Applying the high reliability health care maturity model to assess hospital performance: A VA case study

Joint Commission Journal on Quality and Patient Safety

Volumn 42, Issue 9, 2016, Pages 389-399

  Sullivan, Jennifer L ^a   Rivard, Peter E ^b   Shin, Marlena H ^c   Rosen, Amy K ^d  

^a BOSTON UNIVERSITY SCHOOL OF PUBLIC HEALTH   (United States)

^b SUFFOLK UNIVERSITY   (United States)

^c CHOIR   (United States)

^d BOSTON UNIVERSITY SCHOOL OF MEDICINE   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

CLINICAL STUDY; CONTENT VALIDITY; DIFFERENTIATION; DOCTOR PATIENT RELATION; HUMAN; LEARNING; MATURITY; MODEL; PATIENT SAFETY; PERCEPTION; RELIABILITY; TEAMWORK; VETERAN; CLINICAL TRIAL; HEALTH CARE QUALITY; HOSPITAL MANAGEMENT; LEADERSHIP; MULTICENTER STUDY; NONBIOLOGICAL MODEL; ORGANIZATION; PUBLIC HOSPITAL; STANDARDS; TOTAL QUALITY MANAGEMENT; UNITED STATES;

HOSPITAL ADMINISTRATION; HOSPITALS, VETERANS; HUMANS; LEADERSHIP; MODELS, ORGANIZATIONAL; ORGANIZATIONAL CULTURE; ORGANIZATIONAL INNOVATION; PATIENT SAFETY; QUALITY ASSURANCE, HEALTH CARE; QUALITY IMPROVEMENT; UNITED STATES;

EID: 84994840956     PISSN: 15537250     EISSN: None     Source Type: Journal    
DOI: 10.1016/s1553-7250(16)42080-5     Document Type: Article

References (41)

