The High Reliability Challenge in healthcare, continuing the journey

Sangita Reddy

Sangita Reddy

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Sangita Reddy is the Joint Managing Director of the pioneering Apollo Hospitals Group, a proponent of integrated healthcare delivery. In addition to her operational responsibilities, Sangita led the group’s retail and primary healthcare endeavours. Recently, in partnership with the National Skill Development Corporation; she initiated a unique PPP purpose-designed to skill half a million individuals before 2020. An ardent champion advocating the benefits of a global delivery model through rural hospitals, outreach camps and telemedicine, Sangita is continuously engaged with the governments to deliver innovative health services harnessing digital platforms.

The healthcare industry has embarked upon several initiatives to raise standards of clinical outcomes, quality and patient safety, yet a lot more is needed to ensure the absolute best for the patient. An exemplary case in point, the aviation industry’s repute for safety has been built over decades of perseverance. Similarly, healthcare’s journey towards a Zero Harm state must begin with a priority to hardwire appropriate methodologies, processes and policies.

The contemporary healthcare ecosystem is a complex entity. It is driven by huge expectations, limited by scarce resources and rampant with co-morbidities and complexities. Combine this with an ageing population, multiple inter-personal relationships within hospitals and less than optimal usage of information technology, and you have an environment that is prone to errors. Medication errors, healthcare associated infections, patient falls and pressure ulcers in hospitals are more common than we care to admit and they pose a massive predicament in the aspect of patient safety. This brings us to the burning question: why is it that the healthcare industry is not as reliable as other industries? Why is an industry as critical as this not geared towards zero harm?

Commercial airlines, the nuclear power sector, electrical power grids and even amusement parks, although different in nature, are perfect examples of High Reliability Organisations (HRO). These are the organisations that have high potential for errors and yet they ensure nearly error-free systems and zero harm. An insight into their optimised efficiency may be understood by observing the way they approach risk management. HROs do not overlook their failures but rather use them as windows to look into their systems and processes! They anticipate unexpected events and build up the capability to avert disasters pro-actively.

It is said that every time an aircraft malfunctions, it makes future flying safer. Given the intricacies of healthcare, the guiding principles of HRO give us an opportunity to improve the healthcare scenario. The healthcare system has to cease being satisfied with marginal improvements. A radical shift can occur only when the entire healthcare environment commits to work towards zero harm, or an errorfree system. A commitment is a must to commence the process of taking up the high reliability challenge. Setting the “goal of zero harm” is the first step towards this journey.

Healthcare Institutions Emerging as HROs

The healthcare ecosystem is continuously adapting itself to take steady strides towards high reliability. The first step towards the commitment to zero harm in healthcare is the responsibility of leaders to lead by example. It is the attitude, belief, and behaviour of the leaders in healthcare organisations which is essential to bring about the change in the organisational culture that supports and encourages zero harm. “A culture of safety that fully supports high reliability has three central attributes: trust, report, and improve” (Reason and Hobbs, 2003). When these three essential components of a safety culture work in tandem, they help achieve high reliability systems and processes which will eventually take us closer to our target.

Various initiatives from different high reliability industries including the aviation sector have been identified and implemented in the healthcare system. These include the use of checklists and bundled interventions that help in eliminating errors such as the WHO Surgical Safety Checklist which is used widely by many healthcare entities to ensure patient safety and in preventing wrong site, wrong procedure and wrong patient surgery. The three parts of the checklist are organised in a logical sequence and require the participation of the anaesthetist, the surgeon and the nursing team, in union to ensure a safe surgical environment for the patient.

Another potential area where errors may occur is the clinical handoff between the care givers. The changing patterns of work culture in hospitals and high patient volumes have created the need for improved handover of clinical responsibility and information. Here again, various checklists, tools, and methodologies are used to ensure compliance and reduce scope of error.

Robust Process Improvement (RPI), a multiplex of Six Sigma, Lean, and Change Management are a powerful set of methodologies and targeted processes introduced by the Joint Commission for healthcare organisations to take precise steps towards reducing errors and patient harm. It helps the healthcare organisations to move from a low reliability to a high reliability set up. It helps in identifying issues which are crucial to quality, patient safety and in classifying and eliminating waste. The process uses extensive data to drive this improvement.

Today, with the advent of information technology, healthcare organisations gather an ocean of data from various touch-points, but the fact remains the same: these organisations are data rich and information poor. This change is of the highest priority as it is pivotal that data is collated, sorted, churned, analysed, understood and converted into useful information which eventually guides the actions of the organisation.

