Why high reliability care can no longer wait with Andrew Resnick, MD and Christian Dankers, MD

There’s no question on the benefits of high reliability care—better patient experience and outcomes, improved staff wellness and engagement, and cost savings and margin improvement. Yet achieving high reliability care remains a significant area of opportunity for most health systems.

Andrew Resnick, MD, is Chartis’ Chief Medical and Quality Officer. A nationally recognized expert in quality, patient safety, and high reliability, Andrew helps organizations set and reach goals of top performance through both specific projects and transformational change. He has over 20 years of experience in healthcare, having served as Chief Medical Officer and Chief Quality Officer roles at leading healthcare systems throughout the United States. He is also active clinically as an associate surgeon at Brigham and Women’s Hospital and part-time lecturer at Harvard Medical School.



Christian Dankers, MD, serves as Associate Chief Medical and Quality Officer. In his role, Christian is focused on the expansion of clinical quality and high reliability care, bringing together capabilities across Chartis Consulting and The Greeley Company in medical staff optimization, quality, patient safety, and clinical operations to elevate the quality of care for patients across the country. Christian also continues to work as a hospitalist at Mass General Brigham.

Chartis: High reliability care has become a pressing issue for provider organizations to address. What is the urgency right now?

Andrew Resnick:

It’s always about the patients first and foremost. There's somewhere between 200,000 and 400,000 patient deaths from errors in this country every year. It's the third leading cause of death nationally. That’s completely unacceptable—we must improve quality and safety for our patients.

There’s also greater transparency for patients than ever before. Since the Cures Act was enacted last year, patients have access to their charts. They're now asking questions about what they see—and rightfully so. They want to know why they got an infection or had a complication, and they're unsatisfied with gaps in our care processes.

Another important aspect is the resurgence of value-based care. Increasingly, hospitals are incented on quality and need to improve performance.

And finally, higher quality care is lower cost. With hospitals struggling financially, it is more affordable to take better care of patients. This is for two reasons: first, errors and inefficiencies in care cost money directly—more staff time, more medications, more supplies. Second, with capacity being so strained, backfill opportunity is invaluable and can add millions in additional revenue.

Christian Dankers:

The complexity of care has been increasing rapidly, and patients rightly have higher expectations about the quality, safety, and experience of care that they receive. There’s been some evolution and improvement in the way hospitals provide care, but not enough to keep pace with the increasing complexity and rising expectations of patients.

For the most part, the way that hospitals and health systems have taken up that remaining slack is by working front-line staff harder and relying on them to take on more. The pandemic has shown that this strategy is not scalable. The only way we are going to be able to provide high quality, safe care is by changing the way we do things. And that means becoming more reliable, with better design and smarter people management to meet the demands of a continuously evolving healthcare environment. It's imperative.

Chartis: You've both stated that the way care is delivered needs to change. How should organizations think about care delivery differently to optimize quality and safety?

Dankers: 

Achieving high reliability requires changing your organizational philosophy and approach. It means being very intentional about the way you design systems and manage human performance to deliver high quality, safe care. It’s a series of capabilities that have to be hardwired into the structure of the hospital, with a philosophy of continuous risk assessment and process improvement.

Resnick: 

Things go wrong in healthcare all the time. Our systems are not reliable because they depend on humans to have the time, bandwidth, and memory. Oftentimes, the approach is to recognize when things aren't going as expected and course correct. And that is really a very unsafe way to achieve the outcomes we need in healthcare, which affects people’s lives in a very direct way.

High reliability is a comprehensive approach to making sure we do the right thing every time and get the outcomes we should expect every time. And right now, that's not what healthcare is in this country.

Healthcare is often compared to other industries like nuclear and aviation, but healthcare is more complex. In those industries, they have systems structured so there's a known rate at which every process may fail, and backup systems for when they do fail. That's how we have to approach healthcare—making sure that what we think is going to happen to a patient, whether it's during an office visit or a surgical procedure, happens every time and that our systems are reliable and resilient. And when there's an issue that's unplanned, they're resilient enough that we can still get the right outcome. In a high reliability organization, there are systems in place to make sure that happens, and we learn when it doesn't and fix it.

Chartis: Where would health systems start on the high reliability journey?

Dankers: 

There are two different but related journeys that hospitals need to go on. One is to become a high reliability organization, which requires developing high reliability capabilities. It means thinking differently about how to identify and prioritize your biggest vulnerabilities within the organization, and then developing capabilities for robust system improvement and human performance management.

Then there is the journey to deploy those high reliability capabilities to actually address the specific vulnerabilities that exist within your organization, whether that be a problem with falls, length of stay, surgical site infections, etc. There are certainly common quality and safety challenges that most hospitals face, but there are also specific circumstances and vulnerabilities that are unique to each organization.

Hospitals can be at very different places along the road to reliability and in the specific quality and safety challenges that each faces. Hospitals need to define where they are on the reliability journey and identify their highest return on investment (ROI) opportunities to build and deploy capabilities to improve care. The ROI might be in the form of improved quality and safety for patients, more patient-centered and cost-effective care, hard dollar ROI—it all goes together.

Chartis: What are some of the challenges that health systems are likely to encounter on the high reliability journey, and how can they overcome them?

