Practical Tools for the High Reliability Journey

Friday, 28 July 2017: 2:50 PM

Jane Braaten, PhD, MS
Centura Health, Highlands Ranch, CO, USA

Highly reliable organizations are effective in three domains: leadership commitment to high reliability, a safety culture and robust process improvement (Chassin & Loeb, 2013). However, the nature of healthcare today creates a challenge to high reliability. Healthcare in the hospital today is a whirlwind of highly complex systems and processes, coupled with emergent conditions. Interacting within this chaos daily are human beings seeking and providing care to those who are ill and vulnerable. Human nature and the history of healthcare still lead us to fall back on expecting perfection from humans in this type of system. Current leaders in patient safety state that safety advances when human error is recognized as an attribute of the system and not the cause of it (Woods, et al, 2012). This means that we must expect vulnerability from human beings and create effective systems to mitigate the expected error. Errors occur most often, not because of lack of reliability from humans but because of lack of reliability of our system to prevent humans from error (IOM, 2009). Highly reliable organizations rely on finding system and process solutions to prevent human error in a proactive, rather than reactive manner (Weick & Sutcliffe, 2007). High reliability can become a “buzzword” unless we match the principles of high reliability with our everyday processes. Robust process improvement cannot be simplified by only adopting a process or tool. In order to create high reliability, we also need to be intentional with embedding the principles of high reliability into our process improvement tools. Root Cause Analysis (RCA) and Failure Mode Effects Analysis ( FMEA), when implemented with high reliability principles, can be effective tools to recognize and mitigate the effects of human fallibility by encouraging proactive anticipation of conditions that lead to errors and encouraging robust interventions created by interdisciplinary collaboration to mitigate error from emergent conditions. High reliability depends on crossing traditional barriers and boundaries to innovate. Boundary spanners can be people, objects, or processes that bridge differences and lead to collaboration between diverse areas. Highly reliable improvement tools can serve as boundary spanning processes that bridge the gap between traditional process improvement and highly reliable performance.


The purpose of this presentation is to describe how two robust process improvement tools can be used to promote highly reliable error reduction in a complex hospital environment.


An effective RCA and FMEA is a key feature of a highly reliable organization’s robust process improvement program. The RCA at its most effective considers system issues as causes and human errors as effects, considers and mitigates for sources of bias in the investigation , creates strong actionable, timed interventions that address the root causes found and is supported by the highest levels of organizational leadership (National Patient Safety Foundation, 2015). The RCA is generally used to analyze an event or a close call that has been identified. An FMEA, on the other hand, is used to predict and identify safety or problematic gaps in a process before an event occurs. Both methods if not intentionally facilitated can have challenges to high reliability such as bias, failure to consider system issues, failure to encourage diverse opinions in the process, choosing interventions which do not consider human factors and failure to monitor and sustain the improvement. When used effectively, the tools are a key component of a highly reliably organization, leading to sustainable improvement.


Implementing the robust improvement tools, RCA and FMEA, through the lens of high reliability principles has led to an increase in staff perception of patient safety and how the organization reacts to and prevents adverse events. Improvement in the AHRQ Hospital Survey on Patient Safety was realized in the items of "organizational learning from erro"r and "non-punitive response to error". One RCA led to a system change of the counting process in the operating room that identifies a mandatory time out for counting prior to close. After implementation, there have been no further retained foreign objects over the last year. An FMEA at the same facility identified at least 20 high risk opportunities for failure in a pediatric resuscitation event. Mitigation strategies have been implemented for all opportunities and currently, the process was tested with no deficiencies.

Implications for Nursing Practice

High reliability is dependent upon identifying conditions for adverse events before they occur and creating resilience in the system for staff to react to safety issues before harm to a patient occurs. The RCA and FMEA are tools which promote both anticipation and mitigation and can serve as boundary spanning processes, linking process improvement to high reliability.