Intro: Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.

Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole. And today, we're highlighting the interprofessional team in high-reliability organizations. Joining me is Dr. Anand Iyer. He's the Associate Chief Medical Officer at UAB Medicine. Dr. Iyer, it's a pleasure to have you join us today. When we talk about high-reliability organizations, what makes an organization classify as high-reliability? And why are interprofessional teams essential to HROs?

Dr. Anand Iyer: Thank you, Melanie. It's great to be here. It's a topic I really care deeply about. What we're going to talk about today, the titration task force came directly from interprofessional teams at UAB. I think it has real lessons for anyone trying to build a safer, more reliable system.

So, let me start with a simple truth, right? In healthcare, complexity is our baseline. It's not our exception. High-reliability organizations or HROs are those that operate in high stakes, high complex systems with very low tolerance for failure. But we avoid harm because we're disciplined in several ways.

When you think about the five principles of a high-reliability organization, those are preoccupation with failure, a reluctance to simplify, right? We're a complex system. Sometimes these do take complex solutions. You're sensitive to operations, and the people on the frontline are your team members who really have the best knowledge about solutions. There's a commitment to resilience, solving problems that sustain and, perhaps most importantly, it's about the deference to expertise regardless of your hierarchy. And that one should stick for every hospital that still is operating on this sort of hierarchical command and control model. In a high-reliability organization, authority follows the knowledge, not just the title.

So, you asked why are interprofessional teams essential, because no one really holds the full picture in real time. You got doctors who see the diagnosis. You got nurses who are caring for the patient at the bedside in the middle of the night, pharmacists who's seeing the interaction risk, informatics team members who are seeing the system failure. Remove any one of those steps and you're flying partially blind. So, that's exactly where we found ourselves when we began building the Titration Task Force at UAB.

I mean, medication titration, that's medications like vasoactives or vasopressors that boost your blood pressure up in the ICU or sedative medications when you're on the ventilator. These are about as high stakes as it gets. Real-time decisions are happening around the clock in our ICUs at our hospital. Reliability doesn't just come from one discipline or one person, it comes from the system and the team. So, I really want our listeners to understand that that reframe matters operationally. When something goes wrong, the question should not be who failed, but it should be where did the system fail to protect the patient? High-reliability organizations shift accountability from individuals to systems. And I think that's just a fundamentally different way of looking at things.

Melanie Cole, MS: Isn't this an interesting topic? And as we've seen the healthcare industry change—and even since COVID—the doctors working in silos on their own with patients has really expanded to this multidisciplinary and interdisciplinary collaboration. When we think of these cohesive diverse groups, Dr. Iyer, including the clinician, staff, patients, and as you say, that prioritize safety, open communication, collective expertise, what does that effective interprofessional collaboration really look like through the Titration Task Force? What does that look like for institutions looking to initiate something just like this?

Dr. Anand Iyer: I think there's a big difference in just showing up to the table and actually collaborating. Effective interprofessional collaboration is not just everyone attending the same Zoom meeting, right? It's agenda-driven, structured, shared decision-making where every voice carries real weight and can impact the outcomes.

So, we set up the Titration Task Force in 2023. We were deliberate about its structure. We had nursing leaders, bedside nurses, physician pharmacists, leaders from regulatory quality, informatics, HSIS, and then senior leaders. So, myself, the chief nursing officer, associate chief quality officer, department value officers. It was a big team. And that breadth was intentional because every perspective, voice on that team was a different layer on how care can get delivered, where holes can be seen, where opportunities are to improve.

I came at this problem with a decade of experience as a physician scientist. I have expertise in implementation science, health outcomes research, communication training. And I'm UAB's first Beeson Scholar from the NIH. That's a leadership transformation award. And so, I came at this trying to solve this complex high-stakes problem.

It boils down to starting with step one. That's listening. Not trying to solve it, but listening. I remember the day Dr. Kennedy—she's our chief medical and quality officer, she called me and said, "There's this problem going on across ICUs related to titration. You think you could take this on?" I knew it would be a big one, but I took on the challenge. It came from bedside nurses having the courage to speak up in what we call tracers in different ICUs, and was validated in surveys from Joint Commission findings.

Being that sort of implementation scientist, I said, "Let's truly understand the problem and listen to the people at the bedside." A triad of myself, Christy Nation, our chief nursing officer for UAB St. Vincent's, and Heather Smith, who's a regulatory leader, we set up many focus groups from leaders across ICUs to understand how they saw and view titration and the opportunities to improve. Things emerged when we listened.

At the same time, our chief nursing officer and Associate Chief Quality Officer, Dr. Hayes and Terry Poe, made rounds with frontline staff. They listened in groups to understand what titration really meant to the frontline. And what we heard was pretty illuminating, right? There was a lot of variability, there were gaps, there was confusion. It was a signal of the lived experience of the frontline staff, and it became part of the solution.

And I think, from there, co-design followed. These solutions weren't handed down. They were built with the frontline voices and embedded across the way. I feel like that ownership at the frontline level really drives high reliability. It's ownership what it boils down to.

Melanie Cole, MS: Wow. So, that's really how you went from identifying that problem to implementing the change. Now, Dr. Iyer, when you've mentioned reducing patient harm, preoccupation with failure, you've mentioned a few things. So through this interprofessional collaboration, what were some of the most impactful changes that came out of the titration task force? What did you actually see from the leader rounding and these focus groups? What did you see?

