The High-Reliability Journey Starts with Transparency

The first step on the high-reliability journey is a commitment to transparency within the organization and with patients and family members.

“Until you can get your head around the idea that we have to be frank and honest about how much harm is being produced from our organization, you’re never going to get better,” says Stephen E. Muething, M.D., vice president for safety at the James M. Anderson Center for Health Systems Excellence at Cincinnati Children’s Hospital Medical Center. “And you’re going to have to be able to talk about it in an open enough way that you can learn on a daily basis.”

That openness is only possible if the organization’s board of directors creates an environment of trust.

“That’s what Lee Carter did for us,” Muething says, referring to the leadership of a longtime Cincinnati Children’s board member who has championed the hospital’s high reliability journey. “The board has to say ‘We’re not satisfied with the performance, but it isn’t about you. It’s about the system, and together we’ve got to fix the system.’”

Carter, a Cincinnati Children’s trustee since 1980, says fixing the safety problem that exists in U.S. hospitals today requires leadership from the very top. That means setting objectives — for example, “We will be the best at getting better” or “We will have zero serious safety events” or “We will be the safest hospital in the world” — and follow through with action plans and accountability.

“The board’s role is to set those kinds of objectives — and then it is up to the board and management together to say: ‘How do we get there?’” Carter says.

Muething sees dozens of pediatric hospitals — as well as other health care organizations — embarking on the high reliability journey. In addition to his role at Cincinnati Children’s, he heads the clinical leadership of Solutions for Patient Safety, a network of 85 children’s hospitals that are working together to eliminate serious harm to the patients they care for.

Eight Patient Safety Lessons

Muething shared lessons learned from his work in the high-reliability movement:

1. The CEO must own the safety agenda. Unlike some other strategic goals that a hospital may have, the CEO cannot delegate safety to a subordinate.

2. Culture change is essential to eliminating patient harm, but culture will not change until behaviors change. Hospital leaders must define the behaviors they expect of all staff, teach those behaviors, model them and reinforce them over a long period of time. “You don’t get people to think differently so they will behave differently,” Muething says. “You get them to behave differently and eventually they will think differently.”

3. Managing by prediction is key to preventing harm. “We have come to believe that most harm can be predicted,” he says. “We have dramatically changed how we think about a shift, about a day, about an OR case, about a night in the emergency room.”

Teams and leaders are trained to think about what might go wrong in the coming hours and all staff are coached to speak up about their concerns.

“It’s just incredible to see the confidence build when charge nurses and doctors and respiratory therapists can openly say, ‘Well, I’m a little bit worried this might go wrong,’ and then having leaders say, ‘Perfect. That’s exactly what I wanted to hear from you. Now let’s talk about what we’re going to do about that,’” Muething says.

4. Learning from safety events should happen in near real-time. At first, Cincinnati Children’s did not know how much harm was occurring in the institution. Then it started developing monthly reports and monthly rates of harm for the organization as a whole. Then the reports got down to the unit level, but still based on a retrospective review.

“Today, if there is a significant harmful event to a kid in our hospital, it’s announced to the whole hospital tomorrow morning, and we expect the teams, by tomorrow, to be analyzing that event and seeing what they can learn from it,” Muething says.

That makes learning from safety events a part of standard work. “It’s not something that’s done by another group, or done when we have time, or done after we’re finished with our regular work,” he says.

5. Employee safety and patient safety are the same priority. Cincinnati Children’s was well into its high-reliability journey when it adopted this view after seeing how other industries approached the concept of high reliability. “We came to believe that the two were so inextricably linked that talking about them separately and working on them separately was actually slowing us down,” he says. “So now we put equal weight to the idea that our safety program has to not only keep the kids safe but it has to keep our staff safe as well.”

6. Eliminating patient and employee harm requires resources. “This is not something you do by just agreeing to do it,” Muething says. “If you’re really going to train everybody on their behaviors, you’re going to look at how you develop leaders and you’re going to build an infrastructure and data system that can get you the kind of information that leaders need to be a high reliability organization, it doesn’t come free.”

7. The high reliability journey takes time. Based on his experience with the many hospitals in the Solutions for Patient Safety network, Muething says the first three or four years is consumed with putting the infrastructure — transparency, governance, training and learning processes — in place. “By the end of that time, what we are seeing at hospital after hospital is at least a 50 percent reduction in their serious safety events,” he says.

8. Any pause for applause must be brief. “As we all say, that’s all great, but it is hardly satisfactory,” he says. “We just keep on moving. It becomes a multi-decade journey.”

For more on reducing patient harm, read the June cover story, “Getting to Zero.”

Lola Butcher is a contributing writer to Trustee.