Resnick: 

Everyone wants to do it, but it's a question of bandwidth and knowing how to get there and how to get started. High reliability, as we've said, is a journey, and organizations have to think about it as adopting a new set of ideals and aspirations to become a high reliable organization and committing to that.

It starts typically with senior leadership needing to say we are going to do this when we have a lot of competing priorities. In healthcare, there's never enough money, there's not enough time, everyone is burnt out, there's wellness issues, and we have a pandemic. So it's awfully hard to say, “OK, in addition to everything else going on, we're going to now do this.” But the cost of not doing it is really, really high.

It is precisely because there is this confluence of capacity issues, staff shortages, the pandemic, and burnout that we’ve come to this place in which safety has worsened. High reliability might be a new priority for an organization, but it is not an additional thing on the backs of staff—it is a way to make work more efficient, make care better, improve engagement, and lower cost. It is the solution to the current conditions.

Dankers: 

One of the things hospitals may encounter on the improvement journey in general is that changing the way you operate to address one problem often creates new problems in other places. High reliability organizations have the ability to take a step back and anticipate the impact of changing a system or an approach. You have to know what competing priorities might get created and enable hospitals with the capability to avoid some of those pitfalls in solution design.

Chartis: You’ve mentioned that higher quality care is more affordable. How are cost and quality related?

Resnick: 

One of the reasons the healthcare system in America is so expensive is because we don't just adopt the best practice and do it every time. We have a lot of unnecessary steps, unnecessary variation, or sometimes errors or defects in the care processes. Those add to the cost.

A knee or hip replacement surgery is an example. If you take an organization that hasn't committed to adopting a best practice and standardizing their care, there might be 12 different implants put in. There might be a whole slew of different things that happened during the procedures, and a lot of those are not data-driven and are unnecessary costs that get added. The cost reduction comes in the standardization of care and looking at these variations. The quality improvement comes in by asking, what's the best way to do this? Which way has the best outcomes? By adopting that approach, you both decrease costs and increase quality.

DANKERS: 

Another simple example is hospital acquired conditions—harms that happen to patients during their hospital stay. Those should theoretically be preventable, like a blood clot that develops because a patient hasn't been given medication to prevent blood clots or a urinary tract infection in a patient with a urinary catheter. Any of these types of harms will increase your length of stay, which increases cost. There is a cost associated with these things, and cost savings associated with reducing them—in addition to the obvious benefit of it being better for patients.

Chartis: If standardizing care is key to achieving high reliability, how do you get physicians on board with adopting a consistent approach to care?

Resnick: 

The alignment of providers with the hospital’s goals is a really important piece of the strategy. Providers are very independent and used to having autonomy. But let’s take Christian’s example of blood clots. There are guidelines on blood clot prevention, and it gets really hard to say world expert hematologists don't have the right answer for preventing blood clots through certain medications. When I was at one hospital, we forced the function. We basically put the best practice for prevention of blood clots into the EMR in a very hard-wired way. And that resulted in a 50% decrease in blood clots, which translated to a $2 million savings per year in the direct costs of having to treat blood clots once they occur.

But to your point, the process involved a whole series of discussions to get different departments on board. Providers need to feel that they have a say and that if there's more than one right way, there's wiggle room in certain areas. You almost never have command and control over providers, so you need alignment, goals, and appropriate incentives to begin with, and buy-in is essential. Part of an effective high reliability program is answering, “How do you get the front line to do things differently?” The structure that connects and aligns the organization from the Board to the front line makes all the difference. Many organizations adopt algorithms and go through trainings and wonder why results don’t happen. Structure and alignment is the key.

Chartis: What are some of the key metrics organizations should aim to improve on their journey to high reliability care?

Resnick: 

There's not one framework for what good quality necessarily means, but it is inclusive of a few important metrics, such as mortality rates, infection rates, readmission rates, and patient experience score. And as organizations mature, it gets farther into specialty-specific metrics and the ultimate villain in high reliability—unnecessary variation.

At different organizations I've been part of, the true north looks slightly different. An organization might choose their U.S. News ranking as their true north or a Leapfrog Safety Grade A as their true north. The metrics that an organization wants to tackle first might be slightly different from place to place, but the important thing is to implement a structure and strategy that aligns the organization to improve very quickly in areas that align with better patient care and a positive ROI. Quickly improving mortality or infection rates can be big wins for the organization in many different ways.

Chartis: Any final words?

Dankers: 

The pandemic and the near collapse of our health care systems in certain places demonstrates that our current approach relies heavily on people just doing their best and trying to be careful. It’s made very clear that the time has come for a fundamentally different approach.

Resnick: 

It would be easy to say we're going to do this when things settle down or when we get to it, not recognizing the fact that we're getting further out of shape over time.

Healthcare is getting more complicated, there's more turnover, and there’s a lot of new people. It’s a completely vulnerable situation for unreliable care to persist. High reliability care is better for patients, it's better for staff, and it saves money. It is the mission of healthcare. Organizations need to start on the journey knowing it’s not solved in a few days but also cannot wait.

© 2024 The Chartis Group, LLC. All rights reserved. This content draws on the research and experience of Chartis consultants and other sources. It is for general information purposes only and should not be used as a substitute for consultation with professional advisors.