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Requirements for High Reliability
From QA to QI

In my last column, I discussed the critical role of leaders in shaping organizational culture.  Here we take the next step and look at the requirements for achieving high reliability. Given high rates of adverse events, process failures and patient harm, the idea of achieving high reliability in healthcare may seem absurd. Even so, many well-respected healthcare leaders have sounded the clarion call to make this the primary goal.

Safety and high reliability are key components of patient-centered care. They fulfill the Hippocratic dictum, Primum non nocere – First, do no harm. It is incongruous that the majority of physicians and nurses are not well-engaged in the pursuit of patient safety.

I believe high reliability is achievable, albeit with a major shift in organizational culture, which is why I devoted my last two columns to the topic. When American healthcare leaders confront the basic requirements for high reliability in quality and safety in light of prevailing dysfunctional practices, they will open the door to transformation.

I offer this list for your consideration. It represents my synthesis of the literature on quality and safety, including the work of Juran, Deming, Crosby, Weick and Sutcliffe. I find that leading healthcare organizations are following this general prescription.

  • Senior management knows how to nurture organizational learning and improvement
  • Senior management actively leads the way
  • Quality valued “First among Equals”
  • Collective “Mindfulness”
    • Anticipate, recognize and rapidly act to contain unexpected threats to safety in dynamic, high-risk environments
    • Value a strong response to a weak signal
  • Improvement activity is wide and deep
  • Wholesale candor and diligence in reporting problems and risks
    • All members of the team are valued and have the skills to communicate effectively
  • Rapid cycle non-punitive event analysis
  • Focused on system process learning opportunities  with  default presumption of staff innocence and competence
  • “Stop the Line” events immediately attract resources to resolve
  • Changes are studied to assure their effectiveness
  • Incentives are aligned with safety

I subscribe to the philosophy that leadership is a verb and that organizations are strengthened by fostering leadership behavior at all levels. Nevertheless, you’ve seen that the first two points on my list use the term “management.” I adapted them from Deming and I believe they are still relevant. Those appointed to management positions control resources and have formal power, regardless of how well they lead others. If senior management does not know what to do and does not lead the way, it is highly unlikely that informal leaders lower in the hierarchy will succeed in fostering the needed transformation.

You may wish to add to this list and I invite your feedback. In particular, the concept of “Just Culture” has received a lot of play in healthcare over the past decade, so I will address it in detail in my next column.

Coming Next: Just Culture

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