1. Pronovost PJ, et al. Creating a high-reliability health care system: Improving performance on core processes of care at Johns Hopkins Medicine. Acad Med. 2015;90:165-172.
2. Wachter RM. Patient safety at ten: Unmistakable progress, troubling gaps. Health Aff (Millwood). 2010;29:165-173.
3. Gaba DM. Structural and organizational issues in patient safety: A comparison of health care to other high-hazard industries. Calif Manage Rev. 2001; 43(1):83-102.
4. Gaba DM, et al. Differences in safety climate between hospital personnel and naval aviators. Hum Factors. 2003;45:173-185.
5. O'Neil PD, Krane D. Policy and organizational change in the Federal Aviation Administration: The ontogenesis of a high-reliability organization. Public Admin Rev. 2012;72:98-111.
6. Weick KE, Sutcliffe KM. Managing the Unexpected: Resilient Performance in an Age of Uncertainty, 2nd ed. San Francisco: Jossey-Bass, 2007.
7. Chassin MR, Loeb JM. The ongoing quality improvement journey: Next stop, high reliability. Health Aff (Millwood). 2011;30:559-568.
8. Luria JW, et al. Reliability science and patient safety. Pediatr Clin North Am. 2006;53:1121-1133.
9. Roberts KH. Managing high reliability organizations. Calif Manage Rev. 1990; 32(4):101-113.
10. Chassin MR, Loeb JM. High-reliability health care: Getting there from here. Milbank Q. 2013;91:459-490.
11. Drost EA. Validity and reliability in social science research. Education Research and Perspectives. 2011 Jun 1;38(1):105-123.
12. Commonwealth Fund. Advancing Patient Safety in the U.S. Department of Veterans Affairs. McCarthy D, Chase D. Commonwealth Fund pub. 1477, vol. 9. Mar 2011. Accessed Aug 1, 2016. http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2011/Mar/1477-McCarthy-VA-case-study-FINAL-March-v2.pdf.
13. Shin MH, et al. Examining the validity of AHRQ's Patient Safety Indicators (PSIs): Is variation in PSI composite score related to hospital organizational factors? Med Care Res Rev. 2014;71:599-618.
14. Agency for Healthcare Research and Quality. AHRQ Quality Indicators: Patient Safety Indicators Overview. Accessed Aug 1, 2016. http://www.qualityindicators.ahrq.gov/Modules/psi-resources.aspx.
15. Daley J, et al. Validating risk-Adjusted surgical outcomes: Site visit assessment of process and structure. National VA Surgical Risk Study. J Am Coll Surg. 1997;185:341-351.
16. Young GJ, et al. Best practices for managing surgical services: The role of coordination. Health Care Manage Rev. 1997;22(4):72-81.
17. Young GJ, et al. Patterns of coordination and clinical outcomes: A study of surgical services. Health Serv Res. 1998;33:1211-1236.
18. Reason J, Hobbs A. Managing Maintenance Error: A Practical Guide. Burlington, VT: Ashgate, 1997.
19. Roberts KH, Rousseau DM, La Porte TR. The culture of high reliability: Quantitative and qualitative assessment aboard nuclear-powered aircraft carriers. Journal of High Technology Management Research. 1994;5:141-161.
20. Delli Fraine JL, Langabeer JR 2nd, Nembhard IM. Assessing the evidence of Six Sigma and Lean in the health care industry. Qual Manag Health Care. 2010;19:211-225.
21. DuPree E, et al. Improving patient satisfaction with pain management using Six Sigma tools. Jt Comm J Qual Patient Saf. 2009;35:343-350.
22. Joint Commission Center for Transforming Healthcare. Robust Process Improvement.® Accessed Aug 1, 2016. http://www.centerfortransforminghealthcare.org/about/rpi.aspx.
23. Curry LA, et al. What distinguishes top-performing hospitals in acute myocardial infarction mortality rates? A qualitative study. Ann Intern Med. 2011 Mar 15;154:384-390.
24. Ginsburg LR, et al. The relationship between organizational leadership for safety and learning from patient safety events. Health Serv Res. 2010;45: 607-632.
25. Mohr JJ, Abelson HT, Barach P. Creating effective leadership for improving patient safety. Qual Manag Health Care. 2002;11:69-78.
26. Miles MB, Huberman AM. Qualitative Data Analysis: An Expanded Sourcebook, 2nd ed. Thousand Oaks, CA: Sage, 1994.
27. Leape LL, Berwick DM. Safe health care: Are we up to it? BMJ. 2000 Mar 18;320:725-726.
28. Carroll JS, Rudolph JW. Design of high reliability organizations in health care. Qual Safe Health Care. 2006;15 Suppl 1:i4-i9.
29. Coles G, et al. Using failure mode effects and criticality analysis for high-risk processes at three community hospitals. J Comm J Qual Patient Saf. 2005;31: 132-140.
30. Rodriguez-Gonzalez CG, et al. Use of failure mode, effect and criticality analysis to improve safety in the medication administration process. J Eval Clin Prac. 2015;21:549-559.
31. Steelman VM, Cullen JJ. Designing a safer process to prevent retained surgical sponges: A healthcare failure mode and effect analysis. AORN J. 2011;94: 132-141.
32. Meterko M, Mohr DC, Young GJ. Teamwork culture and patient satisfaction in hospitals. Med Care. 2004;42:492-498.
33. Mills P, Neily J, Dunn E. Teamwork and communication in surgical teams: Implications for patient safety. J Am Coll Surg. 2008;206:107-112.
34. Sanchez JA, Barach PR. High reliability organizations and surgical microsystems: Re-engineering surgical care. Surg Clin North Am. 2012;92:1-14.
35. van Dalen B, Slagmolen B, Taen R. Mindful organizing: How to manage unexpected events and unwanted processes. Nijmegen, Netherlands: Apollo 13 Consult, 2009.
36. Dunn EJ, et al. Medical team training: Applying crew resource management in the Veterans Health Administration. J Comm J Qual Patient Saf. 2007;33:317-325.
37. Lee A, et al. Root cause analysis of serious adverse events among older patients in the Veterans Health Administration. J Comm J Qual Patient Saf. 2014;40:253-262.
38. Percarpio KB, Watts BV. A cross-sectional study on the relationship between utilization of root cause analysis and patient safety at 139 Department of Veterans Affairs medical centers. J Comm J Qual Patient Saf. 2013;39:32-37.
39. Shaqdan K, et al. Root-cause analysis and health failure mode and effect analysis: Two leading techniques in health care quality assessment. J Am Coll Radiol. 2014;11:572-579.
40. Griffith JR. Understanding high-reliability organizations: Are Baldrige recipients models? J Healthc Manag. 2015;60:44-62.
41. Adrian N. Don't just talk the talk. Quality Progress. 2009;42(7):30-33.