What Is High Reliability?

High Reliability occurs when organizations operate consistently, without harm or catastrophic events over a long period of time. It is a philosophy that organizations adapt that, at its heart, embraces a collective, persistent mindfulness. Organizations and businesses that adapted principles of high reliability are the aviation and nuclear power industries, to name two. Studying these organizations and the principles they put in place for high levels of consistent safety has greatly influenced the adaption of those same principles and characteristics in healthcare quality and safety.

Leaders in a Highly Reliable Organization (HRO) recognize that the key to high reliability is firmly establishing and nourishing a culture of safety. This culture must be the foundation for “whole system safety.”  Often, healthcare organizations put processes in place that encourage communication and team involvement, to push forward specific performance improvement projects. Instead, safety must be part of the overall culture and embraced at a systems level. Every individual in the organization becomes a part of this systems approach to safety. Continuous learning, monitoring and enhancing processes becomes the overall philosophy and frame of mind for the HRO. This systems approach is seen in the strong principles of leadership that encourages teamwork and ultimately, behavior change, rather than focusing just on a particular technology, team or process.

High reliability can be seen in five principles first named by Weick and Sutcliffe,  and are adapted by HROs to achieve consistently high levels of safety. The first three elements or characteristics focus on the anticipation of failure. The last two underline the importance of committing to the containment of errors and failure.

Characteristics of High Reliable Organizations include:

1.        Preoccupation With Failure. Always alert to what might happen, high reliability embraces the constant search for where things might fail or go wrong. Everyone in the organization is vigilant, and attentive to small problems that might become opportunities for improvement.

2.       Resist the Temptation to Simplify. By being reluctant to accept work processes at face value, employees in an HRO understand the complexity and subtle differences that on the surface seem safe, but underneath can challenge safety.

3.       Sensitivity to Operations. It is crucial that all members of an organization are involved in operations and feel empowered to report deviations and feel safe to speak freely at any time.

4.       Deference to Expertise. In a crisis or emergency the people with the greatest knowledge are not necessarily the people with the greatest authority for decision making. Those individuals that have the most understanding of a threat or process are empowered to offer their unique expertise. This characteristic puts less emphasis on the established hierarchy and places importance on the climate of shared responsibility.

5.       Commitment to Resilience. Teams in HROs respond quickly to system failures, understanding that if error does happen, it is recognized quickly, and dealt with appropriately. This both prevents harm at the time of error identification, and prevents further errors.

The goal in attaining high reliability in healthcare means creating a safety culture that informs and drives all operations in an organization. Leadership must be completely committed to the constantly evolving playbook that looks for failure, quickly implements new processes, and rewards committed and involved individuals and teams.

Spath, P. (2018). Introduction to Healthcare Quality Management. Third Edition. Chicago: Health Administration Press.

Patient Safety Network. High Reliability. Agency for Healthcare Research and Quality Website. https://psnet.ahrq.gov/primers/primer/31/high-reliability

Chassin, M., Loeb, J. (2013). High-reliability health care: Getting there from here. The Milbank Quarterly. 91(3), p459-490.

Federico, F. (2018). Is your organization highly reliable? Healthcare Executive. 13(1): 76-79.

Brynes, J., Teman, S. (2018). The Need for High Reliability. In The Safety Playbook: A healthcare leader’s guide to building a high-reliability organization. Health Administration Press. 29-33.

Katie Cross, MSN, RNC-OB, LCCE

Genetic Testing…and Me

Genetic Testing…and Me

Written by: Valerie J Connor, MA CCC-SLP, MS CHES

Some years go quickly and are just as quickly forgotten.  Others stick with you because they were memorable.  For example, I specifically remember 2^nd grade because I survived the chicken pox and our family took an amazing trip to Washington D.C.  I also specifically recall 6^th grade, because my younger brother was born.  Of course, 2001 and 2004, will always be important, as those were the years that my children were born.  The other years are pretty much a blur of jumbled memories.  This year – 2018 – will likely stick with me for the rest of my life.  It is the year I found out I am a carrier of the BRCA2 gene mutation.

Over 10 years ago, my dad’s first cousin lost her battle with ovarian and breast cancer.  Before she died, she decided to get genetically tested.  Keep in mind, this was relatively new technology and not widely done, so I consider her to be a bit of a trailblazer.  Her genetic tests results inspired her sister and brother to be tested, along with my dad’s sister – my aunt (Doris).  Doris tested positive for the BRCA2 gene mutation.  She encouraged my dad to be tested, but he was hesitant.  The topic came up in general conversation, but I was young, busy with two small children, and not too concerned.

