Accident and Emergency Care Made High Reliable: Perception of Staff on Factors Affecting Application of High-Reliability Organization Principles in Accident Emergency Units

There is a growing concern regarding patient safety and high reliability which made more intense with this ongoing pandemic. Aim of this study is to assess the organizational factors affecting the practice of High-Reliability Organization (HRO) Principles as perceived by staff in selected Accident and Emergency Units. Methodology: A hospital based cross-sectional study in three Accident and Emergency care setting, among healthcare staff, conducted using a self-administered questionnaire. Results: Out of the five factors affecting HRO practices as perceived by staff, “Organizational Safety Culture” (Mean-4.27., SD-0.49) has the highest mean value followed by Leadership (Mean: 3.96, SD: 0.44) and Teamwork (Mean: 3.95, SD: 0.5). “Work Environment” (Mean: 3.94, SD: 0.46) has the lowest score. All independent and dependent variables have a significant positive correlation with HRO principles (Correlation is significant at the 0.01 level-1-tailed). Multivariate analysis was carried out to assess the proportion variability of the dependent variable. The linear regression model explains 22% of the variability of the HRO practices (dependent variable) by factors affecting HRO practices (independent variables) if all the factors operate together. The distribution of Coefficients, Standardized B value is 0.29 (significant at the 0.01 level), showing if “Organizational Safety Culture” operates together with the other four independent variables 29% of


Introduction
Globally there is a growing concern regarding Patient safety, due to the potentially catastrophic nature of medical errors. According to the World Health Organization report in 2019, unsafe patient care in health setting results in 134 million adverse events annually and 2.6 million deaths per year alone in low-and middle-income countries. Up to four out of every ten patients are harmed in health care in primary and ambulatory care settings (World Patient Safety Day. WHO, 2020). The most harmful errors are in relation to diagnosis, prescription errors and medication errors (World Patient Safety Day. WHO, 2020). Each year is estimated that about 42 billion US$ estimated expenditure is due to is spent on medication errors (World Patient Safety Day. WHO, 2020).
Patient safety to High reliability: Based on previous research by Perrow, Karleen Roberts in the 1990s, Weick and Roberts in 1993, "High Reliability Organizations (HROs) can be defined as organizations in which errors have the potential of catastrophic consequences but which seem to avoid such errors, e.g., Commercial aviation, air traffic control system, nuclear power plants and naval" (Spath, 2011).
Weick and Sutcliffe studied diverse organizations, where the potential for disaster can lead to catastrophic event in the next instance itself. They found that not only HROs have a unique structure but and also it acts differently from other organizations. "Thus, these five principles of High-Reliability Organization that have been identified by Weick & Sutcliffe as responsible for the 'mindfulness' that keeps them working well when facing unexpected situations" (Spath, 2011). HRO principles are, "Preoccupation with failure, Reluctance to simplify interpretations, Sensitivity to operations, Commitment to resilience, Deference to expertise." In the research in financial institutions, Carolyn Libuser identified the following five elements of HROs, processed auditing, appropriate reward, avoiding degradation of quality, risk perception and command and Control (Roberts, Madsen, Desai, & Van Stralen, 2005

Data Collection Instrument
Staff perception of factors associated with practice of HRO principles was also assessed using a self-administered questionnaire which consisted of two parts; the first part (Part A) was designed to 22  (2007) and Mary Dixon-Woods (2012) and adopted to the Sri Lankan setting (Sridharan S., 2017) to assess factors affecting patient safety programme in government hospitals in Sri Lanka. A focused group discussion was conducted with the participation of experts in this field of Health and Safety, to adapt the questionnaire to A and E setting in Sri Lanka.

Pre-testing
The research instrument was pretested in Teaching Hospital Karapitiya, Accident and Emergency Unit and the necessary steps were taken to enhance the response rate to eliminate interviewer variations and possible biases.

