Ever since I started working with High Reliability Organization Safety Programs 36 years ago we have worked on how errors could be prevented and how managers could get their staff to consistently follow safety policies. However, in the last couple of years I have come to accept that “errors are normal” and “deviations from expected behaviors is normal”. Then, last month my perspective shifted further. While listening to the Pre-Accident Investigation podcast, I heard Dr. Erik Hollnagel tell Dr. Todd Conklin that we should “get rid of the word safety”. Having just done a presentation on the new “Safety II” concepts, this was not a shock to me. Hollnagel is a critic of the typical safety program focus on negative events and reacting to conditions and behaviors after they affect outcomes. The Safety II approach calls for a proactive emphasis on improving system performance.
A lot of the activities initiated in response the Institute of Medicine report in 1999 included citing the number of deaths due to medical errors and creating new policies on patient safety. Unfortunately, at the time; the word “error” was immediately associated with punishment, “safety” was primarily associated with falls and incident reporting programs were part of the malpractice risk management program. Not surprisingly one of the main obstacles was the natural defensiveness and denial that occurs when someone is told they are part of a group responsible for 98,000 deaths per year. With Safety II, there is a more positive emphasis on behaviors that can improve current systems. So maybe it is time to focus less on errors?
Regarding the use of the word “safety”, anyone who has sought budget and full-time employee resources for safety programs knows these financial requests are prioritized below requests for operational initiatives that are designed to increase “production”. Also, anyone who does many Root Cause Analyses (RCAs) eventually learns that the causes of almost all events can be traced to the culture of the organization. My experience has been that a well-managed organization will usually be safer, more cost effective and have better morale. These organizations don’t rely on a Chief Morale Officer or a large Safety department. Safety, cost effectiveness and morale are all outcomes of a learning organization. In other words, we should stop focusing on errors and adding safety program requirements and instead concentrate on continuously improving system performance.
What do you think?

Applications of High Reliability Organization Methods to Improve Patient Safety
The Agency for Healthcare Research and Quality (AHRQ) has published operational advice for hospital leaders on becoming a high reliability organization.1 The Joint Commission has also identified steps needed for healthcare to move to high reliability.2 Some healthcare organizations that have embraced the high reliability organization (HRO) principles have reported significant reductions in serious safety events.3 Others have even attained goals of zero incidence of certain hospital acquired conditions.4 While these successes are commendable, they are not the norm. Many organizations have still not embraced a goal of zero for harm events.
Industries that have successfully produced HROs typically build their programs with the understanding that errors are normal daily occurrences that should be expected and factored into processes. Major programs must be designed so that human errors are tolerated. The underlying attitude should be that mistakes are inevitable but harm is preventable. This allows the emphasis to shift from individual accountability and punishment to process improvement.
Although much progress has been made in healthcare using basic HRO practices such as checklists, timeouts, barcoding and Root Cause Analysis, the Joint Commission reports that the cultural changes necessary to truly reach high reliability remain out of reach for many organizations.5 Many leaders still have not recognized that open communications, especially those associated with reporting potential safety incidents, are absolutely required for the HRO safety culture. The engine that drives and maintains a strong safety culture is a low-threshold reporting program. The communication of concerns, followed by feedback from leadership about corrective actions taken, creates the organizational learning and continuous improvement environment essential for a culture of safety. Also, lowering the reporting threshold and focusing on minor issues or good-catches shifts the entire organizational focus to a more proactive position. HROs emphasize reporting of the precursor conditions to more serious events in order to obtain leading indicators of risks versus using the lagging data collected after events have already occurred.
The barriers to creating a strong culture of safety are not small. In many cases, creating a culture of safety requires actions contrary to normal human nature. For example, we ask that errors be self-reported when humans naturally hide their weaknesses and imperfections. We ask for extreme attention to detail and formal communications when humans naturally scan the broader picture and use acronyms and slang in communications. Changing organizational outcomes requires a change in the team behaviors. Behaviors are governed by beliefs, and beliefs come from an individual’s training and personal experiences. Therefore, to create the desired behavior changes that are key to a strong safety culture, leaders may need to change current beliefs. In summary, leaders must build a culture that values open reporting, builds trust and drives for continuous process improvement. Achieving these behaviors will enable healthcare organizations to become true HROs.
After the human behavior and cultural challenges have been incorporated into improvement efforts there will still be plenty of opportunities to make even more progress. A few organizations, such as the Children’s Hospitals’ Solutions for Patient Safety (SPS Network), have become advocates for greater transparency and are reporting their event trends on their external (public) website. The SPS Networks Hospital-Acquired-Conditions and readmissions rates are continuously updated and visible to all stakeholders.6 This approach has been very successful for the SPS network and is a key factor in moving healthcare quality and safety to the next level. In his new book, Marty Makary proposes that healthcare must abandon the code of silence, embrace public reporting and support a high level of transparency because “transparency has the power not just to improve the experience of patients but to transform the business of healthcare in America”.7
In conclusion, it appears healthcare is gradually transforming into an industry of High Reliability Organizations. Progress was slow in the early years, due an overemphasis on human error. However, today we have begun to focus more on human behaviors and building a culture of safety. Further advances and higher levels of performance will be possible as we attain higher levels of transparency.
REFERENCES

1. Hines S, Luna, K, Lofthus J, et al. Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. (Prepared by the Lewin Group under Contract No. 290-04-0011.) AHRQ Publication No. 08-0022. Rockville, MD: Agency for Healthcare Research and Quality. April 2008.
2. Chassin M, Loeb J. High-Reliability Health Care: Getting There from Here. The Milbank Quarterly, Vol. 91, No. 3, 2013 (pp. 459–490)
3. Reida L. Learning from Safety Events: Vidant Health. Presented at the NPSF Patient Safety Congress, May 2014
4. Stokes C. Creating a Culture of Safety: Tactical Strategies for Senior Leaders. Presented at the NPSF Patient Safety Congress. May, 2017
5. The Joint Commission. Sentinel Event Alert, Issue 57: The essential role of leadership in developing a safety culture. March 2017, https://www.joint commission.org/assets/1/18/SEA_57_Safety_Culture_Leadership_0317.pdf (accessed September 21, 2017)
6. Children’s Hospitals Solutions for Patient Safety, www.solutionsforpatientsafety.org (accessed September 21, 2017)
7. Makary M. Unaccountable – What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care, Bloomsbury Press 2012.

