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Director's Letter

Strategies for improving organizational performance are continually evolving, sometimes abetted by a rotating cast of high-priced management consultants and changing fashions in business schools. Previously, the business press was filled with stories on “Toyota Lean” management approaches, a model built on Japanese system engineering principles to reduce waste and error. Many healthcare organizations, including VA, adopted these principals effectively to improve their supply chains, standardize clinical processes, and improve use of data to reduce errors and improve quality. At the same time, it is clear that managing healthcare and reducing medical errors is very different from running the assembly line that produces high-quality, defect-free automobiles. Healthcare is a classic example of what is known as a “complex adaptive system.” In Plsek and Greenhalgh’s 2001 BMJ series, the authors describe a “complex adaptive system is a collection of individual agents with freedom to act in ways that are not always totally predictable, and whose actions are interconnected so that one agent’s actions change the context for other agents.” Thus, rather than being amenable to rigid processes and reductionist thinking, healthcare needs to “accept unpredictability, respect (and utilize) autonomy and creativity, and respond flexibly to emerging patterns.”

How then, in the face of the complex nature of healthcare delivery, can an organization approach the problem of reducing errors and improving quality? The concept of a high reliability organization was coined by Weick and Sutcliffe to describe the principals of an organization that will perform well in the face of such complexity. High reliability is manifested by managing complex, hazardous situations with a high level of safety (e.g., landing a fighter jet on an aircraft carrier in bad weather). The possibility of error is rife in healthcare settings, including misdiagnosing illnesses, prescribing errors, and hospital acquired infections. These problems are further exacerbated by unexpected situations such as the recent COVID outbreak, disruptions to usual processes, and a surge of severely ill patients. Other papers in this issue outline the core characteristics of an HRO, but at its heart it is a culture change that asks all involved staff to understand their role and empowers them to apply their unique expertise to prevent error.

VA launched its enterprise-wide HRO transformation effort in February 2019. The commitment to HRO principals does not mean that creating efficient and reliable processes and relying on evidence-based practices is any less important. The concepts of system engineering and complexity science are both important to creating a better healthcare delivery system. Researchers from the Ann Arbor VA are working with the Office of Organizational Excellence to develop measures by which to gauge the transformation of VA into an HRO. The value of research will be to help VA understand how to assess how much progress we have made – what tools and training help support this change, and how we sustain and strengthen the new culture of safety.

David Atkins, MD, MPH, Director, HSR&D