Analysis
Internal consistency reliability was estimated with the Cronbach ∝ coefficient. In this study questionnaire, Cronbach's α coefficient for section A was 0.745. Test-retest Reliability revealed that the significance level for paired sample correlation and paired samples test is more than 0.05 for all the variables. Therefore, this questionnaire can be regarded as reliable.
Upon completion of data collection, statistical analyses were completed using the Statistical Package for the Social Sciences (SPSS 25.0). Statistical associations between categories were evaluated by the Pearson correlation. Descriptive statistics were used for all primary variables. The six-point Likert Scale was transformed into 1-6 weighted score, and the data obtained after analysis will be expressed as mean ± standard deviation (SD). Data were analyzed to explain the factors associated with HRO principles.

Ethical Considerations
Ethical clearance was obtained from the Ethics Review Committee, Faculty of Medicine, and University of Colombo (Annexure VII). The study was performed in accordance with the ethical principles of the Ethical Review Committee. Faculty of Medicine, University of Colombo, was notified of any amendments to the study proposal.
Permission was obtained from and Heads of all selected three hospitals before data collection.
The purpose of the study was explained to the participants. Informed written consent was obtained after explaining the study. The confidentiality and anonymity of data was maintained.

Results
This is a descriptive cross-sectional study carried out to assess the factors affecting implementation of

HRO principles as perceived by staff working in level one A & E units in three main Sri Lankan
Teaching hospitals, among doctors and nursing staff. A total of 422 were invited to participate in the study of which, 385 participated in giving a response rate of 90%. A self-administered questionnaire (Section A) was used to determine the factors associated with HRO practices as perceived by staff. The response was measured using 1-6 Likert scale, and positive attitudes were defined as having mean of scale scores >3 (More than 03),    Culture. This is a statistically significant (at the level of 0.01) finding.

4.1
Mean age of the population 33 years (SD-4.509) majority of the participants (57%) were between the age of 31-40 years and 92% of the population were less than 40 years, indicating relatively young healthcare staff composition. This shows the benefits long term of interventions (i.e., training), provided retirement age is 60 years will remain in service for another 20 years indicating long term yield of investment on human resources.
Regarding current designation, the majority (60%) were doctors 47.5% (183) of them were Medical Officers, and 12.7% (49) of them were Doctors who had followed of who are having PG qualifications or who are following PG studies This study was conducted to determine the organizational factors associated with the practice of HRO principles as perceived by the staff in selected Tertiary Care Accident and Emergency Units.
Out of the five factors affecting HRO practices as perceived by staff, "Organizational Safety Culture" But correlation does not imply causation . Therefore, some of the independent variables (factors affecting HRO practices) which have relatively a higher correlation has failed in showing a significant effect on the variability of the dependent variable. Therefore, a multivariate analysis was carried out to assess the proportion of the variability of the dependent variable.

Limitations of This Study
The study was carried out only in A & E units in three Line Ministry Hospitals only among medical doctors and nurses. Therefore, factors affecting HRO practices in other hospitals (Provincial General Hospitals, District Hospitals, and Base Hospitals) and perception of the other staff categories who were not included were not identified. Hence, there will be problems in generalizing the findings.
Since, prevailing patient safety culture as being indicated as reactive in a previous study (Amarapathy, 2013) reluctance of the staff to express their views will affect quality of data.
Although the establishment of A and E Units was initiated, the establishment is not completed due to inadequate infrastructure (buildings are under construction) and separate human resource allocation is not done.

Conclusion
Organizational safety culture shows significant (< 0.01) effect on determining HRO practices.
Organizational Safety Culture accounts for 29% of the variability of the HRO practices (dependent variable) if Organizational Safety Culture operates together with the other four factors conceptualized to associate with patient safety (i.e., Leadership, Communication, Teamwork and Work Environment).
Based on above it is recommended that since twenty-nine per cent (29%) of the variability of the HRO practices (dependent variable) can be explained by Organizational Safety Culture, improving organizational safety culture will improve the reliability of Healthcare Institutions.
Patient safety culture explains only 29% variability of the HRO practices. Although the other four factors affecting patient safety are highly correlated, they have demonstrated a significant effect on HRO practices. Therefore, further research is needed to find other factors affecting HRO practices.