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Leading Change: Transitioning the AFMS into a High Reliability Organization

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Technical Report

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Air War College, Air University Maxwell Air Force Base United States

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Healthcare needs to improve its ability to provide consistently safe care. According to The Institute of Medicine 1999 report, To Err Is Human Building a Safer Health System, an estimated 44,000-98,000 unintended patient deaths occurred annually. Healthcare is not a high reliability organization high reliability organizations HRO operate in dangerous environments and yet remain largely error free. Successful HROs, such as commercial aviation and nuclear power plants, make safety the focus of their organizational culture. Healthcare must become a high reliability organization that can consistently provide high quality care to patients in a safe environment. In October 2014 the Secretary of Defense directed improvements to the Military Health System including the movement to become HROs. The Air Force Medical System AFMS, under the guidance of the Air Force Surgeon General, is beginning its transition to a high reliability organization. Successful transformation begins with understanding and changing the organizational culture in all military treatment facilities MTFs. Active leadership support and involvement at all levels is crucial to a successful transformation. Air Force medical personnel must be educated about HRO concepts and be empowered to apply them in their daily work. MTF leaders must create and sustain an environment of trust and collective mindfulness. Every Air Force medic needs to know they are valued, and empowered to suggest changes and stop processes or procedures that put patient safety at risk. The AFMS has multiple resources it can use to measure improvement in patient safety and quality. Useful data showing successful areas and areas that need improvement needs to be easy to read, publically available and shared so that leaders, medics, patients and others know how Air Force clinics and hospitals are doing in their transformation into high reliability organizations.

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