“There is no such thing as a high reliability organization.”1 More accurately, organizations can produce highly reliable outcomes when their leaders nurture a culture and learning system that align with the organization’s values.
The desired outcome of healthcare organizations is the provision of safe medical care for every patient, every day. When they learn from previous events and embrace continuous quality improvement, healthcare teams are better able to provide reliable care. Nevertheless, designing and implementing systems for reliable delivery of medical care remains a daunting task. Through its various education activities that include programs for physician leaders, the CMPA supports members in providing safe medical care.
The Institute for Healthcare Improvement (IHI) and Safe & Reliable Healthcare offer a framework that can be helpful for leaders in planning and designing highly reliable healthcare delivery systems (see Figure).2 This framework describes two main components of a healthcare system: culture and a learning system. Culture results from the interplay of psychological safety, accountability, team communication, and negotiation that together create a positive workplace environment. The learning system is the mechanism that allows the care team to thrive and continuously improve, by deliberately promoting continuous learning, measurement of improvement efforts, implementation of reliable processes, and transparency.
Figure: Framework for Safe, Reliable, and Effective Care
Leaders are the architects of their organization’s culture and the guardians of the learning system. They can demonstrate their own engagement by doing regular executive walk rounds (EWRs). These provide valuable visibility for leaders who might otherwise be unseen in the clinical setting. With EWRs, leaders gain opportunities to converse with frontline providers and get feedback about their past decisions. Because feedback without action adversely affects the learning system and leads to low engagement, skilled leaders listen intently, act on the feedback, and make corrective actions visible.
Indeed, all of a healthcare leader’s actions should aim to support the eight elements of the Framework for Safe, Reliable, and Effective Care described here.2
Psychological safety is the foundational building block needed to support a solid learning system and a positive workplace culture. In teams that provide highly reliable care, all individuals—from housekeeping staff to the chief physician—feel safe to ask questions without fear of looking stupid, to ask for feedback without fear of being perceived as incompetent, to be respectfully critical of a plan without being labeled as disruptive, and to offer suggestions for improvement without being considered negative.
Teams that provide highly reliable care hold themselves accountable. Accountability promotes disclosure of patient safety incidents and near misses, and creates the conditions to proactively identify and correct system flaws before unwanted events occur. Leaders of these teams foster natural justice: healthcare providers know what they are accountable for and how they will be held to account. They trust that when faced with a complaint they will be made aware of its elements, have the opportunity to respond, and know that decisions will be unbiased and fair.
Teamwork and communication
Teams that provide highly reliable care communicate clearly and anticipate problems before they occur. Individual healthcare providers put their personal preferences aside, harmonizing their approach to care and communication, while demonstrating flexibility. Skilled teams hold briefings to prepare for procedures, conduct debriefings to reflect on performance, schedule routine huddles, and use structured communication approaches to convey patient information at transitions of care. These tactics help create situational awareness, that is, they help promote an understanding of what is happening at the moment and allow for the projection of that comprehension into the future to guide safe actions.
Teams also use these activities as a way to identify issues for improvement, which serves as input to the learning system.
An important aspect of effective teamwork and communication is the use of cross-monitoring and critical language to “stop the line”—where anyone can interrupt a process of care at any time if they perceive there is a risk to patient safety. Team members understand that mistakes are inevitable and openly invite others to respectfully challenge them in an effort to prevent harm. Even when they are wrong, team members who speak up are encouraged to speak up again.
Leaders of teams that provide highly reliable care have good negotiation skills. When resolving conflicts, they focus on interests (i.e. needs, fears, ambitions, goals) rather than positions or demands. They seek to repair and maintain relationships when making decisions on corrective actions. The best leaders “play the long game,” that is, regard decision-making and negotiation as an end in itself and a way to build engagement rather than exercise authority.
Leaders of teams that provide highly reliable care incorporate continuous learning in everyday activities. Enabled by the team communication strategies described earlier and paired with frontline empowerment, teams that self-reflect have the ability to continually heal themselves and improve.
Improvement and measurement
When acted upon appropriately, effective feedback facilitates engagement. To achieve highly reliable outcomes, teams use feedback and rapid PDSA (Plan, Do, Study, Act) cycles to objectively measure the impact of their improvement efforts. Team leaders empower and enable frontline providers to take ownership of improvement and support them in learning to recognize potential problems, identify and try solutions, and measure their impact. While many institutions have developed outcome measures, effective teams supplement these with clinically meaningful process measures to gauge the impact of quality improvement efforts.
While quality healthcare is about how well health services are delivered, reliability is concerned with how consistently quality services are delivered day after day, in real-world circumstances. The goal is to provide the appropriate care, to the right patient at the right moment, every time. Teams that provide highly reliable care understand that unnecessary variation is harmful on a population scale, and strive to minimize it to improve safety.
In every aspect of their work, leaders of teams that deliver highly reliable care strive to be as transparent as possible within the parameters of their administrative responsibilities. By making culture and operations more visible to everyone and eliminating operational secrecy, leaders make the stakes and challenges clear and avoid the creation of an elite that purports to know more than others. They create frontline engagement for quality improvement that allows team members to see the impact of their efforts.
Teams that deliver highly reliable care create opportunities for scheduled communication about their goals, their challenges, and their contingency plans. One tool that is helpful to give providers a voice and showcase their central role in quality improvement is the huddle board. The team gathers at its huddle board during routinely held sessions to discuss progress on quality improvement initiatives and flag opportunities for improvement that were identified during debriefs. The huddle board is monitored and updated in real time using clinically pertinent metrics, which helps create a sense of urgency and makes progress clearly visible to all members of the team.
The bottom line
In well-functioning healthcare teams, the desire for learning and improvement is visible. Leaders can build such teams by empowering providers to do what is necessary to promote safe medical care without fear of unfair reprisals. As guardians of the learning system, leaders must create psychological safety in an environment characterized by appropriate accountability, and thereby set the stage for highly reliable care delivery.
- Outcome Engenuity [Internet]. Eden Prairie (US). There is No Such Thing as a High Reliability Organization [cited 2018 Feb 21]. Available from: www.outcome-eng.com/no-thing-high-reliability-organization/
- Frankel A, Haraden C, Federico F, Lenoci-Edwards J. A Framework for Safe, Reliable, and Effective Care [Internet]. Cambridge, MA: Institute for Healthcare Improvement and Safe & Reliable Healthcare; 2017. Available from: www.ihi.org/resources/Pages/IHIWhitePapers/Framework-Safe-Reliable-Effective-Care.aspx