I

PRESIDENT’S MESSAGE

http://dx.doi.org/10.1016/j.aorn.2014

� AORN, Inc, 2014

Overcoming Barriers

to ExcellenceVICTORIA M. STEELMANPhD, RN, CNOR, FAAN, AORN PRESIDENT

t has been 14 years since the Institute of Medicine

released its landmark report, To Err Is Human.1 In

addition to the Institute of Medicine, other orga-

nizations (eg, Institute for Healthcare Improvement,

National Quality Forum) and government agencies

(eg, Centers for Medicare & Medicaid Services,

Agency for Healthcare Research and Quality) are

leading the way, promoting national initiatives to

transform health care into a safer system. Many

improvements have been made, including reductions

in catheter-associated urinary tract infections,2,3

blood stream infections,4,5 and ventilator-associated

pneumonia.6,7

Yet, for perioperative nursing, there is much work

to be done. The Joint Commission reported that

wrong-patient, wrong-procedure, and wrong-site

surgeries, and retained foreign bodies after surgery

were two of the top three sentinel events reported in

2013. Delay in treatment, which also can apply to the

OR, was the most frequently reported sentinel event.8

Reports in the media personalize these experiences,

increasing public demand for a safer health care

system. Perioperative nurses should use techniques

successfully used by high-reliability organizations

(HROs) to realize the goals of achieving a safer health

care system and overcome barriers to excellence.

HIGH-RELIABILITY ORGANIZATIONS

Transforming hospitals into HROs is one frame-

work to improve the quality and safety of health

.07.004

care. High reliability means delivering what is

intended to be delivered 100% of the time. High-

reliability methods have been used successfully by

complex, high-risk industries, including aviation

and nuclear power. Because of their demonstrated

effectiveness and high safety records, the methods

used by HROs have been increasingly adopted in

health care as well. The Joint Commission and

Agency for Healthcare Research and Quality

recommend transforming hospitals into HROs.9,10

Hospitals that have become HROs have developed

five characteristics.11

Sensitivity to Operations

First, leaders and staff members are sensitive to

operations, acutely aware of how processes and

systems affect patient care and desired outcomes.

Each employee pays close attention to what is

working and what is not. These observations are

used to identify risks and improve the processes

and systems, instead of using workarounds.

Reluctance to Simplify

Second, in HROs, leaders and staff members are

reluctant to accept simple explanations of problems

or excuses (eg, inadequate training, communication

failure). Instead, they recognize the complexity of

the processes and systems and place problems

within this context. By doing a “deep dive,” the

underlying cause and contributing factors of prob-

lems can be explored, and acted on.

October 2014 Vol 100 No 4 � AORN Journal j 351

October 2014 Vol 100 No 4 PRESIDENT’S MESSAGE

Preoccupation With Failure

Third, employees in HROs are preoccupied with

failure. Every employee is vigilant, looking for

ways that the systems and processes can break

down. Near misses are reported and investigated,

and corrective actions taken. Instead of blaming

employees or patients, this work focuses on how to

improve processes.

Deference to Expertise

Fourth, HROs defer to the expertise of frontline

staff members who understand the complexity of

processes and the tasks involved. Leaders listen

to these individuals, regardless of seniority or

hierarchy.

Resilience

Five, HROs are resilient. Leaders and staff mem-

bers stay on course, relentlessly seeking out solu-

tions to problems. They have specific, measurable

goals and prioritize these goals. Report cards and

90-day action plans set the stage for meeting

these goals.

BARRIERS TO EXCELLENCE ANDSTRATEGIES FOR CHANGE

Perioperative nurses see the barriers to achieving

high reliability and excellence every day. Most

of these barriers are based on perception. Some

perceived barriers to excellence involve workflow

and schedule changes, attitudes toward failures

and mistakes, and the facility’s response to system’s

issues.

n Workflow and schedule changes throughout a

work shift are sometimes seen as uncontrollable:

n How can I prepare for the changes in the

schedule if I don’t know what they will be?

n If we are efficient, will we be “rewarded”

with another case?

n Failures may be seen as inevitable and accept-

able: mistakes happen, and people are imperfect.

n Or, mistakes may be seen as the fault of an

individual: if she were just more vigilant, she

would not have left that sponge in the patient.

352 j AORN Journal

n There is also a common perception that reports

of adverse events, near misses, and systems

issues are not addressed: if the issue will not

be addressed, then why take the time to report it?

These perceptions lead to complacency and lack

of initiative to implement or even participate in

changes to improve patient care or the workplace.

These barriers may seem overwhelming. But,

strategies developed by HROs can overcome these

barriers and the resulting complacency. Three

simple strategies used by HROs are huddles,

action boards, and daily progress reports.

Huddles

One strategy that can be used effectively to pro-

mote high reliability is the use of huddles.12 The

preprocedural briefing is one type of huddle, focusing

on care of an individual patient. This provides an

opportunity for everyone to prepare for potential

changes that might occur during the procedure. For

example, sharing the anticipation that mesh might

be needed during a hernia repair allows the circu-

lating nurse time to order the mesh and prevent a

delay during surgery. Likewise, knowing that blood

may be needed but none has been ordered allows

the circulating nurse to anticipate and obtain the

blood in a timely manner. Sharing success stories

about prevented delays with surgeons enhances

collaboration.

Another type of huddle is at the unit level, focusing

on the overall flow of the day. Key clinical leaders

convene and discuss potential challenges, such as

delays and add-ons, and develop a plan for ad-

dressing these challenges. This type of huddle is a

stand-up meeting, is less than four minutes long, and

is held at specific times every day (eg, 7 AM, 1 PM).

