ABSTRACT
BACKGROUND: Highly reliable organizations (HROs) are exemplified by forest fire-fighting crews, aircraft carrier flight deck personnel, and operators of nuclear reactors. More recently health care organizations have started to implement principles of HRO acknowledging that we need to create a system for managing the unexpected. Those working in highly reliable organizations apply 5 principles.1 (see Table 1) Hospital Medicine Divisions require these skills in order to anticipate and manage unexpected surges in patient volume and the challenges we are facing managing highly infectious COVID-19 patients. METHODS: We created a voluntary questionnaire to explore these 5 components of HROs to determine what training our faculty require to better manage the unexpected. We applied standard qualitative analysis identifying recurrent themes using N-Vivo software, and accumulating representative quotes related to the 5 elements of HROs. Narrative transcripts have been analyzed using a “memoing” techniques to create an ongoing audit trail to document study findings and to trackmethodological and substantive decisions made during the analysis.2 As more narratives were analyzed, codes were grouped into new and refined thematic categories by applying constant comparative analysis.3 This process was continued until saturation was reached.2,3 RESULTS: We have summarized the themes in Table 1. 1) Faculty are preoccupied with what could go wrong and they identified impediments to care. 2) While our faculty did not ignore these impediments the majority did not use a “root-cause analysis” approach. 3) Faculty were continually looking into standardized protocols to address the challenges. 4) High reliability organizations maintain a positive attitude and our hospitalists found that social connectedness, exercise and teamwork were sources of stability. 5) Our hospital has established an excellent collaborative relationship with our consultants. There was initial hesitancy to see COVID-19 patients which later improved. CONCLUSIONS: Our study shows that there are elements of high reliability that our HospitalMedicine Division displays, particularly around identification of impediments to care. The main area of opportunity for training was around the use of root-cause analysis. The comments about the Division's response to the COVID-19 surges were positive and focused on leadership support. Our results give us guidance on next steps to prepare and improve our organization to achieve the principles of HROs. Hospital Medicine faculty are always tackling challenges in the inpatient setting. Additional training and application of principles of HROs can help in the response to the unexpected.