Do You Have a Culture of High Reliability?

By Paula Wilson, President and CEO, Joint Commission Resources, Joint Commission International

Joint Commission International (JCI) is the global subsidiary of the US-based Joint Commission. JCI is a non-profit organisation committed to helping healthcare organisations (HCOs) provide safe and high-quality care. This year JCI is celebrating its 20th year of accrediting organisations around the world. Over 1,000 healthcare organisations, in over 70 countries, display the JCI Gold Seal. The Middle East is the region with most JCI accredited organisations.

As we look forward to the next 20 years, we are proud of the impact we have had on the quality of care provided in both accredited and non-accredited organisations. However, despite our good work, we also recognise that there is still much more to do.

The JCI International Patient Safety Goals identify six key areas that are especially challenging for healthcare organisations:

Goal 1: Identify patients correctly

Goal 2: Improve effective communication

Goal 3: Improve the safety of high-alert medications

Goal 4: Ensure safe surgery

Goal 5: Reduce the risk of healthcare-associated infections

Goal 6: Reduce the risk of patient harm resulting from falls

Addressing these patient safety challenges is a central component of the JCI survey.  The JCI standards and survey help HCOs improve on reducing infections, falls and ensuring safe surgery. But healthcare organisations everywhere continue to struggle with these and other patient safety issues. Accreditation provides a solid foundation for managing the risks to patients. Our experience has shown that accredited organisations perform better in many areas of care. But we also know that accreditation does not mean zero harm to patients.

Today we are challenging healthcare organisations to imagine a state of zero harm to patients. We are studying the traits of highly reliable organisations (HROs) such as nuclear power and aviation to understand what healthcare can learn from these industries. These industries share the risk and complexities of HCOs but perform at much higher levels of quality over long periods of time.  

We have learned that HROs have strong leaders committed to reaching the highest levels of quality possible. These leaders create a culture that is both safe and just, meaning that staff feel safe to report opportunities to improve processes that are risky to patients. It also means that leadership sets clear boundaries about acceptable and unacceptable behaviours for all staff.

Highly reliable organisations understand that human error is inevitable. Memory lapses, distractions, interruptions, stress and fatigue impact employee’s performance. They reject the commonly held belief in healthcare that great, error free clinical care comes solely from professional training and hard work. They also reject a culture that keeps failures a secret.  HROs see actual mistakes, and equally important, near misses as valuable information, providing insight into where they need to work on improving work processes to mitigate the human factors.

Once an organisation knows where the process problems exist, there are many tools available to help improve these processes. Common process improvement tools come from manufacturing and include the tools of lean and six-sigma. The Joint Commission’s Center for Transforming Healthcare Care has developed Robust Process Improvement or RPI as a performance improvement model that tailors and augments these tools for the healthcare setting. At JCI we use the RPI model to drive our own performance. We have made this the way we work.

The major challenge leaders face in improving quality and organisational performance   is the change management necessary to move the organisation forward. Changing an organisation’s culture as well as changing the way work gets done is always met with resistance from the employees impacted. Organisational culture change means virtually everyone will feel the change. Specific groups, perhaps, are impacted more depending on what operational and clinical processes are undergoing change.

Why is change so hard? And how do leaders overcome the resistance to change? An article from the Harvard Business Review by Elizabeth Kantor Ross provides a top 10 list of why we avoid change. Some of the reasons cited include the fear of losing control, the fear that change is happening too quickly, the uncertainty that comes with change, the potential loss of status and worry that change will mean more work.

Leaders need to spend time on understanding why their staff is fearful of change and then address those fears. Transparency and honesty are important if the change is to be successfully managed. Good leaders begin the process with introspection into their own fears and concerns. They need to make a long-term commitment to implementing change and demonstrate that the change is a new way of working and not a new programme. They need to earn the trust of their employees by behaving as they expect all the staff to behave. They need to show authentic empathy in addressing the concerns of their staff. Anything less breeds cynicism which leads to inevitable failure.

This is all very hard work. It requires focus and discipline over long periods of time. But if done well, it opens the possibility of imagining a time when there is zero harm to patients.