HRO: Sensitivity to Operations

Okay, I confess.  I have seen the movie, "Top Gun" more times than I would like to admit.  The movie is a bit cheesy in parts and totally unrealistic, but it is classic 1980's.  The movie does have unique appeal - in fact, the United States Library of Congress placed the film in the National Film Registry in 2015, calling the movie "culturally significant."  There is a quote towards the beginning of the movie - in the infamous bar scene ("You've lost that loving feeling!").  The two protagonists of the movie, Maverick (an F-14 pilot, played by Tom Cruise in one of the roles that made him famous) and Goose (the Radar Intercept Officer, played by Anthony Edwards, who later starred in the TV series, "ER") are talking about one of the other F-14 pilots, following up on an earlier question in which Maverick had wondered who was the best pilot among all the other pilots at Top Gun.  The quote goes something like this:

Goose:  Mav, you want to know who's the best?  That's him.  Iceman.  It's the way he flies - Ice cold.  No mistakes.  Wears you down.  After enough time, you just get bored and frustrated, you do something stupid, and he's got you.

Iceman (played by the actor, Val Kilmer) is Maverick's nemesis throughout the movie (spoiler alert: they, of course, become the best of friends at the end of the movie) and does everything "by the book."  One could argue that his flying is highly standardized with little variation from the textbook (if such a book on F-14 combat tactics existed) and little variation from minute-to-minute.  In other words, Iceman focuses on "operational excellence", what High Reliability Organizations would call "sensitivity to operations."

Operational excellence is characterized by standardization of best practices and elimination of waste, through continuous process improvement.  It is a scientific management philosophy embedded in quality improvement methodologies, such as Lean, Six Sigma, Zero Defects, Total Quality Leadership (TQL) / Total Quality Management (TQM), and the Model for Improvement.  Operational excellence has developed from concepts originally described by quality control engineers, management gurus, and scientists such as Walter Shewhart, Joseph Juran, Frederick Winslow Taylor, Taiichi Ohno, and W. Edwards Deming. 

Practically, operational excellence in a nuclear power plant (to use a different example of HRO) means that the technicians follow standard operating procedures, each and every time.  The nuclear power plant technicians use checklists and other cues to help them follow highly technical procedures in the exact same sequence from shift to shift, day to day, year to year.  Performance is monitored closely (monitoring is also standardized) - any deviations from normal are quickly recognized and corrected, again according to a defined, standardized protocol.  The nuclear power plant technicians understand measurement and statistical process control.  These technicians use measurement and statistical process control charts in order to understand what is happening in their work environment.

Operational excellence has a role to play in today's health care environment.  I whole-heartedly agree that "patients are not widgets" and that "we shouldn't practice cookbook medicine."  Standardization, one of the key elements in operational excellence, is NOT "cookbook medicine."  There is simply no justification for why we should not standardize the care of common conditions (e.g. management of diabetic ketoacidosis, acute chest pain, or acute asthma exacerbation) or processes (e.g. care and maintenance of central lines, urinary catheters, surgical time-outs) - these are the kinds of conditions and processes that should be managed the same way, every day, by each and every member of the health care team.  With the care of common conditions, there is some room to maneuver, so to speak.  For example, if a patient deviates from the expected clinical course, then and only then should we deviate from a standardized treatment protocol.  However, there is no reason why we should deviate from standardized protocols for surgical time-outs, shift hand-offs, or maintenance of central lines.

If hospitals are to become high reliability organizations, we must embrace the core tenets of operational excellence.  We must be sensitive to operations - what is happening on the front lines of health care.  The good news is that many health care organizations have demonstrated that standardization of best practices and elimination of waste through operational excellence can lead to sustained improvement in outcomes and lower costs.