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Patient Safety and Quality in Pediatric Hematology/Oncology and Stem Cell Transplantation pp 15–28Cite as

Science of Improvement

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Abstract

The seminal To Err is Human report spurred an explosion of growth in the science of patient safety and quality improvement in healthcare. Models and methods of improvement translated or adapted from the broader organizational change and research literature seeded the development of implementation sciences for healthcare delivery. Firm grounding in the evidence-based practices is critical for people in operational roles, while the practice of improving healthcare safety and quality continues to expand the current boundaries of the scientific knowledge base. This chapter synthesizes core definitions and describes key models of continuous improvement from the patient safety, care quality, and organizational research literature. We also summarize insights from research on high-reliability organizations (HROs). HROs excel at maintaining extremely low rates of error or harm despite operating in high-risk environments by building a strong culture of mindful organizing. Finally, we summarize practical principles for high-reliability organizing.

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References

  1. Batalden PB, Davidoff F. What is "quality improvement" and how can it transform healthcare? Qual Saf Health Care. 2007;16(1):2–3.

    Article  PubMed  PubMed Central  Google Scholar 

  2. James BC, Savitz LA. How intermountain trimmed health care costs through robust quality improvement efforts. Health Aff. 2011;30(6):1185–91.

    Article  Google Scholar 

  3. Shojania KG, Grimshaw JM. Evidence-based quality improvement: the state of the science. Health Aff. 2005;24(1):138–50.

    Article  Google Scholar 

  4. Schouten LMT, Hulscher MEJL, van Everdingen JJE, Huijsman R, Grol RPTM. Evidence for the impact of quality improvement collaboratives: systematic review. BMJ. 2008;336(7659):1491–4.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Kaplan HC, Brady PW, Dritz MC, Hooper DK, Linam WM, Froehle CM, et al. The influence of context on quality improvement success in health care: a systematic review of the literature. Milbank Q. 2010;88(4):500–59.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Plsek PE, Blumenthal D, Carlin E, Carlson R, Nordin J, Heckman M, et al. Quality improvement methods in clinical medicine. Pediatrics. 1999;103(1 Suppl E):203–14.

    CAS  PubMed  Google Scholar 

  7. Balasubramanian BA, Cohen DJ, Davis MM, Gunn R, Dickinson LM, Miller WL, et al. Learning evaluation: blending quality improvement and implementation research methods to study healthcare innovations. Implement Sci. 2015;10:31.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Harvey G, Wensing M. Methods for evaluation of small scale quality improvement projects. Qual Saf Health Care. 2003;12(3):210–4.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Jha A, Pronovost P. Toward a safer health care system: the critical need to improve measurement. JAMA. 2016;315:1831.

    Article  CAS  PubMed  Google Scholar 

  10. Cohen ME, Liu Y, Ko CY, Hall BL. Improved surgical outcomes for ACS NSQIP hospitals over time: evaluation of hospital cohorts with up to 8 years of participation. Ann Surg. 2016;263(2):267–73.

    Article  PubMed  Google Scholar 

  11. Berwick DM. Measuring surgical outcomes for improvement: was Codman wrong? JAMA. 2015;313(5):469–70.

    Article  CAS  PubMed  Google Scholar 

  12. Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ. 2008;337:a1714.

    Article  PubMed  Google Scholar 

  13. Rosen MA, Pronovost PJ. Advancing the use of checklists for evaluating performance in health care. Acad Med. 2014;89(7):963–5.

    Article  PubMed  Google Scholar 

  14. Taylor MJ, McNicholas C, Nicolay C, Darzi A, Bell D, Reed JE. Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Qual Saf. 2014;23(4):290–8.

    Article  PubMed  Google Scholar 

  15. Reed JE, Card AJ. The problem with plan-do-study-act cycles. BMJ Qual Saf. 2016;25(3):147–52.

    Article  PubMed  Google Scholar 

  16. Wickramasinghe N, Al-Hakim L, Gonzalez C, Tan J. Lean thinking for healthcare. New York, NY: Springer; 2014.

    Book  Google Scholar 

  17. Womack JP, Jones DT. Lean thinking: banish waste and create wealth in your corporation. New York, NY: Simon and Schuster; 2010.

    Google Scholar 

  18. Ohno T. Toyota production system: beyond large-scale production. Portland, OR: Productivity, Inc.; 1988.

    Google Scholar 

  19. Andersen H, Røvik KA, Ingebrigtsen T. Lean thinking in hospitals: is there a cure for the absence of evidence? a systematic review of reviews. BMJ Open. 2014;4(1):e003873.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Rochlin GI, LaPorte TR, Roberts KH. The self-designing high-reliability organization: aircraft carrier flight operations at sea. Nav War Coll Rev. 1987;(Autum):76–90.

    Google Scholar 

  21. Weick KE, Sutcliffe KM, Obstfeld D. Organizing for high reliability: processes of collective mindfulness. In: Sutton RS, Staw BM, editors. Research in organizational behavior, vol. 1. Greenwich, CT: JAI Press; 1990. p. 81–123.

    Google Scholar 

  22. Sutcliffe KM. High reliability organizations (HROs). Best Pract Res Clin Anaesthesiol. 2011;25(2):133–44.

    Article  PubMed  Google Scholar 

  23. Bierly PE. Culture and high reliability organizations: the case of the nuclear submarine. J Manage. 1995;21(4):639–56.

