Every one of us will be a patient someday, if we haven’t already been one—
and we all have family members who have or will need healthcare. What we want out of these experiences is to receive the best possible care, by all definitions. And if we acknowledge that everyone deserves that level of quality, consistency, and comfort, then we have a responsibility as healthcare professionals to pursue what engineers would call high reliability.
Introduction
High Reliability
Organizations
Attend to where humans are vulnerable to error
Take advantage of where humans can apply their strengths
Foster a culture where preventable defects are discussed and addressed systemically
What is High Reliability?
The easiest way to answer that is to look at groups that pursue this ideal. Called high reliability organizations (HROs), these entities continuously strive for failure-free operations amid extraordinary levels of complexity and the constant threat of catastrophic error. Air traffic controllers, nuclear submarine operators, and space flight command centers are examples of HROs. The cultures, systems, and processes in these entities are designed to effectively manage the unexpected and mitigate the risk of human error, allowing the entity to go for long periods without any significant issues.
High reliability requires creating an environment of mindfulness that helps the organization manage the intricacies of its complex systems and overcome human fallibility. In other words, HROs acknowledge that humans make mistakes and design their systems and processes to limit the likelihood of those mistakes. They do this by attending to where humans are vulnerable to error, taking advantage of where humans can apply their strengths, and fostering a culture where preventable defects are discussed and addressed systemically.
Could a Healthcare Organization Become Highly Reliable?
Over the years, a number of structures have emerged that aim to guide healthcare organizations on the journey to high reliability. These works grew out of a desire to prevent unnecessary harm to patients and improve the quality and consistency of healthcare. Sentinel works by The Joint Commission, The Institute for Healthcare Improvement (IHI), the National Patient Safety Foundation, and the IHI Lucian Leape Institute have advanced the field toward a greater appreciation of what it means to be an HRO.
Our Framework for High Reliability Healthcare represents the next step in this ongoing journey. It is meant to capture in one place, with one lens, and one set of language, all the theories, approaches, knowledge sets, and activities that help healthcare organizations become HROs in practice. For decades, we have delved into what concepts are important and how those relate to each other, but it is time to look past theory and start pursuing practice.
As individuals who have lived and breathed this work around the world, we have had the privilege of seeing how organizations apply the concepts in their day-to-day activities. The results are that patients get better care, and providers find greater joy in their work. We developed this new framework to enable stronger execution of those concepts based on the unique and rich perspectives of the organizations applying them.
A View from 10,000 Feet
Our research and experience show that healthcare organizations that excel in the following four areas are better positioned to pursue failure-free operations over time and characterize themselves as highly reliable.
Creating Healthy Cultures
Harnessing Knowledge
Building Learning Systems
Transforming Leadership
These four characteristics make up our framework’s primary domains, with each one comprising two to four components, which are equally essential in turning the domain’s concepts into actionable strategies.
Visually, the framework is represented as a gear or mechanism that moves and progresses, with every component interacting with every other one. The imagery of constant motion is meant to demonstrate that realizing high reliability is a never-ending journey in service to the care delivered to patients and families and the staff who provide that care. The framework’s central hub reinforces that the work must focus equally on patients and staff because a commitment to both groups is necessary to enable change.
The framework does not just apply to clinical settings but to all departments or units in an organization. The gear’s teeth on the outside of the wheel suggest that these areas should connect with each other. When units, departments, or settings consistently apply the framework, they can align their gears with those of other units or departments, making each area securely fit in the system as a whole and allowing the larger entity to run more smoothly and effectively.
“Culture is foundational because individuals working in an organization function best when certain internal and environmental characteristics are robust.”
Although organizations can start the work by applying any of the framework components, we have found that those that prioritize culture tend to realize the greatest success. Culture is foundational because individuals working in an organization function best when certain internal and environmental characteristics are robust. Individually, people must have courage, commitment, an ability to self-manage, and a sense of agency. They must regularly come together in groups to align their perspectives and reflections. With assistance from good management and sound organizational structure and design, these groups must create a palpable sense of community. When there are disagreements, as there inevitably are in complex environments with smart, caring staff, groups must use collaboration as the mechanism to resolve them.
The environment as a whole must be rooted in trust and respect. People should feel safe speaking up about problems and understand they have a responsibility to do so, knowing that their concerns will be heard, vet- ted, and acted on appropriately and are key to helping the organization move toward greater reliability.
With a cultural foundation, an organization is then able to collect clinical, operational, and cultural data, ensuring that the information is correct and up-to-date and then making it visible and transparent. This data becomes the Knowledge on which the Learning System is based. The cultural foundation and the collection of insights that drive the learning system allow individuals, teams, and leaders to self-reflect and focus their energy and resources more effectively in those areas that warrant improvement, and where improvement will reap the greatest rewards in safety, efficiency, or satis- faction.
All three of these components—Culture, Knowledge, and the Learning System—are only successful with the right kind of Leadership at all organizational levels. First and foremost, senior executives, middle managers, and frontline leaders must agree to safeguard the other components of the framework. They must then serve as examples of the culture they want to achieve and be involved with and visible in the actions highlighted throughout the framework.
If all the above-mentioned domains and characteristics are robust, then an organization can move in the direction of high reliability. When clinical and nonclinical settings are all functioning as HROs, then we can begin to see the kind of operational excellence we want and feel a responsibility to attain.
The four elements of Culture—personal accountability, teamwork and collaboration, healthy environment, and consensus and alignment—weave together to create a sense of community where respect is something that happens at an individual, team, and environmental level. People feel valued as individuals and as community members. They know that the organization does not shy away from things that are difficult to talk about or areas in which the entity is not excelling. When all components exist simultaneously, the culture creates a place where groups can identify defects, understand them together, test ideas, and improve.
Read the Full White Paper
Our validated Framework for High Reliability Healthcare is a compendium of theories, approaches, knowledge sets, and activities needed to achieve and sustain high reliability in practice.
In the full white paper, we dig deeper into each of the framework’s domains and components, highlighting where they interweave and interrelate.
Fill out the form to download a copy of the full white paper.
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