Understanding the outliers: A qualitative analysis of leaders' perspectives on performance and safety in trauma centers.

Abstract

The factors explaining variability in trauma center performance across quality measures are not well understood. We aimed to characterize the influence of social, cultural, and organizational factors on trauma center performance. We used an explanatory sequential design to study ACS TQIP-participating level I and II trauma centers that were ranked as high- and low-performing (first and last decile) across multiple representative quality indicators. The Chief Safety Officers, Directors of Quality and Safety, Trauma Medical Directors, and Trauma Program Managers within these centers were approached for semi-structured interviews guided by the framework of high-reliability organizations (HROs). Qualitative description methodology was used. Salient themes were inductively developed, and themes between centers in the first and last deciles were contrasted. We interviewed 28 participants across 15 centers. Of these, 8 centers were in the first decile, and 7 centers were in the last decile. All participants expressed a commitment to making care safer and to improving hospital performance. Leaders in first decile centers more strongly expressed having adopted and used theory pertinent to safety and high reliability organizations (HROs). This manifested as an increased preoccupation with failure and with the ongoing and never-ending maintenance of safe processes. In first decile centers, leaders were also increasingly focused on communication and relationship-building. Conversely, leaders in last decile centers less frequently referred to following HRO principles, or to the importance of building close relationships within the workplace. Our work suggests an association between trauma center performance and principles of high reliability, as well as safety culture. Leaders in the highest performing centers most consistently referenced and leveraged existing theory on safety and high reliability. These principles represent a useful theoretical foundation for centers wishing to improve their processes and outcomes.