Patient Safety and High Reliability: Getting the People Part Right

Craig Deao, Amanda Bonser

In Brief

6-Minute Read

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“I can’t do all that patient experience stuff!” nurses sometimes say when leaders try to engage them in improving the patient experience. They think it’s fluffy stuff that they don’t have time to deliver on.

In an age when the healthcare industry has engineered world-class clinical solutions with complicated healthcare robotics and transformed the flow of medical information through widespread adoption of digital medical records, the people part of care delivery remains elusive.

Other Industries Excel at High Reliability

And yet, nearly every other high-risk industry — from oil and gas and nuclear power to commercial aviation and the military — have successfully adopted high reliability strategies to dramatically improve operational efficiency, quality and safety. They too function in high-risk, high-stress conditions under extreme time pressures, face a complex regulatory framework with economic pressures and need to operate at high capacity during peak demand.

A circle graphic depicting a culture of excellence being made up of predictable behavior and reliable process. If the problem is that to err is human, how can organizations design processes and collaboration among healthcare teams that are harm-free? Imagine the possibilities if organizations could hardwire zero patient harm and medication errors through reliable systems to prevent, intercept and mitigate the harm that human error causes.

What if the same skill sets used to reduce any variation in human behavior could also be used for consistently excellent results in areas as diverse as Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) performance across different nursing units or monthly revenue collection? Could organizations face fewer unplanned readmissions if medication side effects were explained to every patient every time? The principles of high reliability apply to all our goals across the organization.

High Reliability Defined

High reliability is the science of achieving efficient, error-free operation. That means that a high reliability organization (HRO) is an organization with predictable and repeatable systems in place that allows for the consistent execution of operations while catching and correcting potentially catastrophic errors.

It’s all about reducing variability. When it comes to clinical variation management, the goal is to decrease unwarranted variation in the delivery of care while improving clinical results and reducing costs. To achieve that, organizations must stop chasing averages and focus instead on variations. An HRO is focused at every level on creating predictability and process consistency.

Without a dedicated and reliable process improvement engine, organizations will continue to achieve average results at best. A culture of excellence and high reliability includes a strategic commitment to continuously strive toward predictable, repeatable behaviors and reliable, consistent processes.

A Successful Change Formula

The reality is that across the healthcare spectrum, more than 70% of change and transformation initiatives fail. Why? For starters, 80% of the work in managing successful process improvement has nothing to do with tools and everything to do with perceptions. There is a slow drift away from the norm toward catastrophic failure with workarounds, shortcuts and organizational pressure — especially when workers feel forced to make decisions without support from leaders.

So what works to ensure that front-line staff consistently embrace the agreed-upon process, even during a busy shift? It’s a comprehensive approach to high reliability that includes (1) a shared vision, (2) skills and training, (3) incentives, (4) resources for support and (5) required action. The absence of any one of these five ingredients puts lasting change in jeopardy.

The Engine for High Reliability

A successful HRO strategy begins with a solid foundation of leadership development and accountability. The Evidence-Based LeadershipSM framework provides the foundation by modeling, creating and sustaining a culture where alignment, accountability and standardization are at the very heart of the organization’s high reliability journey. In essence, it provides the “chassis” to bolt on specific HRO initiatives.

Because goals cascade to every level and department, high reliability no longer risks becoming a project on the quality side of the house. So many efforts at high reliability in healthcare have failed because they focused on process improvement — like Lean or Six Sigma — at the expense of examining the habits of people who need to implement such processes when time or staff are in short supply. Conversely, Evidence-Based Leadership systematizes process improvements by assigning clear goals to employees and helping people learn new behaviors that address variation consistently over time.

Engagement Is Essential

Leader, clinician and employee engagement are also critical. As noted in The E-Factor: How Engaged Patients, Clinicians, Leaders, and Employees Will Transform Healthcare, the research confirms the importance of unlocking the team’s potential and building the capacity of front-line staff in the high reliability journey.

When leaders engage their teams, it builds efficacy and self-confidence in speaking up. Likewise, engaged leaders have an important role to play in supporting the team through continually improving processes and ensuring sufficient resources to deploy to provide excellent care without exception.

In the end, high reliability is about providing the kind of care anyone would demand for their own family members. Healthcare needs to restore trust that it will get it right for every individual every time, just as people trust that when a plane drops during turbulence at high altitudes, the odds of something bad happening are almost nonexistent.

The good news is this: There are already HRO trailblazers succeeding in our industry today. High reliability is increasingly well understood, and organizations are getting more efficient at operationalizing it.

High Reliability in Federal Healthcare

In recent years, the federal government has stepped up its interest in high reliability, implementing initiatives in key branches of the military under the Defense Health Agency as well as in the Veterans Health Administration (VHA). They’re taking note of the traction high reliability organizations are gaining in the private sector and getting on board.

As in the private sector, the federal government is tapping into best practices in high reliability due to an increasing focus on patient safety and providing top quality care. In some cases — such as for the VHA and military — hospitals face high visibility in the media and congressional scrutiny. That provides additional impetus to ensure a culture of zero harm.


  • Think differently.
    Understand how predictable behaviors and consistent processes underpin a culture of excellence.
  • Plan differently.
    Establish a framework that systematically engages leaders, clinicians and employees around alignment and accountability, which are at the heart of high reliability and the ability to provide excellent care for every patient, every time.
  • Act differently.
    Build a highly reliable organization by focusing on the elements that make behavior change stick.

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