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Letter from the Chair

Jeffrey J. Pothof, MD, FACEP

Jeffrey PothofWhat exactly is reliability? Is it showing up for work on time? Is it making sure the mortgage payment is made every month or that our children have a ride home from school?

Thomas Nolan, senior fellow at the Institute for Healthcare Improvement defined reliability as “failure free operation over time, from the point of view of the patient.”1 For those of you who enjoy formulas, it looks like this:
Number of actions that achieve the desired result

Reliability = _________________________________________________________
                                                                  Total number of actions taken

Medicine frequently looks to other industries to gauge how well we perform compared to the standouts such as the airline industry or nuclear power plants. In the 2016 ICAO safety report2 the airline industry logged 2.8 accidents per 1 million departures. Looking solely at fatal flights, there were 6 fatal flights over 33 million departures. In comparison, numerous studies have pegged healthcare as logging one adverse event for every 10 to 20 encounters.3,4 Although the numbers published vary, medical errors are the cause of 44,000 to 400,000 preventable deaths annually.5,6

It seems paradoxical that healthcare providers, some committing a fair portion of their lives learning the knowledge and skills needed to save people’s lives, belong to one of the least safe industries. Clearly these are not intentional acts or bad people, but why this disconnect?
What do those organizations that receive the “ultra-safe” moniker have in common? They adhere and practice a set of guiding principles that allow them to be highly reliable. These 5 principles are7:

  1. Preoccupation with Failure – everyone is focused on what might not be going right before it goes wrong. Staff is praised for bringing forward near misses so the system can be improved. No one is scared they will be punished for speaking up. They have a “just culture”.
  2. Reluctance to Simplify – It’s easy and comforting to offer a simple explanation for a complex problem, but frequently this leads to false re-assurance. Highly reliable organization keep asking “why” to get to the root of the problem and challenge long held beliefs.
  3. Sensitivity to Operations – Healthcare is complex and intricate. High reliability comes from all members of the team understanding and knowing the intricacies of the work and the moment to moment changes. Transparency is valued. Leaders interact with the front line to gain first-hand knowledge of the work being done.
  4. Commitment to Resilience – Individuals in high reliability organizations are committed to staying on course. Despite setbacks they improve while keeping their eye on the goal. They understand why they do the work they do and how it contributes to safety and performance.
  5. Deference to Expertise – Expertise is not defined by the floor your office is on or the letters after your name. Highly reliable organizations listen to the people who have the most developed knowledge of the task or issue at hand. In a complex system no one can know everything, utilize those closest to the problem so you can best understand it.

Highly reliable organizations also strive to reduce variation. They know the human mind is fallible and create tools such as checklists to ensure repeatable standardization.
I’m certain you can think of instances where these principles were used in your organization, but also times when greater adherence to these ideals may have benefitted patients. Healthcare has not yet arrived on the high reliability scene. We have a long ways to go. All of us learned physiology, pharmacology, and a multitude of complex skills, yet most of us didn’t learn or were ever taught how to create or function within highly reliable systems. Is it possible the disconnect between our core desire to help others and the reality of patient safety in our healthcare system today is a result of too narrowly focused expectations of our role in the healthcare system? Maybe we need to be the voice that advocates for safer systems. Perhaps more physicians need to be engaged with health system leadership to challenge the status quo. In essence, it may no longer be good enough to just take care of patients at the bedside; we need to also take care of our systems, to imbed these ideas into our environment to ensure we are reliable and our patients safe.

  1. Nolan T, Resar R, Haraden C, Griffin F. Improving the reliability of health care. Innovation Series 2004 Whitepaper, Institute for Healthcare Improvement. Available at: http:// www.ihi.org/IHI/Results/WhitePapers/ImprovingtheReliability ofHealthCare.htm. Accessed August 29, 2016.
  2. International Civil Aviation Organization “ICAO Safety Report” Available online at “http://www.icao.int/safety/Documents/ICAO_SR%202016_final_13July.pdf. Accessed Aug 29, 2016.
  3. Baker GR, Norton PG, Flintoft V, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ. 2004;170(11):1678-86.
  4. Zwaan L, De bruijne M, Wagner C, et al. Patient record review of the incidence, consequences, and causes of diagnostic adverse events. Arch Intern Med. 2010;170(12):1015-21.
  5. Kohn, L. T., Corrigan, J., & Donaldson, M. S. (2000). To err is human: Building a safer health system. Washington, D.C: National Academy Press.
  6. James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013;9(3):122-8.
  7. Weick KE, Sutcliffe KM. Managing the Unexpected, Sustained Performance in a Complex World. John Wiley & Sons; 2015. 


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