A model for developing high-reliability teams

riley w., davis s.e., miller k.k. & mccullough m. (2010) Journal of Nursing Management 18, 556–563
A model for developing high-reliability teams Aim To develop a model for high reliability in health care quality and patient safety. Background A high-reliability health organization (HRO) has measurable near perfect performance in quality and safety. High reliability is necessary in health care where the consequences of error are high and the frequency is low. Key issues Despite a decade of intense focus on quality and safety since a series of reports from the Institute of Medicine (IOM), health care is not a completely safe industry and quality is not what it should be to ensure high reliability for patients. Conclusions A model for high reliability is presented that includes the individual skills necessary to assure high-reliability teams on a patient care unit. High-reliability teams (HRT) form an essential core of a HRO. These teams and their organizations value a culture of safety every day with every patient encounter. Implications for nursing management Nurse managers can lead in creating a HRO by first developing HRTs on their patient care unit.     

Achieving a high-reliability organization through implementation of the ARCC model for systemwide sustainability of evidence-based practice

High-reliability health care organizations are those that provide care that is safe and one that minimizes errors while achieving exceptional performance in quality and safety. This article presents major concepts and characteristics of a patient safety culture and a high-reliability health care organization and explains how building a culture of evidence-based practice can assist organizations in achieving high reliability. The ARCC (Advancing Research and Clinical practice through close Collaboration) model for systemwide implementation and sustainability of evidence-based practice is highlighted as a key strategy in achieving high reliability in health care organizations.     

Patient satisfaction with nursing care: a concept analysis within a nursing framework

Title.  Patient satisfaction with nursing care: a concept analysis within a nursing framework.
Background.  Patient satisfaction is an important indicator of quality of care, and healthcare facilities are interested in maintaining high levels of satisfaction in order to stay competitive in the healthcare market. Nursing care has a prominent role in patient satisfaction. Using a nursing model to measure patient satisfaction with nursing care helps define and clarify this concept.
Data sources.  Rodgers' evolutionary method of concept analysis provided the framework for this analysis. Data were retrieved from the Cumulative Index of Nursing and Allied Health Literature and MEDLINE databases and the ABI/INFORM global business database. The literature search used the keywords patient satisfaction, nursing care and hospital. The sample included 44 papers published in English, between 1998 and 2007.
Results.  Cox's Interaction Model of Client Health Behavior was used to analyse the concept of patient satisfaction with nursing care. The attributes leading to the health outcome of patient satisfaction with nursing care were categorized as affective support, health information, decisional control and professional/technical competencies. Antecedents embodied the uniqueness of the patient in terms of demographic data, social influence, previous healthcare experiences, environmental resources, intrinsic motivation, cognitive appraisal and affective response. Consequences of achieving patient satisfaction with nursing care included greater market share of healthcare finances, compliance with healthcare regimens and better health outcomes.
Conclusion.  The meaning of patient satisfaction continues to evolve. Using a nursing model to measure patient satisfaction with nursing care delineates the concept from other measures of patient satisfaction.     

Pioneering a new role: the beginning, current practice and future of the Clinical Nurse Leader

Aim  To discuss the development of a new nursing role in response to the health care crisis in the United States.
Background  The nursing shortage and fragmentation of care has contributed to the need for nurses who are prepared to laterally integrate care, bring evidence-based practice to the bedside and provide continuity of care to patients and families.
Evaluation  The CNLs review the literature, share their experiences, and discuss outcomes related to improved quality of care.
Key issues  Having clinical nurses with a global perspective acting as facilitators and integrators of care is essential to maintaining a high standard of care. Organizational and management support is critical. The more CNLs that can be embedded in an institution, the more successful the role can be.
Conclusions  The varied utilization of the CNLs in this practice setting has proven its value in a short period of time and facilitated better communication and collaboration among patients and their health care team.
Implications for nursing management  The flexibility and broad scope of this role allows for its use in any practice setting to realize gains in quality outcomes, cost savings, improved patient flow, increased safety, nurse satisfaction and increasing organizational capacity.     

Responding to health care reform by addressing the institute of medicine report on the future of nursing

The current health care environment has heightened the importance of achieving positive patient outcomes and excellent customer satisfaction. To remain competitive, health care organizations must adapt quickly to changing regulatory requirements, quality improvement initiatives, and customer expectations. To ensure nursing practice at the Saint Clare's Health System in Northwest New Jersey is at the forefront of leading change, the nursing staff has embraced the Institute of Medicine report The Future of Nursing: Leading Change. The empowered nursing team has applied Benner's Novice to Expert model and McCauley's Careful Nursing Theory as the foundation for nursing practice. The ability to apply evidence-based nursing research and cultivate professional development at the bedside has resulted in retention of expert nurses at the bedside. Engaging the nursing team has resulted in increased patient satisfaction and improved clinical outcomes. Advanced practice nurses play an important role to mentor the nursing staff and promote an interdisciplinary, collaborative relationship between all health care disciplines and community support programs. Nurses are recognized for their accomplishments and encouraged to obtain specialty certification, advanced degrees, and earn state and national recognition through professional organizations. The professional nurses at the Saint Clare's Health System are prepared to work in whatever environment the new normal creates.     

