Healthcare needs more than quality management. We need a new scientific standard for high reliability

This article is adapted from The Leaders Guide to Managing Risk: A Proven Method to Build Resilience and Reliability (HarperCollins Leadership, 2023)
In the mid-twentieth century, Edwards Deming taught the world a better business strategy: Improving quality reduced expenses and increased productivity and market share. Like a Navy SEAL team working to the mantra “slow is smooth; smooth is fast,” he showed automobile manufacturers how to pay attention to systems, processes, and people in a way that balanced productivity and cost. Quality methods guided organizations to document, monitor, and measure, which produced superior results.

Other industries have adopted his methods and improved their reliability, but healthcare is not among them, for good reasons. After all, you’re not going to install carmakers’ stop-the-conveyor-belt cords in surgical suites and ICUs. When a severely injured or sick patient arrives at an emergency room, the hospital doesn’t have the option of assembling a team of quality control experts. In several ways, hospitals are more complex than most other industries. They have tens of thousands of points of delivery; moving targets of unavoidable risk such as mutating antibiotic resistant microbes; an excess of regulatory agencies siloed by specialties; and a necessary but risky reliance on human-centric delivery.

With these challenges, it’s no surprise that healthcare has not matched the engineering-based auto industry’s success. One-and-done training; blame and shame cultures that threaten the loss of employment, license, and livelihood; individual certifications without proficiency evaluations and consistent follow-ups; and an array of unaligned or even misaligned activities will not yield consistent outcomes. Instead, healthcare needs consistent definitions and standards. We need answers to the questions: What is high reliability? What is just culture? Without them, organizations will struggle to achieve and replicate results.

Simply borrowing from other industries and hoping for the best won’t work. We need a better business model to guide us: a standard based on science that’s evidence-based and evidence-producing, one that’s easy to understand and can be employed in a variety of settings, and manages risk in a dynamic, ever-changing world. Most important, we need to establish cultures that live up to the promises of psychological safety for all employees, contractors, physicians, and advanced-practice providers ‒ we need documented, auditable programs and systems that ensure collaborative, just responses when risk is reported.

Simply put, high reliability is sustained performance over time. The scientific way to accomplish this is not to focus on outcomes, but to see the underlying and often hidden forces that contribute to both good and bad outcomes. Successful organizations are good at measuring outcomes, but few measure and manage the risk factors that contribute to bad outcomes. This makes them vulnerable.

In my new book, The Leaders Guide to Managing Risk: A Proven Method to Build Resilience and Reliability (HarperCollins Leadership 2023), I explain how hospitals can identify in advance the predictable patterns that cause crises, and I share the foolproof strategy for reliability. The “Sequence of Reliability” is a simple, straightforward strategy that works for any endeavor—from crashes and pandemics to avoiding medical mistakes, to improving workforce morale, to achieving better results in our everyday lives. This sequence can make you consistently reliable over time and allow you to adapt to any risk while working with a diverse array of people and resources. There are two steps in the Sequence of Reliability:
1. See and understand risk. Seeing risk means having vision. Understanding risk means knowing why and how it harms us. We must recognize how the risk is perceived by individuals, teams, and the organization at large.
2. Manage reliability in this order:
a. Systems (to become effective and resilient)
b. Humans (human performance and human behavior)
c. Organizations (achieve sustainment and become predictive)

The Leader’s Guide to Managing Risk dives deeply into the Sequence of Reliability. Through a progression of logical building blocks, the book makes complex socio-technical principles easy to understand so hospitals and the entire healthcare industry can reduce risk and achieve better results: financial, operational, and customer-facing.

To become reliable, an organization must have four key elements: 1) executive commitment to achieving and sustaining operational reliability; 2) a culture that supports risk identification and reporting; 3) alignment between all high-reliability attributes of the enterprise (customer service, safety, quality, privacy, operational integrity, financial responsibility and equity); and 4) a standard for high reliability that defines it in scientific, measurable terms, against which an organization’s status can be independently audited and verified.

In the book I describe a new standard known as Collaborative High Reliability® and its first building block, the Collaborative Just Culture® program, which I evolved over decades of work in high-consequence industries – including aviation, railroads, emergency medical services, firefighting, law enforcement, and energy. But now healthcare is leading the way. The main building blocks of this evidence-based approach are:
• A voluntary reporting program comprising management, employees, unions, and regulators that encourages reporting risks without fear of losing your job or accreditation. This collaborative approach to finding solutions rather than assigning blame is exemplified by the U.S. airline industry's highly successful Aviation Safety Action Program, which has been a dominant contributor to the 95% reduction the fatal accident rate over the past three decades.
• Combining engineering and behavioral sciences with legal and ethical systems of justice to guide human resources departments and professional boards to a more consistent response to human behaviors.
• Following ISO 9001 and quality management principles that require organizations to “document, monitor, and measure” what works.
• Most important, aligning all activities into a reliability management system, eliminating what doesn’t work and developing processes, programs, and systems into an integrated whole.

A key component of this success is independent assessment by a third-party accreditation body required to achieve qualification standards on a two-year, periodic schedule. DNV Healthcare is licensed as the independent, third-party auditor of the Collaborative High Reliability standards.

The time for guessing what works and what doesn’t should be over. The healthcare industry should represent the best that we have to offer, from medicine to engineering to behavioral science, along with the ethical attributes of diversity, equity, and inclusion. It’s time to adopt a scientific approach that works and discard activities that don’t. It’s time for a new standard.

K. Scott Griffith is the author of “The Leaders Guide to Managing Risk: A Proven Method to Build Resilience and Reliability” (HarperCollins Leadership 2023) and the founder and managing partner of SG Collaborative Solutions, LLC (sgcpartners.com), developers of the first Collaborative High Reliability® and Collaborative Just Culture® standards, independently audited by DNV Healthcare, a global accreditation organization. He is a socio-technical physicist and former international airline captain and chief safety officer at American Airlines. Griffith is widely recognized as the father of the airline industry’s landmark Aviation Safety Action Program.