Achieving Zero Harm in High Reliability Healthcare

"Zero harm should be the natural byproduct of the care we provide every day." Mark Chassin, MD, President and CEO, The Joint Commission (High Reliability in Healthcare, 2020)

1. Achieving Zero Harm in High Reliability Healthcare

Organizations that operate in complex, high-hazard domains for extended periods without serious accidents or catastrophic failure are called High Reliability Organizations (HRO). Aviation adopted the principles of high reliability and has seen a steady decline in airline accidents since 1997. The airline industry, like healthcare, does complex, high-stakes work where mistakes can cause great harm. Many hospitals today are embracing the values of HROs, whose systems make them extraordinarily consistent in accomplishing goals and avoiding potentially catastrophic events.

Zero harm in healthcare is the holy grail we are all striving for, which is why the concept of high reliability is so attractive. The principles of high reliability go beyond standardization; high reliability is a kind of "collective mindfulness" in which all workers look for and report small problems or unsafe conditions before they pose a risk to an organization. HROs cultivate resilience by relentlessly prioritizing safety over other performance pressures. Staff have the authority to make real-time adjustments to maintain safe operations.

HROs use systems thinking to design systems and processes for safety while being aware that new threats are constantly emerging. They anticipate potential problems, detect them early, and respond quickly to prevent catastrophic consequences.

Five characteristics shape this way of thinking:

• preoccupation with failure (i.e., viewing near misses as opportunities for improvement)
• reluctance to simplify explanations of operations, successes, and failures (i.e., accepting that work is complex, with the potential to fail in new and unexpected ways)
• sensitivity to operations (i.e., situation awareness)
• deference to frontline expertise (i.e., valuing insights from staff with relevant expertise over those with greater seniority)
• commitment to resilience (i.e., prioritizing emergency training for many unlikely, but possible, system failures)

The Joint Commission suggests that healthcare organizations and hospitals create a strong foundation before they can elevate to an HRO. The foundational building blocks include developing a strong commitment within leadership to achieving zero harm, establishing a positive safety culture, and empowering a workforce to use robust process-improvement methods to drive significant and sustainable change.

Zero harm is an achievable goal. Take the case of an organization that went over five years without a retained foreign object and over 12 months without zero central line infections.

High reliability is an approach that has been effective in other similar industries, such as aviation, and can be a game-changer in healthcare. The sections and modules that follow will delve into the foundational building blocks that organizations need to fully implement before moving to an HRO. Implementation of safety culture, the cornerstone of an HRO, is the first priority.

Authored by Cindy Ebner, MSN, RN, CPHRM, FASHRM

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