The Exec: How to Promote High Reliability in the Hospital Setting
By Christopher Cheney
Establishing high reliability at a hospital requires leadership discipline and cultural commitment, according to the new CMO of Providence Saint Joseph Medical Center in Burbank, California.
Joe Kim, MD, MPH, became CMO of the Providence hospital in January. Kim’s prior leadership experience includes serving as CMO of MemorialCare‘s Long Beach Medical Center and CMO and vice president of medical affairs at Dignity Health‘s California Hospital Medical Center.
The are several components of promoting high reliability in the hospital setting, Kim explains.
“High reliability is not just a project or checklist,” Kim says. “The primary elements of high-reliability transformation include consistent leadership behaviors that create psychological safety, the standardization of high-risk processes, and transparency around patient safety data.”
A hospital CMO can play a key role in promoting high reliability, according to Kim.
“The most important thing a CMO can do is model the behaviors that you expect among physicians and all staff members,” Kim says. “That means creating an environment where physicians and staff members feel safe in speaking up and focusing on fixing systems rather than blaming individuals when adverse events occur.”
The foundation of establishing high reliability is psychological safety and a just culture, according to Kim.
Kim has experience promoting psychological safety.
“I hold myself accountable,” Kim says. “I try to create a working environment that is not punitive. Every staff member needs to be focused on patient safety, including fixing the systems and processes that can put an individual staff member into a situation where their decisions are influenced inappropriately.”
A hospital CMO needs to create systems and processes that support the principles of high reliability such as daily safety huddles, which Kim explains are foundational.
“In these huddles, key leaders representing departments across a hospital come together for about 30 minutes every day to honestly discuss issues that can present a potential safety problem,” Kim says. “The idea is to identify those risks before they result in a patient safety event.”
Just-culture training programs for frontline staff such as physicians are another systemic approach to supporting high reliability, according to Kim.
“You should have human resources personnel who coach and counsel staff to embed high-reliability principles in everything you do at a hospital,” Kim says. “Staff members should not feel afraid of retaliation or any punishment. This creates a culture with honesty.”
Succeeding in case management
Case management is most successful when it is clinically integrated and aligned with workflows and other processes that put the patient at the center of care, according to Kim.
“One of the core principles of clinically integrated case management is team-based care,” Kim says. “This requires not only physicians and nurses but also other staff members such as physical therapists, pharmacists, dieticians, and environmental services team members.”
Multidisciplinary rounds are an element of team-based care that supports case management, Kim explains.
“A multidisciplinary team that is caring for a patient including physicians, nurses, case managers, and social workers should all be aligned around the patient’s goals,” Kim says. “By holding multidisciplinary rounds, the care team can get on the same page, set the patient’s plan for the day, and get a jump on discharge planning.”
As part of case management, scheduling elements of care should be embedded into workflows, according to Kim.
“Patients can have multiple tests and multiple milestones that they need to meet before they are clinically safe for discharge,” Kim says. “So, you need to have coordination of care. Instead of having all of the disciplines that are taking care of the patient operating in siloes, you need to choreograph care.”
Case management includes addressing socioeconomic scenarios or insurance authorizations that impact whether a patient is going to get the appropriate support when they leave the hospital, Kim explains.
Kim says a lot of the planning to address socioeconomic factors or insurance authorizations occurs as soon as a patient is admitted to a hospital.
Promoting health equity
Health equity initiatives are most successful when they are embedded into existing initiatives such as quality, operations, and population health programs rather than standalone programs, according to Kim.
“Equity comes into play in everything we do, including care access, care transitions, language services, and addressing the complexities of high-risk patients after discharge,” Kim says.
CMOs and other hospital leaders need to make an intentional effort to embed health equity initiatives into existing programs, Kim explains.
“It takes a global lens to make sure that when we are implementing programs in areas such as quality and population health, we are also looking at them from the perspective of equity,” Kim says. “You need to realize that patients do not have equal access to resources.”
Depending on a patient’s resources, they have different services available to them, according to Kim.
“Case managers can do a great job in identifying the available resources for a patient that may not be covered by their insurance,” Kim says.
Kim has worked with community organizations on health equity initiatives.
“This has involved working with some of our most challenging patients and making sure they are getting community resources that can provide access to shelter, food, and timely access to healthcare,” Kim says.
Christopher Cheney is the CMO editor at HealthLeaders.