The clinical nurse leader: a catalyst for improving quality and patient safety

Aim  The clinical nurse leader (CNL^®) is a new nursing role introduced by the American Association of Colleges of Nursing (AACN). This paper describes its potential impact in practice.
Background  Significant pressures are being placed on health care delivery systems to improve patient care outcomes and lower costs in an environment of diminishing resources.
Method  A naturalistic approach is used to evaluate the impact the CNL has had on outcomes of care. Case studies describe the CNL implementation experiences at three different practice settings within the same geographic region.
Results  Cost savings, including improvement on Centers for Medicare and Medicaid Services (CMS) core measures, are realized quickly in settings where the CNL role has been integrated into the care delivery model.
Conclusions  With the growing calls for improved outcomes and more cost-effective care, the CNL role provides an opportunity for nursing to lead innovation by maximizing health care quality while minimizing costs.
Implications for nursing management  Nursing is in a unique position to address problems that plague the nation's health system. The CNL represents an exciting and promising opportunity for nursing to take a leadership role, in collaboration with multiple practice partners, and implement quality improvement and patient safety initiatives across all health care settings.     

Nurse Leaders: Transforming Interprofessional Relationships to Bridge Healthcare Quality and Safety

Health care remains an exceedingly complex, high-risk industry with the potential for errors resulting in patient injury or mortality. Many health care systems have progressed toward high reliability principles to improve quality and safety. Nurse leaders are integral to high reliability as they establish a vision and operational objectives that permeate an organizational commitment to safety. Interprofessional relationships and team dynamics among clinicians can enhance or impede their ability to collaborate and provide care. In this paper, we discuss the influence of clinician relationships on health care performance and provide insights into nurse leader interventions to improve interprofessional collaboration and drive high reliability.     

Safeguarding patients: complexity science, high reliability organizations, and implications for team training in healthcare

Serious events within healthcare occur daily exposing the failure of the system to safeguard patient and providers. The complex nature of healthcare contributes to myriad ambiguities affecting quality nursing care and patient outcomes. Leaders in healthcare organizations are looking outside the industry for ways to improve care because of the slow rates of improvement in patient safety and insufficient application of evidenced-based research in practice. Military and aviation industry strategies are recognized by clinicians in high-risk care settings such as the operating room, emergency departments, and intensive care units as having great potential to create safe and effective systems of care. Complexity science forms the basis for high reliability teams to recognize even the most minor variances in expected outcomes and take strong action to prevent serious error from occurring. Cultural and system barriers to achieving high reliability performance within healthcare and implications for team training are discussed.     

Safe practice of population-focused nursing care: Development of a public health nursing concept

Patient safety, a cornerstone of quality nursing care in most healthcare organizations, has not received attention in the specialty of public health nursing, owing to the conceptual challenges of applying this individual level concept to populations. Public health nurses (PHNs), by definition, provide population-focused care. Safe practice of population-focused nursing care involves preventing errors that would affect the health of entire populations and communities. The purpose of this article is to conceptually develop the public health nursing concept of safe practice of population-focused care and calls for related research. Key literature on patient safety is reviewed. Concepts applying to population-focused care are organized based on Donabedian's Framework. Structural, operational and system failures and process errors of omission and commission can occur at the population level of practice and potentially influence outcomes for population-patients. Practice, research and policy implications are discussed. Safe PHN population-focused practice deserves attention.     

Leveraging EBP to Establish Best Practices,Achieve Quality Outcomes,and Actualize High Reliability: Building EBP Competency Is Not Enough

Health care in the United States has been in a critical state for decades and the recent pandemic has added additional stress to a system that is underpinned by widespread variation in practice and care. Evidence-based practice (EBP) is a methodological, problem-solving approach to identify best practices that, when implemented and sustained, leads to quality outcomes, and actualization of true high reliability. To reap the benefits of EBP, however, leaders must do more than simply build EBP competencies. This article provides clarity, guidance, and resources for leaders who are beginning or advancing integration of EBP in their organizations.     

