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High-reliability organizations (HROs): What they know that we don't (Part I)

From the July 14, 2005

Healthcare is a highly complex, error-prone industry. From treating patients in a hectic emergency department to the daily pressures of dispensing thousands of medications, the delivery of healthcare exemplifies an unprecedented level of non-stop activity, specialization, and intricate interdisciplinary processes where the slightest mistake could be catastrophic. There are a number of other industries that are equally complex and error-prone, and where the consequences of an error are just as dire. Yet, many of these high-hazard industries have a much better safety record than healthcare. Examples include chemical manufacturing, nuclear power production, nuclear arms handling, and aviation. Leaders in these industries, known as high-reliability organizations (HROs), manage for safe, reliable performance. The fundamental differences between these industries with laudable safety records and the healthcare industry are deeply rooted in their respective cultures. In fact, researchers who have studied HROs believe a strong safety culture is the most critical underlying feature of their accomplishments related to safety.(1)

Culture is defined as a pattern of shared basic assumptions about the organization's values (what is important), beliefs (how things work), and behaviors (the way we do things) that have been taught to the workforce in both explicit and implicit ways.(2) While individuals in the workforce may hold varying attitudes and beliefs, cultural assumptions in an organization typically embody the philosophies of senior leaders. An exact definition of a culture of safety is still emerging in healthcare, but recurrent themes in HROs offer an opportunity to reflect on how these respective cultures may differ.(3) Part I presents the first six recurrent themes; Part II (to be published in the next issue) will present the remaining themes.

Strategic emphasis on safety. HROs have a palpable passion for safety, which is grounded in a healthy acknowledgment of the high-risk nature of the business and a preoccupation with the potential for failure. The leaders know that, while safety doesn't guarantee quality, it's an absolute prerequisite for the delivery of high-quality service. It's the way they do business that's articulated in specific terms, not safety jargon or buzzwords, and incorporated into strategic plans with generous budgets. The leaders realize that errors are costly in financial terms, but the strategic emphasis on safety is driven largely by consideration of important societal values such as freedom from accidental injury that hold great value in the collective culture.

Consistent message from managers. Leaders in HROs clearly garner support and enthusiasm for safety from the workforce. However, they know that middle managers actually convey the culture to the frontline workers. Seeing how middle managers value safety is what permits frontline workers to prioritize their work accordingly. The message that safety is a top priority is believable to the workforce in HROs because middle managers' behaviors consistently support that message.

Just culture. HROs have embraced a just set of values and characteristics that support the reporting and investigation of hazards and errors. The culture does not advocate a "name, blame, shame, and train" philosophy, or deny that errors occur except to "bad apples;" rather, the leaders and workforce support a fierce intolerance for intentional risk-taking, and fair treatment of individuals who make errors, regardless of the outcome or frequency. Thus, the workforce trusts each other and their leaders, and reports hazards and errors without fear of retribution or embarrassment. When discussing errors, the language is positive; near misses are great catches, errors are opportunities to learn. Leaders sincerely demonstrate that all reports, contributions, and concerns about safety are valued, respected, appreciated, and rewarded.

Feedback loops. HROs have established cross-departmental, meaningful feedback systems that keep the workforce informed about safety, errors, and causal trends-not just in sophisticated charts and graphs, but also in rich stories about safety that can be recalled as a constant reminder and sound rationale to keep safety a priority. Likewise, leaders are visible in work areas to hold discussions with the workforce to learn firsthand about the barriers to safe work, and also to share strategic goals, build trust, and demonstrate safety priorities.

Learning organization. HROs have a strong desire to learn in a way that generates relevant knowledge. Learning is not the same as training. Training is typically episodic and passive with little or no link to the desired results. Learning is different; it means to enhance capacity through real-life experiences gained over time. Thus, HROs see learning as inseparable from everyday work and a necessary precursor to change. From the perspective of the workforce, it's the difference between training for operational skills and learning reflection and inquiry skills that allow them to talk about tough issues without defensiveness. From the perspective of leaders, it's the difference between trying to make the workforce perform flawlessly (training) and understanding the constraints that are keeping them from flawless work (learning).(4)

Desire to change. HROs embrace change that comes from meaningful learning. However, the leaders know that little significant change is driven from the top alone. They do not buy into the myth that leaders are the few special people blessed with the ability to command, influence, and bring about change. Leaders in HROs know that profound change comes from commitment, not management-driven compliance that directs the workforce to "just do it" or be at odds with the boss. They know the workforce is skeptical about the "flavor of the month" strategies, and that people cling to old habits without a commitment to change. In fact, they clearly recognize that the workforce carries a great deal of power when it comes to either maintaining the status quo or changing. Thus, HROs typically employ leadership communities comprising local line leaders, internal networkers, and managing leaders to drive change.(4)

The local line leaders (frontline workers and managers) are the only ones who can undertake a test of change, evaluate its practicality, see how it fits into the workflow, and ultimately change the way that service is delivered. Internal networkers (staff such as physicians who are not limited to a specific department or unit) are used as a natural seed carrier of new ideas to generate a sense of urgency to spread the change. Managing leaders support, guide, and fund the changes, as well as help create an urgency to change.

References will appear in Part II of the article, to be published in the July 28, 2005 newsletter.

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