Can Hospitals Really Become High-Reliability Organizations?

William T. Choctaw, MD, JD, CSSBB

William T. Choctaw , MD, JD, CSSBB

Physician Advisor, The Joint Commission Center for Transforming Health Care

Published May 07, 2019

Depiction of a highly reliable hospital

Because of the incredible complexity and risk involved in healthcare, mistakes and catastrophic errors may seem inevitable. But if that's the case, how do we explain the airline industry?

Aviation's complexity rivals that of medicine. And yet safety initiatives over the past few decades have decreased the rate of fatal crashes to 1 in 2.5 million flights — virtually zero. In other words, airlines have become high-reliability organizations (HROs).

HROs are those that have managed to drastically reduce or eliminate accidents and disasters despite operating in complex, risky domains. Researchers have documented high reliability in the air traffic control system, on naval aircraft carriers, and at nuclear power plants, among other places.

But can we really compare hospitals to aircraft carriers? Research suggests that to a large degree, we can. In this article, we'll look at the characteristics of high-reliability healthcare organizations. We'll also discuss process tools that can help hospitals and health systems improve their reliability.

What makes a healthcare organization highly reliable?

A number of studies have identified behaviors and values common to HROs. Examples include keeping a close pulse on operations, reluctance to oversimplify problems, preoccupation with failure, deference to expertise, and resilience in the face of setbacks.

In a landmark 2013 study, Mark Chassin, MD, MPP, MPH, and Jerod M. Loeb, PhD, of The Joint Commission applied reliability science to healthcare organizations. In introducing their findings, the authors noted that:

"Despite serious and widespread efforts to improve the quality of health care, many patients still suffer preventable harm every day. Hospitals find improvement difficult to sustain, and they suffer 'project fatigue' because so many problems need attention. No hospitals or health systems have achieved consistent excellence throughout their institutions."

Chassin and Loeb concluded that existing models of reliability could not be directly applied to hospitals. However, they did identify three factors that indicated hospitals' readiness for and progress toward high reliability:

  • Leadership, as defined by commitment to zero patient harm
  • Safety culture
  • Robust Process Improvement (RPI), a methodology adopted by The Joint Commission that combines Lean Six Sigma with formal change management

According to Chassin and Loeb, these three domains have a dynamic interrelationship with one another that isn’t well understood. In particular, the RPI domain has a strong effect on strengthening or weakening an organization’s safety culture.

What is RPI?

While many hospitals are interested in reliability, lack of maturity in the RPI domain inhibits their progress.

RPI was conceived by The Joint Commission as a practical and effective set of process improvement tools for healthcare organizations. RPI methodology blends Lean Six Sigma and formal change management. Its goal is to allow hospitals and health systems to take a definitive first step toward becoming HROs.

During my seven years as Chief Transformation Officer at a regional health system, I was responsible for development and deployment of a system-wide RPI program, with assistance from the Joint Commission Center for Transforming Healthcare. Based on my experiences, there are three ways RPI strengthens safety culture:

1. Building trust

Trust is the oxygen required for all organizational leaders to be effective. If trust is not present or is lacking, hospital processes will be weak, feeble, ineffective, and unsafe.

Trust flows from the executive leaders to the team, not the reverse. Simply put: Leaders must go first. They must walk the talk. The healthcare team will not trust leadership unless it communicates clear goals supported by clear action.

RPI provides leaders with a structured, organized framework that helps them deliver on their promises. I found RPI particularly helpful with some of our most complex projects like sepsis, patient falls, and emergency department overcrowding.

2. Road mapping process excellence

Simply put: Excellent processes keep our patients safe.

The desired goals of any process or system are usually easily defined. Common examples include increasing patient satisfaction or decreasing surgical site infections. Nevertheless, it’s often difficult to choose the best way, i.e. “the process,” to reach the desired goals.

In a complex system like healthcare, there may be hundreds of processes that can potentially impact the goal. That's why RPI is an ideal methodology for healthcare improvement. Lean Six Sigma is based on an analytical framework that requires us to follow certain steps when choosing projects:

  • Define
  • Measure
  • Analyze
  • Improve
  • Control

When used properly, the RPI road map can lead to a statistically significant goal or outcome. It is virtually impossible to solve a problem if the problem is not clearly defined to all members of the team. The RPI roadmap helps the team define the problem. Moreover, RPI’s inclusion of change management ensures the goal, once achieved, will be successfully implemented with staff members.

Safety culture is defined as the drastic reduction or elimination of mistakes and defects based on the team’s culture (beliefs and behaviors). A truism is that when mistakes occur in a healthcare organization, it’s often “the process, not the people” that is the cause. Broken processes are far more common than broken people.

However, if broken processes are not fixed, they will eventually begin to destroy the team, leading to a less safe environment (e.g. an environment of understaffed and poorly paid nurses).

Don’t fire staff when mistakes occur. Fix the broken process causing the mistakes, or the mistakes will reoccur. Use of RPI reinforces the message that it is about improving systems and not about blaming people.

3. Improving physician engagement

It would be naïve to believe you could create a high-reliability organization in the airline industry without engaging pilots. It is equally naive to believe you can have an HRO in the healthcare industry without engaging physicians.

The complexity of physician engagement is discussed almost daily in hospitals nationally, but few actually define it. By following the RPI road map, I define physician engagement as:

“Physician-hospital collaboration based on mutual respect, mutual trust, and good communication that improves the patient experience.”

As noted above, the first step to solving an issue is defining it. The above physician engagement definition has three elements:

  • Collaboration
  • Relationship
  • Patient-centered focus

Physicians are a leading cause of disruptive behavior in our hospitals. Disruptive physicians are not engaged physicians. The Joint Commission identified in 2009 that disruptive behavior from anyone in healthcare is serious, because it undercuts the culture of safety.

However, in general, people don’t come to work to disrupt. We must all redouble our efforts to engage our physicians in a sustainable manner.

In my experience, inviting physicians and physician leaders to participate in RPI training translates into an invitation to participate in the organization’s important improvement initiatives. The language and methods of RPI can then be used as a unifying force for all staff — including physicians.

In summary

While hospitals face many challenges on their way to high reliability, medical errors and catastrophes are far from inevitable. By committing to strong leadership, a safety culture, and robust process improvement, hospitals can move toward increased reliability and patient safety.

This fundamental change in our healthcare organizations can't happen without input, support, and engagement from front-line physicians and providers. If you are a provider or administrator interested in bringing RPI to your organization, visit The Joint Commission Center for Transforming Healthcare to learn more.

This post is adapted from Dr. Choctaw's article "Three Ways Robust Process Improvement Strengthens Safety Culture," published April 3, 2019, at

Originally published May 7, 2019.

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