    Google Scholar 

  24. Christianson MK, Sutcliffe KM, Miller MA, Iwashyna TJ. Becoming a high reliability organization. Crit Care. 2011 Jan;15(6):314.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Edmondson AC. Learning from failure in health care: frequent opportunities, pervasive barriers. Qual Saf Health Care. 2004;13(Suppl 2):ii3–9.

    PubMed  PubMed Central  Google Scholar 

  26. Weick KE, Sutcliffe KM. Managing the unexpected. 2nd ed. San Francisco, CA: Jossey-Bass; 2007.

    Google Scholar 

  27. Sutcliffe KM, Paine L, Pronovost PJ. Re-examining high reliability: actively organising for safety. BMJ Qual Saf. 2016;26(3):248–251.

    Google Scholar 

  28. Weick KE, Sutcliffe KM. Managing the unexpected. 3rd ed. Hoboken, NJ: Wiley; 2015.

    Google Scholar 

  29. Vogus TJ, Iacobucci D. Creating highly reliable health care: how reliability-enhancing work practices affect patient safety in hospitals. ILR Rev. 2016;7:0019793916642759.

    Google Scholar 

  30. Weaver SJ, Che X-X, Pronovost PJ, Goeschel CA, Kosel KC, Rosen MA. Improving patient safety and care quality: a multiteam system perspective. InPushing the boundaries: Multiteam systems in research and practice 2014 Sep; 24 (pp. 35–60). Emerald Group Publishing Limited.

    Google Scholar 

  31. Schein EH. Organizational culture and leadership. 4th ed. Hoboken, NJ: Jossey-Bass; 2010.

    Google Scholar 

  32. Vogus TJ, Sutcliffe KM, Weick KE. Doing no harm: enabling, enacting, and elaborating a culture of safety in health care. Acad Manag Perspect. 2010;24:60–77.

    Google Scholar 

  33. Zohar D, Luria G. A multilevel model of safety climate: cross-level relationships between organization and group-level climates. J Appl Psychol. 2005;90(4):616–28.

    Article  PubMed  Google Scholar 

  34. Nembhard IM, Edmondson ACMYC. Making it safe: the effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams. J Organ Behav. 2006;27(7):941–66.

    Article  Google Scholar 

  35. Zohar D. Thirty years of safety climate research: reflections and future directions. Accid Anal Prev. 2010;42(5):1517–22.

    Article  PubMed  Google Scholar 

  36. Weaver SJ, Lubomksi LH, Wilson RRF, Pfoh ER, Martinez KA, Dy SM, et al. Promoting a culture of safety as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):369–74.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Paull DE, Mazzia LM, Wood SD, Theis MS, Robinson LD, Carney B, et al. Briefing guide study: preoperative briefing and postoperative debriefing checklists in the veterans health administration medical team training program. Am J Surg. 2010;200(5):620–3.

    Article  PubMed  Google Scholar 

  38. Vashdi DR, Bamberger PA, Erez M, Weiss-Meilik A. Briefing-debriefing: using a reflexive organizational learning model from the military to enhance the performance of surgical teams. Hum Resour Manag. 2007;46(1):115–42.

    Article  Google Scholar 

  39. Makary MA, Mukherjee A, Sexton JB, Syin D, Goodrich E, Hartmann E, et al. Operating room briefings and wrong-site surgery. J Am Coll Surg. 2007;204(2):236–43.

    Article  PubMed  Google Scholar 

  40. Berenholtz SM, Hartsell TL, Pronovost PJ. Learning from defects to enhance morbidity and mortality conferences. Am J Med Qual. 2009;24(3):192–5.

    Article  PubMed  Google Scholar 

  41. Agency for Healthcare Research and Quality. AHRQ CUSP Toolkit: Learn from Defects Tool [Internet]. 2012 [cited 2016 Mar 1]. Available from: http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/toolkit/learndefects.html.

  42. Vogus TJ, Sutcliffe KM. The safety organizing scale: development and validation of a behavioral measure of safety culture in hospital nursing units. Med Care. 2007;45(1):46–54.

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Anesthesiology and Critical Care Medicine, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, 750 E. Pratt Street, 15th Floor, Baltimore, MD, 21202, USA

    Michael A. Rosen & Sallie J. Weaver

Authors
  1. Michael A. Rosen
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  2. Sallie J. Weaver
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Corresponding author

Correspondence to Michael A. Rosen .

Editor information

Editors and Affiliations

  1. Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA

    Christopher E. Dandoy

  2. Center for Cancer and Blood Disorders, Children’s Hospital Colorado, Aurora, Colorado, USA

    Joanne M. Hilden

  3. Boston Children’s Cancer and Blood Disorders Center, Dana-Farber, Boston, Massachusetts, USA

    Amy L. Billett

  4. Johns Hopkins All Children’s Hospital, St. Petersburg, Florida, USA

    Brigitta U. Mueller

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© 2017 Springer International Publishing AG

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Rosen, M.A., Weaver, S.J. (2017). Science of Improvement. In: Dandoy, C., Hilden, J., Billett, A., Mueller, B. (eds) Patient Safety and Quality in Pediatric Hematology/Oncology and Stem Cell Transplantation. Springer, Cham. https://doi.org/10.1007/978-3-319-53790-0_2

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  • DOI: https://doi.org/10.1007/978-3-319-53790-0_2

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-53788-7

  • Online ISBN: 978-3-319-53790-0

  • eBook Packages: MedicineMedicine (R0)

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