A model for developing high-reliability teams

Journal of Nursing Management

Volumn 18, Issue 5, 2010, Pages 556-563

  Riley, William ^a   Davis, Stanley E ^b   Miller, Kristi K ^c   Mccullough, Mac ^a  

^a UNIVERSITY OF MINNESOTA   (United States)

^b Teamwork and Simulation   (United States)

^c Fairview Health Services   (United States)

Author keywords

Culture of safety; High reliability health care organizations; High reliability teams; Human factors; Model for high reliability; Non technical skills

Indexed keywords

ARTICLE; HEALTH CARE QUALITY; HUMAN; LEADERSHIP; MODEL; NONBIOLOGICAL MODEL; NURSE ADMINISTRATOR; NURSING; ORGANIZATION; ORGANIZATION AND MANAGEMENT; PATIENT CARE; QUALITY CONTROL; SAFETY; STANDARD; UNITED STATES;

BENCHMARKING; HUMANS; LEADERSHIP; MODELS, NURSING; MODELS, ORGANIZATIONAL; NURSE ADMINISTRATORS; NURSING, SUPERVISORY; ORGANIZATIONAL CULTURE; PATIENT CARE; QUALITY OF HEALTH CARE; SAFETY; UNITED STATES;

EID: 77957135275     PISSN: 09660429     EISSN: 1365263X     Source Type: Journal    
DOI: 10.1111/j.1365-2834.2010.01121.x     Document Type: Article

References (52)