The Agency for Healthcare Research and Quality (AHRQ) has published operational advice for hospital leaders on becoming a high reliability organization.[1] The Joint Commission has also identified steps needed for healthcare to move to high reliability.[2] Some healthcare organizations that have embraced the high reliability organization (HRO) principles have reported significant reductions in serious safety events.[3]
Others have even attained goals of zero incidence of certain hospital acquired conditions.[4] While these successes are commendable, they are not the norm. Many organizations have still not embraced a goal of zero for harm events.
Industries that have successfully produced HROs typically build their programs with the understanding that errors are normal daily occurrences that should be expected and factored into processes. Major programs must be designed so that human errors are tolerated. The underlying attitude should be that mistakes are inevitable but harm is preventable. This allows the emphasis to shift from individual accountability and punishment to process improvement.
Although much progress has been made in healthcare using basic HRO practices such as checklists, timeouts, barcoding and Root Cause Analysis, the Joint Commission reports that the cultural changes necessary to truly reach high reliability remain out of reach for many organizations.[5] Many leaders still have not recognized that open communications, especially those associated with reporting potential safety incidents, are absolutely required for the HRO safety culture. The engine that drives and maintains a strong safety culture is a low-threshold reporting program. The communication of concerns, followed by feedback from leadership about corrective actions taken, creates the organizational learning and continuous improvement environment essential for a culture of safety. Also, lowering the reporting threshold and focusing on minor issues or good-catches shifts the entire organizational focus to a more proactive position. HROs emphasize reporting of the precursor conditions to more serious events in order to obtain leading indicators of risks versus using the lagging data collected after events have already occurred.
The barriers to creating a strong culture of safety are not small. In many cases, creating a culture of safety requires actions contrary to normal human nature. For example, we ask that errors be self-reported when humans naturally hide their weaknesses and imperfections. We ask for extreme attention to detail and formal communications when humans naturally scan the broader picture and use acronyms and slang in communications. Changing organizational outcomes requires a change in the team behaviors. Behaviors are governed by beliefs, and beliefs come from an individual’s training and personal experiences. Therefore, to create the desired behavior changes that are key to a strong safety culture, leaders may need to change current beliefs. In summary, leaders must build a culture that values open reporting, builds trust and drives for continuous process improvement. Achieving these behaviors will enable healthcare organizations to become true HROs.
After the human behavior and cultural challenges have been incorporated into improvement efforts there will still be plenty of opportunities to make even more progress. A few organizations, such as the Children’s Hospitals’ Solutions for Patient Safety (SPS Network), have become advocates for greater transparency and are reporting their event trends on their external (public) website. The SPS Networks Hospital-Acquired-Conditions and readmissions rates are continuously updated and visible to all stakeholders.[6] This approach has been very successful for the SPS network and is a key factor in moving healthcare quality and safety to the next level. In his new book, Makary proposes that healthcare must abandon the code of silence, embrace public reporting and support a high level of transparency because “transparency has the power not just to improve the experience of patients but to transform the business of healthcare in America”.[7]
In conclusion, it appears healthcare is gradually transforming into an industry of High Reliability Organizations. Progress was slow in the early years, due an overemphasis on human error. However, today we have begun to focus more on human behaviors and building a culture of safety. Further advances and higher levels of performance will be possible as we attain higher levels of transparency.
REFERENCES

1. Hines S, Luna, K, Lofthus J, et al. Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. (Prepared by the Lewin Group under Contract No. 290-04-0011.) AHRQ Publication No. 08-0022. Rockville, MD: Agency for Healthcare Research and Quality. April 2008.
2. Chassin M, Loeb J. High-Reliability Health Care: Getting There from Here. The Milbank Quarterly, Vol. 91, No. 3, 2013 (pp. 459–490)
3. Reida L. Learning from Safety Events: Vidant Health. Presented at the NPSF Patient Safety Congress, May 2014
4. Stokes C. Creating a Culture of Safety: Tactical Strategies for Senior Leaders. Presented at the NPSF Patient Safety Congress. May, 2017
5. The Joint Commission. Sentinel Event Alert, Issue 57: The essential role of leadership in developing a safety culture. March 2017, https://www.joint commission.org/assets/1/18/SEA_57_Safety_Culture_Leadership_0317.pdf (accessed September 21, 2017)
6. Children’s Hospitals Solutions for Patient Safety, www.solutionsforpatientsafety.org (accessed September 21, 2017)
7. Makary M. Unaccountable – What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care, Bloomsbury Press 2012

Howard Bergendahl presented “Patient Safety: Lessons Learned from the Nuclear Power Industry” and led the Ohio Panel on Patient Safety at the May 8, 2013 Health Policy Institute of Ohio Health Innovations 2013 conference, Columbus, Ohio. See more at Health Policy Ohio/Events. View the powerpoint presentation.

Howard Bergendahl gave a presentation entitled “Getting Through the Day Event Free, The Challenges of Today’s Therapists” at the Penn Medicine Department of Radiation Oncology, 2^nd Annual Radiation Therapy Continuing Education Day for Radiation Therapy Professionals – Dec. 2012.