The Role of High Reliability Organization Foundational Practices in Building a Culture of Safety
Background: High reliability organizations are designed to operate under complex conditions for extended periods by strengthening systems that help serious adverse events for patients. The US Department of Veterans Affairs formally began its enterprise-wide journey to high reliability in 2019. Four foundational practices were identified to advance a culture of safety across all Veterans Health Administration facilities. This article describes these practices, summarizes supporting evidence from the literature, and illustrates strong practices for improving safety.
Observations: A literature review was conducted from 2018 to March 2023 to identify recent evidence outlining the value of implementing the 4 foundational high reliability organization practices to improve patient safety. This evidence was used to create and implement formal processes for the foundational practices. For each foundational practice, a representative example of a strong practice within the Veterans Health Administration is provided.
Conclusions: Effective and sustained application of the foundational organization practices described can support a health care organization’s journey to high reliability. Collectively, the 4 foundational practices can be adopted and implemented by other organizations in the continued pursuit of high reliability in health care.
Tiered Safety Huddles
Based on the processes of high reliability industries like aviation and nuclear power, tiered safety huddles have been increasingly adopted in health care. Huddles (health care, utilizing, deliberate, discussion,linking, and events) are department-level interdisciplinary meetings that last no more than 15 minutes.15 Their purpose is to improve communication by sharing day-to-day information across multiple disciplines, identify issues that may impact the delivery of care (eg, patient and staff safety concerns, staffing issues, or inadequate supplies) and resolve problems.
Tiered safety huddles are gaining popularity, especially in organizations seeking high reliability. They are more complex than traditional huddles because of the mechanics of elevating safety issues (eg, bedside to executive leadership teams), feedback loops, and sequencing, among other factors.15,16
Tiered safety huddles are focused, transparent forums with multidisciplinary staff, including frontline workers, along with senior leadership.15,16 When initially implemented, tiered safety huddles may take longer than the suggested 15 minutes; however, as teams become more experienced, huddles become more efficient.15 The goal of tiered safety huddles is to proactively identify, share, address, and resolve problems that have the potential to impact the delivery of safe and quality patient care. This may include addressing staffing shortfalls, inadequate allocation of supplies and equipment, operational issues, etc.8,15 Critical to theeffective utilization of tiered safety huddles is the appropriate escalation of issues between tiers. The most critical issues are elevated to higher tiers so they are addressed by the most qualified person in the organization.
Deciding on the number of tiers typically depends on the size and scope of services provided by the health care organization or integrated system. For example, tiered huddles in the VHA originate at the point of service (eg, critical care unit). Tier 1 includes staff members at the unit/team level along with immediate supervisors/managers. Tier 2 involves departments and service lines (eg, pharmacy, podiatry, or internal medicine) including their respective leadership. Tier 3 is the executive leadership team. This process allows for bidirectional communication instead of the traditional hierarchical communication pathway (Figure 4). Issues identified that cannot be addressed at a particular tier are elevated to the next tier. Elevated issues typically involve systems or processes requiring attention and resolution by senior leadership.15 Tier 4 huddles at the Veterans Integrated Services Network level and Tier 5 huddles at the VHA Central Office level are being initiated. These additional levels will more effectively identify system-level risks and issues that may impact multiple VHA facilities and may be addressed through centralized functions and resources.
Tiered safety huddles have been found to be instrumental to ensuring the flow of information across organizations, improving multidisciplinary and leadership engagement and collaboration, as well as increasing accountability for safety. Tiered safety huddles increase situational awareness, which improves an organization’s ability to appropriately respond to safety concerns. Furthermore, tiered safety huddles enhance teamwork and interprofessional collaboration, and have been found to significantly increase the reporting of patient safety events.15-19
The VA Connecticut Healthcare System tiered huddles followed a pilot testing implementation process. After receiving executive-level commitment, an evidence-based process was enacted, including staff education, selecting a VMS, determining tier interaction, and deciding on metrics to track.15