Jump ahead about 12 years.  During this time, my aunt did everything right.  Due to a previous hysterectomy, she no longer had her ovaries, so ovarian cancer was not a concern.  She was considered “high risk”, so she alternated mammograms with MRI testing every six months.  She consulted with an oncologist who prescribed various anti-cancer medications as the years progressed.  In 2018, a small tumor was found during a routine MRI.  Within weeks, a double mastectomy with reconstruction was scheduled.  Fortunately for Doris, the cancer did not spread and no extra treatments were required. 

As soon as my aunt was diagnosed with breast cancer, my health and wellbeing took front stage.  I immediately called my primary care physician who referred me to a genetic counselor through Genesis Health Systems.  I honestly didn’t even know that position existed and I work for Genesis.  My spit was collected and shipped off to the same genetic testing facility my aunt’s doctor had used.  Apparently, it is helpful if you use the same testing facility so they can compare results – it reduces false positives.  Depending on how you look at it, I lost the genetic lottery.  There was a 50/50 chance I carried the gene mutation, and I was on the losing 50%.

Since that time, I have had an oophorectomy – removal of both ovaries and fallopian tubes.  BRCA2 gene mutation carriers have a 45% chance of developing ovarian cancer, but ovarian cancer is difficult to detect.  Once it’s detected, it’s extremely hard to treat.  The decision to remove my ovaries was simple.  Once the ovaries were removed, my risk of developing breast cancer went from 85% to 45%.  Although I miss estrogen coursing through my body, apparently it is not helpful to people with the BRCA2 gene mutation.

Yesterday I had my first (and possibly last) breast MRI.  I meet with a surgeon in a few weeks and we’ll discuss options.  I haven’t completely decided yet, but I don’t relish the thought of taking anti-cancer drugs or getting tested every 6 months.  I’m more of a “just fix it and forget it,” type gal, so I’m leaning toward surgical options.

However, just because I remove my ovaries and breasts, I won’t be completely free of cancer risks.  I’m still at high risk for pancreatic cancer. 

I’ve spoken about this journey with many people over the last few months.  The reactions are a mix of sympathy and questions.  I encourage everyone to consider professional genetic testing if there is familial history of cancer.  Pop-science versions are available, but these tests might only look at very specific genetic markers and not the entire spectrum.  Also, once you send off your DNA to a service such as 23andme, you lose all rights to privacy.  With professional genetic testing, your DNA results are protected by HIPAA’s Privacy Rule, as well as a slew of other ethical protections.

The genetic counselors at Genesis were amazing at asking all the right questions and pointing me in the right direction.  Testing was completely covered by my insurance, as have the subsequent doctors visits and surgery.  It’s empowering to have all this knowledge at my disposal.  I can be pro-active and make decisions without the complications of fear and urgency.

Eventually, my two kids will have to be tested.  BRCA2 is a cancer that develops later in life, so there is no rush.  They also have a 50/50 percent chance of inheriting the gene mutation.  I sincerely hope they win the genetic lottery.

Spiritual Rituals within the Long-Term Care Community

Author:   D. Eargle, Ph.D., M.Ed.   2018

Spiritual Rituals within the Long-Term Care Community

“wanting to finish my living…”

 Many Chaplains and Spiritual Care Practitioners offer their belief that long-term care facilities should be in the business of helping elder residents finish-their-living, while also creating a strong community presence.  They go further in arguing that spiritual care must be an integral part of the facility’s service programs, with spiritual assessment and care planning being as essential as nutrition, physical therapy, and nursing care plans. 

 Familiar religious rituals should be anticipated and regularly scheduled throughout the year.  All residents, regardless of their health status, should be encouraged to play meaningful roles in spiritual practice. 

While it is beyond the scope of this blog, I wish to share several methods effectively used by practitioners in their spiritual practice with long-term care residents.

Forgiveness, Guided Reminiscence, and Life Review

“seeking forgiveness…”

An important question posed to Pastoral Counselors and Spiritual Care Providers: “What is the biggest need motivating older adults to seek spiritual guidance?”  Resoundingly, the answer went something like this… healing old wounds of troubled relationships, resentments, anger, regrets, forgiving Self, forgiving Others. (Ramsey, 2008).

On an interesting side note: as a scientific field of research, forgiveness has had a brief history.  Since the 1980s, however, it has become a major topic in medicine, psychology, and theology.

According to Ramsey, a family therapist, all forgiveness work includes a life story.  Moving forward in life is perhaps best facilitated for struggling older adults when a spiritual guide helps the person search for exceptions, imagine new and more hopeful endings, and begin to assume more flexible, empowering roles rather than the passive suffering of victimhood (Ramsey, 2008).