Performance assessment in health care providers: a critical review of evidence and current practice

Aim  To evaluate methods of performance assessment through an international literature review and a survey of current practice.
Background  Over the past two decades health care organizations have focussed on promoting high quality care in conjunction with retaining motivated staff. Cognisant of such initiatives, we sought to evaluate assessment methods for qualified staff according to their utility in the working environment.
Methods  A systematic literature search was completed and each paper independently reviewed. All health care organizations in Northern Ireland submitted details of their performance assessments. Each was critically appraised using a utility index.
Results  Performance was not universally defined. A broad range of assessments were identified, each method had advantages and disadvantages. Although many lacked rigorous testing, areas of good practice were also noted.
Conclusions  No single method is appropriate for assessing clinical performance. Rather, this study endorses proposals for a multi-method strategy to ensure that performance assessment demonstrates all attributes required for effective nursing and midwifery practice.     

Careful counsel: Management of unintended pregnancy

Purpose: To provide a guideline for the care of women with unintended pregnancies, highlight the magnitude of unintended pregnancy, identify the demographic population at highest risk, offer assessment and diagnostic information, and describe the importance and practice of comprehensive, nondirective pregnancy options counseling, including information on abortion, adoption, and parenthood.
Data sources: Extensive literature review of government publications, professional clinical, nursing, and medical journals and textbooks.
Conclusions: The practice of counseling women and couples in a nondirective manner and providing comprehensive overview of options is paramount and should be the standard practice for all clinicians, especially within organizations funded by Title X funds.
Implications for practice: As we strive toward diligent patient advocacy, it is essential that NPs implement and endorse the ethical provision of options counseling through promoting values clarification and continuing education.     

Theories of risk and safety: what is their relevance to nursing?

Aim  The aim of this paper is to review key theories of risk and safety and their implications for nursing.
Background  The concept of of patient safety has only recently risen to prominence as an organising principle in healthcare. The paper considers the wider social context in which contemporary concepts of risk and safety have developed. In particular it looks at sociological debates about the rise of risk culture and the risk society and their influence on the patient safety movement.
Key issues  The paper discusses three bodies of theory which have attempted to explain the management of risk and safety in organisations: normal accident theory, high reliability theory, and grid-group cultural theory. It examine debates between these theories and their implications for healthcare. It discusses reasons for the dominance of high reliability theory in healthcare and its strengths and limitations.
Conclusion  The paper suggest that high reliability theory has particular difficulties in explaining some aspects of organisational culture. It also suggest that the implementation of high reliability theory in healthcare has involved over reliance on numerical indicators. It suggests that patient safety could be improved by openness to a wider range of theoretical perspectives.     

Framework for patient safety, part 1: culture as an imperative

Nurse leaders play a critical role in patient safety. They are essential in building a culture of safety and engineering resilience into workflows and patient care processes enabling healthcare organizations to progress toward high reliability. In part 1 of this 2-part series, the authors discuss the critical nature of a safety culture: why trust and respect lead to teamwork and collaboration in preventing serious safety events. Part 2 will introduce the emerging healthcare concept of high reliability, described through examples of health systems that have successfully adapted models from other industries. Use of technology and other advancements provides a context for advancing patient safety. Aligning culture and engineering technology for safety, when coupled with effective leadership, can provide a long-term approach for safe and effective care.     

Creating reporting and learning cultures in health-care organizations

Patient safety has emerged as an important issue in Canadian health care, as reflected in the Canadian Council on Health Services Accreditation's patient/client safety goals. Achieving these goals calls for concerted efforts within health-care organizations. To assist nurse leaders in their efforts in developing a culture of safety that is receptive to reporting and learning from adverse events and near misses, the authors explore the challenges and provide four recommendations for action. By enacting these recommendations, nurse leaders can support the analysis and actions necessary to identify improvements that will create safer health-care environments.     

Nursing Leaders as Visionaries and Enablers of Action

ObjectivesThe engagement of nursing leaders is critical for the future of the cancer nursing profession, quality cancer care, and the overall health care system. The field of cancer care is facing enormous challenges, requiring strong nursing leadership. Cancer nursing leadership is needed to overcome the challenges caused by workforce shortages, restricted resources, historic and ongoing under-recognition of nursing, unsafe working conditions, and unequal access to education. The aim of this article is to contribute to the discussion about how cancer nursing leaders can act as visionaries and support transformation of cancer nursing for the future.Data SourcesAuthor experience, journal articles and organizational position papers were used.ConclusionTo improve the state of cancer nursing and the working conditions of the cancer nursing workforce, nursing leadership practices need to be embraced on all governance levels in clinical practice and academia. When effective and high-quality nursing leadership is enacted, positive outcomes for people affected by cancer, nursing, and health care systems can be achieved. Cancer nursing leadership needs to be supported through nursing scholarship, influencing national and global policies and strategies and by active involvement in national and international health care management.Implications for Nursing PracticeNursing leadership and governance is critical to strengthening the cancer nursing workforce. Strong nursing leadership is required to realize the vision for transforming the health care systems and cancer care. Therefore, collaboration among multidisciplinary leadership, health care organizations, academic institutions, professional organizations, and policy-making structures is warranted.     

