High Reliability Organizations in Healthcare

Over the last 18 months I have been thinking about the social, moral and financial impact of the COVID-19 pandemic. I am seeing historic levels of workforce shortages, clinical burnout and moral injury, as well as continued cost escalation. The pandemic is not over, and these issues are escalating daily. Is it time we look at our past practices and rethink our patient visitation practices that could be reshaped and reimagined to support a culture of high reliability?

Many of our healthcare organizations have adopted a philosophy of eliminating patient harm events. It is an initiative I feel passionately about. When I was Chair of ACHE’s Board of Governors, I instigated the development of “Leading a Culture of Safety: A Blueprint for Success.” In 2016, medical error became the third leading cause of death in the United States. It has been reported that medical error accounts for more than 242,000 deaths annually, and some sources believe the number could be closer to 400,000 deaths per year.

In 2020, medical error dropped to fourth place due to the COVID-19 pandemic, which has killed more than 4 million people worldwide and more than 600,000 people in the U.S. The pandemic is far from over as vaccination has slowed and variants continue to emerge. We cannot ignore the immediate needs of the pandemic, but neither can we take our focus off the slow, persistent crisis of preventable harm.

As an industry, we have managed SARS, H1N1, Ebola and virulent flu seasons. Viral pandemic events are tragic in nature; however, we have lived with nosocomial infections for decades and have come to accept these harm events as routine and expected. Infectious disease experts tell us that at least 15% of the population has some pathogen that they can pass along to an immunocompromised patient. When we consider the millions of visitors entering our hospitals each day, from patients’ loved ones to food delivery personnel, the implications for zero-harm are heavy.

On the other hand, a great deal of research exists around the benefits to both patients and staff that result from visitors. The emotional and psychological support and goodwill when patients see their family and friends can aid in a speedy recovery. Staff can also be saved many steps when attentive visitors stay with a patient to assist with their care. In a time when every bed is needed, and burnout is prevalent, these benefits hold considerable weight in the conversation.

I started my healthcare career as a critical care nurse, so I certainly understand both the benefits and detriments of open visitation policies. That said, my zeal for safety has long led me to advocate for limiting access to our healthcare facilities. We managed this in the earliest days of the pandemic, implementing strict no-visitor policies; as time went on we made empathetic exceptions for cases such as children and childbirth.

Please indulge me for a few more thoughts. As a nurse, as a hospital CEO and as a patient safety advocate, I ask—how might we balance empathy with the imperative to control nosocomial infections and “do no harm?”

What if we advance the empathy policies we adopted for children and pregnant persons, and create a policy that allows one family member, friend or significant other to stay with a patient—but all other visitations would be done via telephone/video calls? Visitors could be trained to assist with routine tasks such as getting ice and water, personal hygiene or ambulating the patient to reduce demands and stress for nursing and support staff. They can wrangle the phone calls and Skype chats, and learn how to care for and support the patient when they are discharged from the hospital, potentially improving recidivism.

This could be a win-win proposition for the clinical staff as well as the patient. In addition, if this policy is held over long-term, there are numerous potential benefits to the hospital—from cost savings in the parking garages and cafeterias, to reduced security risks.

We have been talking about transformational change in healthcare for the last decade. We must become more intentional about our efforts. There are so many things that need to be addressed in this transformation and by embracing the voice of the front-line clinicians and hospital support staff, executive leadership will accelerate our progress in addressing cost, access, patient safety and consumer-centric care. As the public become more enlightened about the spread of infection due to the pandemic, they may be much more receptive to rethinking visitation policies in healthcare facilities.

Charles D. Stokes, FACHE, is founding partner, Relia Healthcare Advisors, Huntsville, Ala.