Patient Safety Monitor Journal interviewed Gary L. Sculli, MSN, ATP, one of the study authors and the director of clinical training programs at NCPS, about how the HRH project came to be and what made it work.

Here are the 10 steps that Truman and researchers used to become an HRH.

  • A baseline and yearly assessment/patient safety site visit

During these visits, the NCPS used a standardized assessment tool comprising a series of questions, evaluated facility root cause analysis (RCA) reports, and assessed Truman’s compliance with NCPS Patient Safety Alerts and Advisories.

  • Patient safety culture assessment

The assessments were made using two different methodologies, a Patient Safety Culture Survey (PSCS) and a Teamwork and Safety Climate Questionnaire (TSCQ), which were done six and 12 months after staff received Clinical Team Training (CTT).

  1. Annual frontline staff RCA training

NCPS provided annual RCA training to a group of Truman frontline staff, who then trained latter groups of staff. This training covered risk scoring, team composition, event flow diagramming, interviewing techniques, root cause statements and rules of causation, strength of action planning, and outcome measures.

  • Leadership walk-arounds

Truman implemented a Leader Walk-Around Program, where the leadership team conducted monthly in-person conversations with frontline staff to gather direct input, respond to concerns, and reinforce HRH principles.

  • Monthly patient safety forum

These patient safety forums were open to all Truman staff and leadership. During these, attendees would review adverse events that triggered an RCA, discuss system root causes and corrective actions, and celebration of staff members who identified and acted upon on safety concerns.

  • Annual assessment of infrastructure and processes for standardization

A standardization team was assembled annually to review infrastructure and processes that had high levels of variability to establish a strategic plan. The team then selected an annual project to work on.

  • Just Culture training

The NCPS conducted interactive Just Culture training for facility leadership, midlevel managers, and frontline supervisors to convey Just Culture core concepts including the application of a Just Culture decision support tool to case studies.

  • Clinical Team Training for all units

Clinical Team Training (CTT) comprised an initial training session, an annual unit-based safety project, monthly NCPS coaching sessions, and one-year refresher training on topics such as high reliability organization theory, threat and error management, participatory leader behaviors, and effective follower behaviors.

  • Unit-based improvement project implementation and monitoring

Each month, staff were required to identify a patient safety challenge and implement an improvement project.

  • CTT simulation education

The NCPS educated the Truman staff in the use of simulation to provide opportunities for unit-based teams to practice the communication, teamwork, and situational awareness tools imparted in the program. The NCPS held an annual simulation “boot camp” instructing facility-based simulation educators on delivering unit-based curriculum.


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