A magnet nursing service approach to nursing's role in quality improvement

The heightened focus on quality and the rise of health care consumerism are manifestations of numerous interrelated dynamics, especially including the aging of the "baby boomers" and greater prevalence of chronic conditions, the explosion of biomedical scientific knowledge and technology, changes in prevailing methods of health care financing, a recent prolonged period of economic prosperity, widespread concerns about patient safety, return of disproportionate health care cost, and the democratization of medical knowledge consequent to widespread use of the Internet. Quality improvement in nursing was first introduced by Florence Nightingale during the Crimean War. Today, nursing quality continues to look at process, but has evolved to an emphasis on patient care outcomes. This article discusses nursing quality structure, processes, and outcomes at a large, teaching, tertiary medical center in Los Angeles, California. The medical center is one of two designated magnet nursing services in California. Nursing's role in achieving clinical and service quality for patients, communities, and staff are essential characteristics of magnet-designated nursing service organizations.     

Nurses create a culture of patient safety: it takes more than projects

Healthcare organizations are embracing the sciences of safety, improvement, human factors, and complexity to transform their culture into a culture of safety and high reliability. Nurses are the front lines of healthcare delivery, and as such, the front lines of safety and quality processes and outcomes. Nurses are required to both understand and develop the skills needed to improve care processes and to own the work of improvement as a professional responsibility. These changes demand that nurses understand both the complex demands of providing harm-free care and the system dynamics needed to create the conditions for improved outcomes, organizational, and system performance, and intraprofessional development and teamwork. The author presents the challenge of maintaining a safe patient care environment and describes a model that can detect and mitigate the migration of safe nursing care into at-risk and unsafe nursing care. She emphasizes the importance of healthcare organizations performing as high reliability organizations and outlines 'planned practices' steps to introduce new technology and innovation, and concludes by considering the interaction between individual practice and system performance.     

Identifying key nursing and team behaviours to achieve high reliability

Aim  The aim of the present study was to measure markers of key nursing behaviours in interdisciplinary teams during critical events to assess the extent of high reliability.
Background  Technical and team competence are necessary to achieve high reliability to ensure safe patient care. Technical competence is generally assured because of professional training, licensure and practice standards. During critical events, team competence is difficult to observe, measure and evaluate in interdisciplinary teams.
Method  During critical events, in situ simulation was the method used to observe interdisciplinary interaction of nursing behaviours regarding communication. Seventeen trials were conducted and videotaped for evaluation at four hospital sites.
Results  Key nursing behavioural markers for interdisciplinary interaction were described: situational awareness, use of situation, background, assessment, recommendation-response (SBAR-R), closed-loop communication and shared mental model.
Conclusion  Skills necessary for nurses to contribute to highly reliable, interdisciplinary teams are not consistently observed during critical events and constitute breaches in defensive barriers for ensuring patient safety.
Implications for nursing management  Nurses have a key role in assuring effective team performance through the transfer of critical information. Nurses need to recognize and identify important clinical and environmental cues, and act in order to ensure that the team progresses along the optimal course for patient safety.     

The Leadership Role of Nurse Educators in Mental Health Nursing

Leadership behaviors and actions influence others to act, and leadership in clinical practice is an important mediator influencing patient outcomes and staff satisfaction. Indeed, positive clinical leadership has been positioned as a crucial element for transformation of health care services and has led to the development of the Practice Doctorate Movement in the United States. Nurse educators in health care have a vital leadership role as clinical experts, role models, mentors, change agents, and supporters of quality projects. By enacting these leadership attributes, nurse educators ensure a skilled and confident workforce that is focused on optimizing opportunities for students and graduates to integrate theory and practice in the workplace as well as developing more holistic models of care for the consumer. Nurse educators need to be active in supporting staff and students in health care environments and be visible leaders who can drive policy and practice changes and engage in professional forums, research, and scholarship. Although nurse educators have always been a feature of the nursing workplace, there is a paucity of literature on the role of nurse educators as clinical leaders. This discursive article describes the role and attributes of nurse educators with a focus on their role as leaders in mental health nursing. We argue that embracing the leadership role is fundamental to nurse educators and to influencing consumer-focused care in mental health. We also make recommendations for developing the leadership role of nurse educators and provide considerations for further research such as examining the impact of clinical leaders on client, staff, and organizational outcomes.