The Cooperative High Reliability Organization: Approaching a Zero-Defect Culture

How the U.S. Air Force’s new reliability model focusing on task saturation improved antibiotic stewardship and overall value-based care quickly and cost-effectively

By Lt. Col. Jared A. Mort, MSN, MBA; Becky Alsup, BSN, RN; and Fabian Fregoli, MD

Overuse of antibiotics leads to drug-resistant microbes, placing patients at risk for more serious infections and sepsis, and placing more dependence on broad-spectrum antibiotics. This leads to a vicious cycle, as stronger antibiotics increase the risk of more drug-resistant microbes. Sepsis accounts for a high proportion of inpatient morbidity and mortality (Hall, Levant, & DeFrances, 2013), placing it among the top eight diagnoses that lead to inpatient death and costs. In addition, the incidence of sepsis has increased by 17% over the last decade, while other diagnoses have fallen by double digits.

Antibiotic stewardship can avoid preventable morbidity and mortality, and by extension, reduce healthcare costs. Recognizing this, the U.S. Army commissioned a new research arm to address the global threat of antibiotic overuse and preventable drug-resistant infections. In April 2016, Army scientists identified a dangerous strain of E. coli bacteria (MRSN 388634) in a patient that tested positive for resistance to colistin. The discovery gave new urgency to measures throughout the military and federal government on how to control its spread. The Army even created the Multidrug-Resistant Organism Repository and Surveillance Network (MRSN) in 2009 for biosurveillance (Sun, 2016).

In addition to discoveries in the laboratory, innovative military care delivery models can improve antibiotic stewardship. One example of innovation is the Cooperative High Reliability Organization (CHRO), a delivery model developed at Wright-Patterson (Wright-Patt) Air Force Base Medical Center (Barber, 2016) and based on the process improvement methodology called the Military Acuity Model, or MAM (Elnahal et al., 2015).

The purpose of a CHRO is to predict critical task failures (in this case, inappropriate antibiotic prescriptions) in a manner that is faster, more comprehensive, and requires fewer resources. MAM enables the CHRO to predict task failures in advance, to focus and force-multiply teams in high reliability organizations (HROs), making it possible to strive for a zero-defect culture. This care delivery improvement approach is complemented by the Fractal Model for Quality Management (Pronovost & Marteller, 2014), which helps create more easily replicable quality teams, to ensure simplicity and rapid scalability.

Aims for this study, which deployed CHRO in the Trinity Health System alongside Air Force project teams, focused on determining the advantages of:

Notifications that micro-target only predicted task failures, to in turn reduce the effort, interruptions, and other burdens placed on small footprint teams

Targeting patients “further upstream” before they become septic

Assessing the consequent reduction in restricted antibiotics, as well as other values offered by the new approach


The study population in the suburban Michigan medical setting consisted of approximately 800 patients over a four-month time period that had signs of infection, with alerting focused on 113 patient cases associated with three study cohorts.

The key “high value” tasks studied were the sepsis bundle, including lactic acid draw, blood culture draw, antibiotic administration, IV bolus administration, repeat lactic acid draw, and vasopressor tasks being completed within time limits. In the cohort identified to have tasks at risk of failure, the compliance for these high-value tasks essentially doubled from less than 40% on average to over 80% once the micro-targeting method was put in place beyond the weekdays’ day shift for the hospital. So, initially there was success in one key metric of the study.

The intervention in the CHRO was deployment of dynamic rather than static checklists to the emergency department (ED) charge nurses and sepsis team by predicting compliance. Organizing work in this way reduced task overload, focusing and force-multiplying teams. This enabled improved task shifting to minimize staff overloads (reducing failure to rescue) and under-loads (reducing opportunity costs).