High Reliability Systems Case Study

Business case 

Radiation oncology department in multi hospital system set goals to (1) eliminate near-miss conditions and (2) confusion on patient order process that led to staff, proceduralist, and patient dissatisfaction

Initial Conditionradiation-oncology-department

  • Near miss rate approaching 11 per month
  • 1 treatment deviation per year
  • Compliance rate with patient ID verification 55%
  • 85% accuracy and clarity in physician orders

Target Condition

  • Near miss rate reduced to zero
  • Zero treatment deviations
  • 100% patient ID verification
  • 100% accuracy and clarity in physician orders

Planned Activities / Intervention

  • Step 1. Develop change-initiative skills for key leadership positions and organizational structure that will support the new culture
  • Step 2. Providing training in teamwork and communication to support desired culture-changing behaviors such as situational awareness, cross-check and assertion, mutual support, pre-briefing and debriefing protocols
  • Step 3. Create and implement site-specific safety tools such as checklists, structured handoffs, new protocols, algorithms, and team huddles to hardwire the teamwork behaviors into daily patient care processes
  • Step 4. Collect and analyze data to document results.

Achieved Metrics

  • Increase in efficiency and profitability: patient volume increased by 11% with the same level of staffing
  • Reduction in treatment deviations to 0 incidents over the last 3 years
  • Improvement of clarity of physicians’ orders to 97% at 6-months post implementation and after
  • Identified cases where ambiguity or conflicting documentation could have resulted in inappropriate treatment or significant patient harm
  • Processes streamlined and standardized across two clinics allowing for flexibility in staff deployment and elimination of overtime costs