These Three Mistakes will Doom Your High Reliability Program Before You Get Started

“We’ve been at this for a while now…”

Doest this sound familiar?

  • We realized that the Joint Commission considers high reliability as the pathway to zero harm for our patients.
  • But – when the Joint Commission surveyor asked where we were on our high reliability journey, we didn’t know enough about high reliability to form an appropriate response.
  • We partnered with a consulting group to improve our safety culture, and another consulting group to help our process improvement department.
  • We have another Joint Commission survey coming up, and we still have harm. We still have falls with injuries.  Our rate of hospital acquired infections is essentially unchanged, and we still struggle delivering best practice care to every patient, every time despite months of work from more than one performance improvement team.
  • We’ve been “doing” high reliability for a long-time but we simply aren’t seeing the results we need. . .

The high reliability concept is not that complicated.  So, why do organizations struggle with actually becoming a high reliability organization? Why does the concept often fade from organizational consciousness and disappear as another failed “program of the month?”

Why does the concept often fade from organizational consciousness and disappear as another failed “program of the month?

See the Joint Commission’s Paper: High-Reliability Health Care: Getting There from Here by Chassin and Loeb.

Marty Scott, M.D., MBA

Don’t Stumble at the Starting Gate!

Many initiatives fail because of a lack of important foundational work.  We see people make three huge mistakes right out of the gate that make success impossible:

  1. Failing to create the right expectations
  2. Not setting achievable goals; and
  3. Not understanding where high reliability REALLY occurs.

High Reliability is NOT a “Project”

Too many teams approach high reliability as a “project.” This implies it has a defined beginning and end. There will be a day we can declare patient safety victory! There will be T-shirts, posters, and cupcakes to celebrate our accomplishment.

Well – ideally we have something to celebrate but it’s NOT an endpoint.  Far from it.  A high reliability journey is not a project! I am even uncomfortable calling it a journey; because that implies there is a destination. Let’s think of high reliability as an ongoing transformation – that never ends. You can always find something you can do better for the next patient.

The most successful high reliability organizations are always talking about the next thing they want to accomplish. It’s a thousand-mile marathon, and with a little luck, a lot of hard work, and perseverance we might accomplish the first quarter mile in the first year.  

Think about your organizational safety “DNA”…

A high reliability transformation requires reshaping our organizational DNA and building a new culture. It takes dedication and commitment to your patients, your staff, and your community.

Oh, and those celebrations – be sure to have them along the way. Be clear what you are celebrating – 6 months without a hospital acquired urinary tract infection in your ICU for example – but not for declaring victory in achieving high reliability.

Early in my career I thought the organization I was working with had succeeded. We had a lengthy period without a patient harm event. We printed those t-shirts, hung those posters, had a that reception. The very next week we had a devastating patient harm event. All that time without patient harm meant nothing to that family. It’s the next patient we must provide that highly reliable patient experience, and so on, and so on.

Early in my career I thought the organization I was working with had succeeded. . . . We printed those t-shirts, hung those posters, had a that reception. The very next week we had a devastating patient harm event.

(How do you change culture? See: Culture Change without Talking about “Culture”)

Is Zero Harm Realistic?  Achievable Goals

The Joint Commission will tell you the goal is Zero Harm. We all know that’s true. We pledged to Hippocrates or Florence Nightingale that we would do no harm in rendering care to our fellow man.  Every single person that comes to work in our hospitals does so to make a difference in the lives of the patients and families they have the privilege to touch.

But we are human; and humans make mistakes. High reliability organizations are not free from error. They make mistakes. The difference is that high reliability organizations can still accomplish their goal despite our human errors.

You may be thinking zero harm is impossible. It is possible, and there are hospitals that have done it. If you are thinking zero harm is impossible, your staff is also thinking the same thing. So how do we have a goal of zero harm but make it achievable and use it not only as a measuring stick but also as a motivational tool for your staff?

Example – Work on Zero Harm Incrementally.

First, you can work on zero harm incrementally. For example, you want to eliminate hospital acquired infections and one of your biggest opportunity is catheter associated urinary tract infections (CAUTI). Depending on the magnitude of your CAUTI rate you may not be able to get to zero in one year.

Your goal can be a steady reduction to zero over a period of time. Can you use that goal to motivate your team? You bet! Instead of stating the goal as a number of infections reduced, state it as a goal of a defined number of days between CAUTI.

If you have a CAUTI, you do not give up. You learn from that episode and work on creating another streak.

I often think about the Vince Lombardi quote when working with zero harm goals. Vince Lombardi was the legendary coach of the Green Bay Packers He once told a reporter his goal for the Packers was perfection. Of course, the reporter pushed back on that statement. Coach Lombardi went on to explain that only by pursuing perfection can you capture excellence. That is where we must focus our efforts.

Know Where High Reliability Happens

Finally, you should understand where high reliability actually occurs. A successful high reliability transformation does NOT happen in the boardroom, or at the system headquarters, or in the Medical Executive Committee.

(See; The Room Where it Happens – Getting to Zero Harm)

Those are all important and have definite contributions to transforming the culture. However, where the culture change begins is with the nurses, the doctors, the techs, the pharmacists, and all those team members working at the point of care.

. . . Places like the bedside, the surgical suite, the blood bank, sterile processing, and many others too numerous to list. Those places where decisions are made – hundreds to thousands of decisions daily that create the outstanding patient experience and outcomes all of us want for every patient, every time. How those team members are empowered and supported to learn new behaviors and turn those new behaviors into habits will be the recipe to create your new organizational DNA of a highly reliable culture.

To Learn More about J3P’s innovative approach to High Reliability, visit us at