1. Team Strategies and Tools to Enhance Performance and Patient Safety 2007, Team-STEPPS Curriculum-2007, US Government Printing Office, Washington, DC
2. Altman L. Even the Elite hospitals aren't immune to errors. New York Times 2003, 18. February 23. Section 1
3. Amalberti R, Auroy Y, Berwick D, Barach P. Improving patient care, five system barriers to achieving ultrasafe health care. Annals of Internal Medicine 2005, 142:756-764.
4. Baker DP, Gustafson S, Beaubien JM, Salas E, Barach P. Advances in Patient Safety: From Research to Implementation. Medical Team Training Programs in Health Care 2005, AHRQ Publication No. 05-0021-4, (Vol. 4), Agency for Healthcare Research and Quality, Rockville, MD
5. Baker DP, Day R, Salas E. Teamwork as an essential component of high-reliability organizations. Health Services Research 2006, 41(4):1576-1598.
6. Benneyan J, Resar R, Scoville R. Designing Reliable Healthcare Processes 2006, National Forum on Quality Improvement in Healthcare, Orlando, FL
7. Berwick D, Leape L. Forward. Achieving Safe and Reliable Healthcare 2004, vii-x. Leonard M, Frankel ASimmonds TVega K. eds, Health Administration Press, Chicago, IL
8. Burke CS, Salas E, Wilson-Donnelly K, Priest H. How to turn a team of experts into an expert medical team: guidance from the aviation and military communities. Quality and Safety in Health Care 2004, 13:i96-i104.
9. Cherouny PH, Federico FA, Haraden C, Gullo SL, Resar R. Idealized Design of Perinatal Care 2005, http://www.ihi.org/IHI/Results/WhitePapers/IdealizedDesignofPerinatalCareWhitePaper.htm, [WWW document]. URL , accessed 18 September 2007
10. Davis S, Miller K, Riley W. Reducing Patient Harm Through Interdisciplinary Team Training with In Situ Simulation. 2008 Improving Patient Safety Conference 2008, Robinson College Cambridge, Cambridge, UK
11. Davis S, Riley W, Gurses AP, Miller K, Hansen H. Failure modes and effects analysis based on in situ simulations: a methodology to improve understanding of risks and failures. Advances in Patient Safety: New Directions and Administrative Approaches 2009, 145-160. Henriksen K, Battles JB, Keyes MA, Grady ML, eds, Agency for Healthcare Research and Quality, Rockville, MD
12. Flin R, O'Connor P, Crichton M. Safety at the Sharp End 2008, Ashgate Publishing Company, Burlington, VT
13. Gauthier AK, Davis K, Schoenbaum SC. Achieving a high performance health care system: high reliability organizations within a broader agenda. Health Services Research 2006, 41(4):1710-1720.
14. Godfrey MM, Nelson EC, Wasson JH, Mohr JJ, Batalden PB. Microsystems in healthcare: Part 3 planning patient- centered services. Joint Commission Journal on Quality and Safety 2003, 29(4):159-170.
15. Gosbee J. Human factors engineering and patient safety. Quality and Safety in Health Care 2002, 11:352-354.
16. Henriksen K, Patterson M. Simulation in health care: setting realistic expectations. Journal of Patient and Safety 2007, 3(3):127-134.
17. Protecting 5 million Lives Campaign Overview 2007, http://www.ihi.org/IHI/Programs/Campaign/Campaign.htm?TabId=1, [WWW document]. URL ) accessed 18 March 2010
18. To Err is Human 1999, National Academies Press, Washington, DC
19. The Just Culture Community: Moderated by Outcome Engineering 2010, http://www.justculture.org/communityinfo.aspx, [WWW]. URL , accessed 29 March 2010
20. Kizer KW. The " new VA": a national laboratory for health care quality management. American Journal of Medical Quality 1999, 14(1):3-20.
21. Knox GE, Simpson KR. Teamwork: the fundamental building block of high-reliability organizations and patient safety. Patient Safety Handbook 2004, 379-414. Youngberg BJ, Hatlie M. eds, Jones and Bartlett Publishers, Boston, MA
22. Knox GE, Simpson KR, Garite TJ. High reliability in perinatal units; an approach to the prevention of patient injury and medical malpractice claims. Journal of Healthcare Risk Management 2000, 19(2):27-35.
23. Leape L. 2000, Testimony to the United States Congress, United States Senate Subcommittee on Labor, Health and Human Services, and Education. January 25
24. Leape LL, Berwick DM. Five years after to err is human: what have we learned? Journal of the American Medical Association 2005, 293(19):2384.
25. Leonard M, Frankel A, Simmonds T, Vega KB. Achieving Safe and Reliable Healthcare 2004, Health Administration Press, Chicago, IL
26. Liker JK. The Toyota Way: 14 Management Principles from the World's Greatest Manufacturer 2004, McGraw-Hill, New York, NY
27. Marx D. Patient Safety and the " Just Culture": A Primer for Health Care Executives 2001, Columbia University, New York, NY
28. Marx D. Whack-a-Mole: The Price We Pay For Expecting Perfection 2009, By Your Side Studios, Plano, TX
29. McGlynn EA, Asch SM, Adams J. The quality of health care delivered to adults in the United States. New England Journal of Medicine 2003, 348(26):2635-2645.
30. McIntyre RM, Salas E. Measuring and managing for team performance: emerging principles from complex environments. Team Effectiveness and Decision Making in Organizations 1995, 149-203. Guzzo RA, Salas E. eds, Jossey-Bass, San Francisco, CA
31. Miller K, Riley W, Davis S, Hanson H. In situ simulation: a method of experiential learning to promote safety and team behavior. The Journal of Perinatal and Neonatal Nursing 2008, 22(2):105-113.
32. Miller K, Riley W, Davis S. Identifying key nursing and team behaviours to achieve high reliability. Journal of Nursing Management 2009, 17:247-255.
33. Montgomery DC. Introduction to Statistical Quality Control 2005, 5th edn, John Wiley & Sons, Phoenix, AZ
34. Nelson E, Batalden P, Godfrey M. Quality by Design: A Clinical Microsystems Approach 2007, Jossey-Bass, San Francisco, CA
35. Nolan T, Resar R, Haraden C, Griffin FA. Improving the Reliability of Health Care. IHI Innovation Series White Paper 2004, Institute for Healthcare Improvement, Boston, MA
36. Paisley AM, Baldwin PJ, Paterson-Brown S. Validity of surgical simulation for the assessment of operative skill. British Journal of Surgery 2001, 88:1525-1532.
37. Reason J. Understanding adverse events: human factors. Quality and Safety in Health Care 1995, 4:80-89.
38. Reason J. Understanding adverse events: the human factor. Clinical Risk Management: Enhancing Patient Safety 2001, 9-30. Vincent C. ed, BMJ Books, London
39. Reason J. Safety in the operating theatre Part 2: Human error and organisational failure. Quality and Safety in Health Care 2005, 14:56-60.
40. Reinertsen JL, Clancy C. Keeping our promises: research, practice and policy issues in healthcare reliability. A special issue of health services research (Forward). Health Services Research 2006, 41(4):1535-1538.
41. Rice-Simpson K, Knox GE. Adverse Perinatal Outcomes: Recognizing, Understanding & Preventing Common Accidents. Association of Women's Health, Obstetric and Neonatal Nurses Lifelines 2003, 7(3):224-235.
42. Riley W, Hansen H, Gurses A, Davis S, Miller K, Priester R. The nature, characteristics and patterns of perinatal critical events teams. Advances in Patient Safety: New Directions and Administrative Approaches 2008, 131-144. Henriksen K, Battles JB, Keyes MA, Grady ML, eds, Agency for Healthcare Research and Quality, Rockville, MD
43. Riley W. High Reliability and Implications for Nursing Leaders. Journal of Nursing Management 2009, 17:238-246.
44. Riley W, Davis S, Miller K, Hansen H, Sweet R. Detecting breaches in defensive barriers using in situ simulation for obstetric emergencies. Quality and Safety in Health Care 2010, (in press)
45. Roberts KH. Managing high reliability organizations. California Management Review 1990, 32:101-113.
46. Salas E, Burke CS, Cannon-Bowers JA. Teamwork: emerging principles. International Journal of Management Review 2000, 2:339-356.
47. Salisbury ML, Simon R. Growing nursing leadership in the field of patient safety. The Patient Safety Handbook 2004, 341-358. Youngberg BJ, Hatlie M. eds, Jones and Bartlett Publishers, Boston, MA
48. Shortell S, Schmittdiel J, Wang MC. An empirical assessment of high-performing medical groups: results from a national study. Medical Care Research and Review 2005, 62(4):407-434.
49. Simpson KR, Knox GE. Strategies for developing an evidence-based approach to perinatal care. The American Journal of Maternal and Child Nursing 2000, 24(3):122-131.
50. Weick KE. The reduction of medical errors through mindful interdependence. Medical Error: What do we know? What do we do? 2002, 177-199. Rosenthal MMSutcliffe KM. eds, Jossey-Bass, San Francisco, CA
51. Weick KE, Sutcliffe KM. Managing the Unexpected: Assuring High Performance in an Age of Complexity 2001, Jossey-Bass, San Francisco, CA
52. Yule S, Flin R, Maran N. Surgeons' non-technical skills in the operating room: reliability testing of the NOTSS behavior rating system. World Journal of Surgery 2007, 32:548-556.