Apollo Hospitals is hardwiring the HRO principles towards zero harm. Apollo Hospitals is committed to healthcare quality and clinical excellence, Apollo uses a structured and wide-ranging set of initiatives in an integrated plan. Apollo Hospitals took on the goal of being accredited by the Joint Commission International (JCI); the undisputed gold standard of quality in global healthcare. Way back in 2005, Apollo Hospitals, Delhi became the first organisation in the country to be accredited by JCI. The hospitals fine-tuned systems and processes to get them in sync with the established international standards. The International Patient Safety Goals helped Apollo to implement processes to get rid of the most common causes of sentinel events. Today, eight of the Apollo hospitals are accredited by Joint Commission International and fourteen hospitals are accredited by NABH and all locations follow the ‘Apollo Clinical Excellence’ model.

While on its journey towards international and national accreditations, ‘The Apollo Standards of Clinical Care’ (TASCC) were developed with a vision to establish uniform standards of clinical care across the Apollo Group of Hospitals to deliver safe and quality clinical care to its patients and ensure zero harm. It embodies a set of process requirements and outcome measures that underlie Apollo Hospitals' approach to clinical care.

TASCC comprises of the six components including Apollo Clinical Excellence Dashboard (ACE I and ACE II), Apollo Quality Improvement Plan, Apollo Incident Reporting System, Apollo Critical Policies, Plans and Procedures and Apollo Mortality Review, all of which focus on providing care of the highest quality and ensuring safety for patients.

Apollo Clinical Excellence Dashboard is a clinical balanced scorecard focusing on outcomes, clinical excellence, patient safety and the functional efficiency of a hospital, benchmarked against some of the world’s best published outcomes in high impact journals. Apollo Hospitals has also developed a comprehensive set of best practices, the Apollo Quality Program, which helps monitor clinical handovers, International Patient Safety Goals, surgical care improvement and zero medication errors, are a few. All these initiatives promote a safety culture and quality improvement DNA across all levels of the organisation from Housekeeping to Senior Clinicians.

The Apollo critical policies, plans and procedures are 25 policies covering clinical care, nursing care, managerial processes, utility systems and infrastructural requirements. Apollo Hospitals has established a system for reporting and tracking of incidents/near misses and other serious health care errors including sentinel events that pose an actual or potential safety risk to patients, families, visitors and staff; these events include patient falls, needle stick injuries and patient pressure ulcers. For Example - Two checklists, including one for surgical safety and the other for the patients admitted in ICUs have been developed to mitigate any adverse events and ensure high quality safe patient care.

Regular mortality review of all deaths is conducted to help detect quality issues that would have otherwise remained hidden and subsequently prevent learning from the situation. This review involves senior clinicians, along with the hospital leadership; it helps to identify areas of improvement in clinical care processes.

In the end, a culture of safety is the bedrock of an HRO. The leadership must ensure that all staff members are encouraged to share their thoughts for preventing any errors or sentinel events. Staff members have to be empowered to report errors and near-misses; raise concern with any practitioner for unsafe behaviour and if needed, even stop a process that poses a risk to the safety of a patient. A practice of ‘walk rounds’ by the senior leadership, ‘safety briefings’ at shift changes and ‘multidisciplinary huddles’ must be included into the work flows.

On similar lines followed by other industries, in a healthcare organisation, the path towards high reliability begins with the commitment to patient safety. A key characteristic of an HRO is to create an atmosphere of collective mindfulness; an environment, where the employees are not hesitant to report even the smallest of problems or raise concerns about any unsafe conditions, thus enabling the system to intervene and achieve zero harm. Over time, several leaders across the globe have introduced different ways and methods to make their organisations into high reliability organisations; however, there are some key characteristics that are common to such organisations.

As described by Karl E. Weick, PhD, and Kathleen M. Sutcliffe, PhD, in their book “Managing the Unexpected: Resilient Performance in an Age of Uncertainty”, they have identified few unique characteristics of an HRO. There must be a preoccupation with failure where an organisation should not be satisfied with no accidents for a length of time and is to be alert to the smallest signs of new threats to safety that may be developing, along with a reluctance to simplify observations. The system should be able to identify subtle differences among threats that may be the differentiator between an early and late indicator for a potential error. All HROs must also show sensitivity to operations, commitment to resilience and deference to expertise in any field.


The foundation of creating a high reliability organisation with the mission of zero harm is laid down by committed leaders. The journey starts with the leaders guiding the entire team on the quest for the highest levels of patient safety and improvement in healthcare quality. With the ever increasing complexity of healthcare systems, higher patient expectations, the omnipresent web and introduction of advanced technology, it’s the need of the hour for the healthcare organisations to raise the bar higher, and strengthen their processes to ensure that zero harm is the common vision that guides every facet of modern healthcare delivery.

Finally and most significantly, if the team feels like family and are committed to a common vision and mission, the universalisation of Quality is possible. And then the team can focus on treating every patient like FAMILY.

--Issue 39--