High reliability organizations have common traits including: preoccupation with failure, sensitivity to operations, reluctance to simplify, deference to expertise and commitment to resilience. Using these traits as the key drivers, we aimed to develop a high reliability unit (HRU) – a medical-surgical clinical microsystem with targeted outcomes related to patient safety, quality improvement, throughput and patient experience within a 12 month period. A Neurology/Neurosurgery medical-surgical unit was identified for a pilot program to create a HRU clinical microsystem in November of 2015. A Hospitalist Medical Director, Nurse Manager and Quality Consultant led the project and a key driver diagram (KDD) was developed (Figure 1). Process and outcome metrics were developed for each of the defined goals including: decrease in hospital acquired conditions and serious safety events, improved discharge efficiency and throughput, decrease in length of stay, cost and resource utilization for unit specific diagnoses, and enhanced patient, family and provider experiences and satisfaction. Baseline data as well as pre-pilot implementation surveys were used in defining improvement targets. The IHI model for improvement was used with interventions outlined within the key driver diagram using a series of PDSA cycles. Clinical pathways, including post-surgical pathways for Chiari malformation and tethered cord repair, were developed targeting a decrease length of stay and unnecessary resource utilization. Multidisciplinary daily management rounds were instituted including case management involvement with a focus on identifying and prioritizing discharges and timeliness of the orders related to discharges. Unit digiboards as well a monthly newsletter were utilized to promote transparency and accountability to defined process and outcomes metrics as well as for educational and informative purposes. HRU outcome dashboard is shown in Figure 2. Serious safety events on the unit remained at zero. Severe peripheral IV infiltration/extravasation rates decreased by 27% in 2016 compared to 2015. Interventions targeted at improved throughput resulted in a 10% improvement in patients discharged by 1400. Clinical pathways were created and, most significantly for Chiari malformation repair, resulted in improved length of stay and direct cost compared to baseline institutional and PHIS (Pediatric Health Information System) benchmark data. Overall patient satisfaction also improved from institutional and NRC (National Research Council) benchmark. Nurse, hospitalist and specialist satisfaction demonstrated improvement when comparing pre- and post-pilot survey results. Using high reliability principles, a clinical microsystem HRU was developed with demonstrated improvement in the targeted aims related to patient safety, throughput discharge efficiency, diagnosis specific length of stay and cost and patient and provider experience. Instrumental factors to success included the joint leadership between physician, nursing and quality as well as the creation of a microsystem with unit level accountability and defined metrics. Next steps include sustained improvement and expansion to additional units.

Figure 1

HRU Key Driver Diagram

Figure 1

HRU Key Driver Diagram

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Figure 2

HRU Outcome Dashboard

Figure 2

HRU Outcome Dashboard

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