It is important that it happens at the same time each

day to use the time efficiently and to promote ex-

pectations of punctuality and attendance. The team

composition depends on the facility but often in-

cludes the manager or charge nurse and the anes-

thesia director. In a large hospital, the team also

might include clinical coordinators or the medi-

cal director.

PRESIDENT’S MESSAGE www.aornjournal.org

Unit level huddles have distinct benefits. They

harvest the daily learning that is needed for deci-

sion making. They also provide a time and place to

discuss events that occur. Huddles provide structure

for a culture of transparency and a safe mechanism

for open communication. They provide a culture

that promotes recovery from adverse events and

inclusiveness in decision making. Huddles also

enhance interpersonal relationships to continually

improve teamwork.12

Consider the following scenario as an example.

During the 7 AM huddle, the charge nurse reports

that there is a patient in the emergency department

with an open fracture. Discussing this, the team

develops a shared mental model of how the po-

tential surgery can be worked into the flow of the

day. The charge nurse alerts the staff in Room 1

that they may be receiving the patient after their

first surgery is completed. By discussing alternative

views on how and where to work the surgery in up

front, the team avoids rework that might occur

without a shared mental model.

Action Boards

Another strategy used by some high-reliability ORs

is posting action boards in the hallway or lounge.

Staff members or physicians post an issue on a red

“defect” board. The note identifies a defect that

needs to be addressed and is signed by the person

posting the note. For example, an issue identified

during a postoperative debriefing might be laparo-

scopic instrument trays that are missing a specific

instrument. The RN circulator could post this on

the defect board. Next, a staff member would ac-

cept the responsibility for addressing the defect. In

this case, it might be a staff member in general

surgery or an assistant manager. This person would

move the note to a yellow “in process” board, and

identify himself or herself on the note as the person

accepting responsibility. After the issue has been

resolved, the note would be moved to the green

“resolved” board. Over time, the number of notes

that have been moved to the green board increases.

The use of action boards overcomes the percep-

tion that nothing is done when issues are reported

and overcomes complacency. As more and more

defects move to the green board, team members

take pride in their contributions and buy into the

change in culture. Physicians see that issues are ad-

dressed and are more likely to engage in initiatives.

Daily Progress Reports

Daily reports about progress on safety issues also

overcome complacency. For example, staff mem-

bers can be complacent about using precautions

to prevent sharps injuries and slip into unsafe hand-

to-hand passing techniques. Posting the number of

days since a sharps injury reminds everyone that

these injuries can occur and diminishes the com-

placency that can so easily develop. Posting the

number of days since a back injury reminds staff

members to use mechanical lifting devices. When

the posting shows “0” or “1,” it inspires discussion

among staff members and a heightened vigilance.

One hospital had a problem with instruments being

sent to sterile reprocessing in a manner that made

cleaning difficult. Posting the number of days

since this occurred recognized the efforts of staff

members and gave them a sense of pride in doing

the right thing.

Daily progress reports are also an ideal way to

communicate the importance and progress made

toward addressing patient safety issues. For exam-

ple, posting the number of days since a missed

intraoperative antibiotic redosing reminds everyone

of the importance of this infection prevention mea-

sure. If focusing on prevention of pressure injuries

is a priority for a hospital, then posting the number

of days since the last OR-acquired pressure injury

reminds staff members to be vigilant in prevention.

These reports are also an effective strategy for

communicating with surgeons and anesthesia pro-

fessionals that an issue is high priority and is be-

ing addressed.

Daily progress reports do not necessarily need

to be added to the workload of one individual, such

AORN Journal j 353

October 2014 Vol 100 No 4 PRESIDENT’S MESSAGE

as the manager. These updates often can be more

effective when delegated to staff members who have

passion for the issues. They can “own” the report

and update it as part of their routine assignments.

SUMMARY

The safety and quality of health care is at the

forefront of attention from professional organiza-

tions, federal agencies, and the public. Our unified

goal is ensuring that patients receive the right care

at the right time, every time, with “zero harm.”

Many improvements have been made during the

past 10 years, and success is apparent. Yet, our

pursuit of excellence continues.

Barriers to achieving high reliability are well

known to perioperative nurses. Overcoming these

barriers requires active engagement on the part of

all of us. Three strategies used by HROs have been

discussed here. I encourage perioperative nurses to

share their successes on ORNurseLinkTM at http://

www.ornurselink.org. These stories are inspira-

tional to all of us and keep us on track on our

pursuit of excellence. Additional resources about

HROs are available here:

n Hines S, Luna K, Lofthus J, et al. Becoming a

High Reliability Organization: Operational

Advice for Hospital Leaders. (Prepared by the

Lewin Group under Contract No. 290-04-0011.)

AHRQ Publication No. 08-0022. Rockville, MD:

Agency for Healthcare Research and Quality;

2008. http://www.ahrq.gov/professionals/quality

-patient-safety/quality-resources/tools/hroadvice/

hroadvice1.html. Accessed July 9, 2014.

n The Joint Commission. Joint Commission Center

for Transforming Healthcare, SCHA collaborate

on high-reliability program. Bull Am Coll Surg.

2013;98(4):65.

Editor’s note: ORNurseLink is a trademark of

AORN, Denver, CO.

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VictoriaM. Steelman, PhD, RN, CNOR, FAAN,

is the AORN President and an assistant professor

at The University of Iowa College of Nursing,

Iowa City. Dr Steelman has no declared

affiliation that could be perceived as posing a

potential conflict of interest in the publication

of this article.