Dr. Anand Iyer: Our process was discover, design, simulate, pilot, and refine, and then scale, right? And I think I'm most proud of our simulation phase. After we had listened and understood the levels of the problems and the variety of problems, we built a simulation, in a safe environment where nurses, providers, pharmacists could interact with electronic medical record and enhancements and see where our pain points and friction points were.

I want people listening to understand that simulation can really help you pre-launch your initiatives for improvement in a safe environment. Then, we launched the pilot phase in a few ICUs in our hospital with just a couple of our medications. And that iterative approach helped us learn along the way before we implemented housewide.

The path wasn't linear. There were setbacks. There were times when we had to ask, "Were our design changes really great? Were there opportunities to improve, and where team members were reluctant to see that a change was needed?" In those moments, we dug deep. We invited people from outside the institution to help us discern if there were some opportunities for improvement, and we made a lot of changes.

So, there were some on the tangible side and some on the culture side. So, I'll list a few, but I don't want to bog you down with a bunch of them. Our team, and so many pharmacists on the team, they overhauled every single vasopressor medication to match up-to-date evidence-based guidelines in titration.

We executed several EMR enhancements and workflow designs. We built new orders, one called the therapeutic target parameters. That was an explicit shared goal embedded in the EMR and quickly accessible by nurses and team members instead of being buried deep in the EMR where nobody could find it. We standardized titration weaning plans, and we updated the policies to match Joint Commission best practices.

What that did was reduce variability, which is the enemy in high-reliability care. It's not really the order sets that I'm most proud of with the shared mental model. We really made titration part of the culture, right? A nurse and a physician could be looking at the same patient and seeing totally different goals, weaning plans, and who's responsible. There were scope problems. And that's a system problem, a failure to create shared mental models. After this work now, there's a common language. There's clarity. There's structure in the system. That infrastructure really helps make the organization high reliable. The task force still meets. We're not meeting weekly. We're on a quarterly basis, but we're committed to that resilience I mentioned at the beginning, ongoing monitoring, periodically bolusing the system with titration education, partnering with our tele-intensivist program for titration oversight, and keeping the system safe. And like I said in the beginning, preoccupied with failure, titration is ongoing, it just doesn't stop.

Melanie Cole, MS: Well, I think that that really institution-wide and nationwide, when you talk about that resilient culture, as the teams become more adaptable, effective at navigating these complex crises in the OR, in the ER, and in all of the different aspects, for teams to be able to come together and understand what one hand is doing because that's where the confusion lies. And also when we think of the electronic system that our medical system is now on for data and safety information, that it's more easily understood and widely shared among clinicians is just such an important aspect of all of this.

If you were to say, Dr. Iyer, the biggest lessons for leaders trying to build these high-reliability interprofessional teams, what would you tell them? What did it take for you to—I mean, you obviously were an expert in this as you came to UAB to take this role on, but for other clinicians that may not have that same foresight that you have, what would you like them to know or biggest lessons you learned so they can take them forward to their teams?

Dr. Anand Iyer: I joke. Because in a way, I've become kind of like a chief titration officer for the hospital. That's not a real role. That's just somebody who really understands complex problems, domain complex solutions that are durable, practical, and work at the system level.

So, lessons that I can give to leaders trying to build high-reliable teams, first, start with a clear purpose-driven mission. Repeat that why constantly. You can't really lead your teams around something vague. You've got to have an explicit why and center it along the way. Why does titration matter? Why does scope of practice for nurses matter? What are we trying to prevent? What does success look like for the patient tomorrow if we implement this solution?

Second, the frontline's not your audience, right? They're your co-authors or co-team members. If the people doing the work aren't shaping the solution, you're designing for something hypothetical, theoretical—it's not real. So, you got to keep them there building with you.

Third, you got to build for sustainability, not just for the launch. You don't build the system at once. You tend to it. In the office of the chief medical and quality officer, this is where we see huge potential in building partnership between clinician leaders and operational managers and senior directors in operations as co-leads. That dyadic relationship works really well and can really help the high-reliability organization be successful.

Fourth, leadership doesn't just flow downward. Some of the most powerful change agents along the way during our titration task force story were the advanced practice providers and the charge nurses or nurse educators in our units who were the unit-level champions. They had way more credibility with their peers than I do as an associate chief medical officer, even as an ICU doctor. I can't replicate that level of credibility at the nursing level. We invested in those champions and we gave them the support they need and got out of their way.

And finally, the fifth lesson is high reliability is ultimately cultural. You can build the right structure, the protocols, the order sets, all that stuff, but if the culture on the unit doesn't support speaking up, challenging, naming the problems, it will fail. That's what I think organizations that get this right, they're the ones that seek those hard questions and where people feel safe to speak up and do that kind of stuff.

Melanie Cole, MS: That's what these podcasts are really all about, Dr. Iyer, is about discussing topics like this with actual solutions and results. And I can imagine that not only are you seeing these among your staff when it comes to frustration, burnout, all the things that go along with medical teams, but patient satisfaction.

Because when the teams are all together, understanding, working together, that's when you're going to get the best outcomes, the best results. Thank you so much, Dr. Iyer, for sharing your unique, incredible expertise for other providers. Thank you, again, for joining us. And for more information, you can always visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole.