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.
Implementing Foundational Practices
To examine the progress of the implementation of the 4 foundational HRO practices, quarterly metrics derived from the OLT are reviewed to determine whether each is being implemented and sustained. The OLT also tracks progress over time. For example, at the 27 cohort 2 and lead sites that initiated leader coaching in 2021 and continued through 2022, coaches observed a 27% increase in leader rounding for high reliability and a 46% increase in the use of VMSs. For the 66 cohort 3 sites that began leader coaching in 2022, coaches documented similar changes, ranging from a 40% increase in leader rounding for high reliability to a 66% increase in the use of safety forums. Additional data continue to be collected and analyzed to publish more comprehensive findings.
DISCUSSION
Incorporating leader rounding for high reliability, VMSs, safety forums, and tiered safety huddles into daily operations is critical to building and sustaining a robust culture of safety.8 The 4 foundational HRO practices are instrumental in providing psychologically safe forums for staff to share concerns and actively participate. These practices also promote continual, efficient bidirectional communication throughout organizational lines and across services. The increased visibility and transparency of leaders demonstrate the importance of fostering trust, enhancing closed-loop communication with issues that arise, and building momentum to achieve high reliability. The interconnectedness of the foundational HRO practices identified and implemented by the VHA helps foster teamwork and collaboration built on trust, respect, enthusiasm for improvement, and the delivery of exceptional patient care.
CONCLUSIONS
Incorporating the 4 foundational practices into daily operations is beneficial to the delivery of safe, high-quality health care. This effective and sustained application can strengthen a health care organization on its journey to high reliability and establishing a culture of safety. To be effective, these foundational practices should be personalized to support the unique circumstances of every health care environment. While the exact methodology by which organizations implement these practices may differ, they will help organizations approach patient safety in a more transparent and thoughtful manner.
Acknowledgments
The authors thank Aaron M. Sawyer, PhD, PMP, and Jessica Fankhauser, MA, for their unwavering administrative support, and Jeff Wright for exceptional graphic design support.
