The Role of High Reliability Organization Foundational Practices in Building a Culture of Safety
Background: High reliability organizations are designed to operate under complex conditions for extended periods by strengthening systems that help serious adverse events for patients. The US Department of Veterans Affairs formally began its enterprise-wide journey to high reliability in 2019. Four foundational practices were identified to advance a culture of safety across all Veterans Health Administration facilities. This article describes these practices, summarizes supporting evidence from the literature, and illustrates strong practices for improving safety.
Observations: A literature review was conducted from 2018 to March 2023 to identify recent evidence outlining the value of implementing the 4 foundational high reliability organization practices to improve patient safety. This evidence was used to create and implement formal processes for the foundational practices. For each foundational practice, a representative example of a strong practice within the Veterans Health Administration is provided.
Conclusions: Effective and sustained application of the foundational organization practices described can support a health care organization’s journey to high reliability. Collectively, the 4 foundational practices can be adopted and implemented by other organizations in the continued pursuit of high reliability in health care.
Visual Management Systems
A visual management system (VMS) displays clinical and operational performance aligned with HRO goals and practices. It is used to view and guide discussions between interdisciplinary teams during tiered safety huddles, leader rounds for high reliability, and frontline staff on the current status and safety trends in a particular area.8,9 A VMS is highly effective in creating an environment where all staff members, especially frontline workers, feel empowered to voice their concerns related to safety or to identify improvement opportunities.8,10 Increased leader engagement in patient safety and heightened transparency of information associated with the use of a VMS improves staff morale and professional satisfaction.10
A VMS may be a dry-erase or whiteboard display, paper-based display, or electronic status board.8 VMSs are usually located in or near work settings (eg, nurses’ station, staff break room, or conference room).8 Although they can take different forms and display several types of information, a VMS should be easy to update and meet the specific needs of a work area. In the VHA, a VMS displays: (1) essential information for staff members to effectively perform their work; (2) improvement project ideas; (3) current work in progress; (4) tracking of implemented improvement activities; (5) strong practices that have been effective; and (6) staff recognition for those who have enhanced patient safety, including the reporting of close calls and near misses.
The VHA uses the MESS (methods, equipment, staffing, and supplies) VMS format. This format empowers staff to identify whether proper procedures and practices are in place, essential equipment and supplies are readily available in the quantity needed, and appropriate staffing is on hand to provide safe, high-quality patient care.8 Colored magnets are used as visual cues in a stoplight classification system to identify low or no safety risks (green), at risk (yellow), or high risk (red). Green coded issues are addressed locally by a manager or supervisor. Yellow coded concerns require increased staff and leadership vigilance. Red coded issues indicate that patient care would be impacted that day and therefore need to be immediately escalated and addressed with senior leaders to mitigate the threat.4,11 Dayton VAMC successfully implemented a VMS, using both physical and electronic visual management boards. The Dayton VAMC VMS boards are closely tied to tiered safety huddles and leader rounding for high reliability.
Safety Forums
Safety forums are another foundational practice of VHA health care organizations seeking high reliability. Recurring monthly, safety forums focus on reinforcing HRO principles and practices, safety programs, the importance and appreciation of reporting, and just culture. The emphasis on just culture reminds staff that adverse events in the organization are viewed as valuable learning opportunities to understand the factors leading to the situation as opposed to immediately assigning blame.12
Psychological safety is another important focus. When individuals feel psychologically safe, they are more likely to voice concerns and act without fear of reprisal, which supports a culture of safety.13 Safety forums are open to all members of the health care organization, including both clinical and nonclinical staff. Forums can be conducted by an HRO Lead, HRO Champion, Patient Safety Manager, or even executive leadership. Rotating the responsibility of leading these forums demonstrates that high reliability and safety are everyone’s responsibility.
Safety forums publicly review and discuss errors, adverse events, close calls, and near misses. Time is also spent discussing root cause analysis trends and highlighting continuous process improvement principles and current projects. During safety forums, leaders should recognize individuals for safety behaviors and reward reporting through a safety awards program.14 All forums should conclude with a question-and-answer session. Forums typically occur in virtual 30-minute sessionsbut can last up to 60 minutes when guest speakers attend and continuing education credit is offered.
The Jesse Brown VAMC in Chicago developed an interactive monthly safety forum appealing to a broad audience. Each forum is attended by about 200 staff members and includes leader engagement and panel discussions led by the chief medical officer, with topics on both patient and team safety connecting with HRO principles. A planning committee prepares guest speakers and offers continuing education credits.