Reminiscence & Life Review:

Depending upon the individual, guided reminiscence may take different forms and serve various adaptive functions, e.g., recalling the “good old days,” reinforcing one’s positive self-image & abilities, and entertaining others via story telling.  Some reminiscing, however, may serve the purpose of a life review, often in preparation for death.  Pressing topics typically include resolving issues of the past, seeking forgiveness, leaving a legacy, and completing one’s “unfinished business.”

Ramsey counsels Spiritual Care Providers to help elders use this life review as an impetus to evaluate, make peace with, and give thanks for what has been.  She goes further in encouraging elders to become spiritual mentors to young adults, a life stage that is also often filled with struggles, conflicts, fears, and lack of meaning (Ramsey, 2008).

Fr. Oberle, a Spiritual Care Director, offers a definition of forgiveness that I find especially meaningful:

“Forgiveness is the giving up of all hope of a better past” (Oberle, 2002, p. 7).

  By acknowledging that the past cannot be changed, forgiveness focuses on the future.  This process can be particularly important for elders nearing the end of life. 

Spiritual Legacies, Autobiographies, Ethical Wills,

Life Stories, Journals, and Story Telling

As noted throughout the thanatology research, most older adults have a willingness and a need to speak openly about death.  In fact, elders express a greater openness to such discussions than do younger generations.  Most practitioners are also in agreement that leaving a spiritual legacy is vital for elders nearing the close of life.  In addressing their own mortality, many questions surface:

  Will I be remembered?    How Will I be remembered?

Did my life matter?

In what ways can I contribute to something of lasting value?

Spiritual autobiographies and ethical wills are two examples of avenues for contributing something of spiritual substance to others.  According to Richards, the importance of life stories for all generations can be affirmed in the context of the story of a Higher Power, religious beliefs, and personally important values.  Others find that keeping a written or taped journal, formally or informally, plays a central role in their legacies and can also be experienced as a stress management tool (Richards, 2008).

Reflection Question

Many view our Internet Age as providing additional ways in which older adults can document and share their stories and legacies.  Do you feel our advanced Computer Technologies will impact the ways in which we provide spiritual care in the future?

In Closing…

The following quote has meaning for me, so I want to share with you….

Aging is a moral and spiritual frontier because its unknowns, blessings, terrors, and mysteries cannot be successfully crossed without humility and self-knowledge; without love and compassion; without acceptance of physical decline and mortality; and a sense of the sacred (Cole & Winkler, 1994, p. 5)

Resources

Aging & Spiritual Rituals

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Address, R. (2005).  Creating Sacred Scenarios:  Opportunities for New Rituals.  In Religion, Spirituality, and Aging.  Binghamton, NY:  The Haworth Press.

Black, K., & Elkins, H. (2005).  Wising Up:  Ritual Resources for Women of Faith in their Journey of Aging.  Cleveland: Pilgrim Press.

Cavanaugh, J., & Blanchard-Fields, F.  (2014).  Adult development and aging (7^th ed.).   Belmont, CA: Thompson Wadsworth.

Cole, T., & Winkler, M.  (1994).  The Oxford book of aging: Reflections on the journey of life.  New York: Oxford University Press.

Griffin, R.  (2005).  Caregiving and our inner elder: Insights from a spiritual master.  In H. R. Moody (ed.) Religion, Spirituality, and Aging.  Binghamton, NY: Haworth Press.

Hooyman, N., & Kiyak, H.  (2018).  Social gerontology: A multidisciplinary perspective (10^th ed.).  Boston: Allyn and Bacon.

Moody, H. R.  (2005).  Knowledge, practice, and hope.  In Religion, spirituality, and aging.  Binghamton, NY:  Haworth Press.

Moody, H.R. (2010).  Aging: Concepts & Controversaries (6^th ed).  Thousand Oaks, CA: Pine Forge Press/Sage Publications. 

Nelson-Becker, H., Nakashima, M., & Canda, E. (2012).  Spiritual Assessment in Aging: A Framework for Clinicians.  Journal of Gerontological Social Work, 48, 331-347.

Oberle, J.  (Fall 2002).  Forgiveness: A spiritual value that fosters physical, psychological and spiritual health.  In Newsletter of the Forum on Religion, Spirituality and Aging. 14(3), 7.

Ramsey, J.  (Summer 2008).  Forgiveness and healing in later life.  Generations, 32(2), 51-54.

Richards, M. (Summer 2008). Spiritual Challenges and Hope in Sharing Care.  Generations. 32(2), 68-69.

Blog Author:

Dr. Donnelle Eargle  

deargle@sjcme.edu 

With a background in geriatric rehabilitation psychology, Dr. Eargle teaches gerontology-related courses at Saint Joseph’s College.  Standish, Maine.