High Reliability Healthcare

The ultimate goal for healthcare providers is zero harm to patients, families and the workforce. In order to achieve and maintain this in the long-run, you have to learn how to walk before you can run.

Patient safety expert, Dr. Michael Shabot, offers healthcare leaders the foundational tools to measure, build and sustain a culture of safety in the workplace.

ASA/ACHE Podcast on Establishing a Patient Safety Culture

(Click here for link to podcast)

Brought to you by the American Society of Anesthesiologist and the American College of Healthcare Executives


  • Jane Easdown MDCM, MHPE
    Professor of Anesthesiology
    Vanderbilt University Medical Center
  • M. Michael Shabot, MD
    Executive VP & System Chief Clinical Officer
    Memorial Hermann Health System
  • Butch Uejima, MD, MMM, FAAP, CPHRM
    Chief Medical Officer
    Chairman, Dept of Pediatric Anesthesiology and Perioperative Medicine
    Nemours/AI duPont Hospital for Children
    Professor of Anesthesiology and Pediatrics
    Sidney Kimmel Medical College
    of Thomas Jefferson University

In collaboration with ASA and ACHE, this podcast discusses leadership’s role in establishing a patient safety culture that extends beyond a grassroots conversation. Adoption of high-reliability safety by senior leadership and board members is an absolute requirement for success. Patient safety culture must be clearly supported as a key mission by the governing board. The 25-minute Q&A-format discussion provides perspectives from clinical and administrative viewpoints.

Why Safety and Quality Depend on Equity–and Vice Versa

How can safety and quality care in our healthcare institutions depend upon equity?

It has long been true that every patient deserves safe and high-quality care, but today’s diverse population demands that we focus now on eliminating healthcare disparities in our institutions, according to Jack Lynch, FACHE, president and CEO of Main Line Health (MLH), Bryn Mawr, PA, in a recent article in the Journal of Healthcare Management (J Healthc Manag. 2017 Sep/Oct;62(5):298-301).

What is the connection between equity and the delivery of safe and quality care? Past research has demonstrated a simple fact accepted by healthcare leaders today: patients identifying as racial minorities or LGBQT face increased risk for adverse safety events in our healthcare system. With our population rapidly diversifying—according to the US Census Bureau (2017), minorities will make up 54% of the American population by 2050—we must commit now to an unequivocal pledge of safety and quality care for every patient. Falling short of this, we will risk providing suboptimal care for fully one of every two patients who seek our assistance.

According to Lynch, the pledge to achieve equity at MLH is built on three mandates:

  • Commitment to the STEEEP principles (to deliver care that is Safe, Timely, Efficient, Effective, Equitable and Patient centered)
  • Education for cultural competence
  • Organizational culture that rewards employees who take a stand for safety

“As healthcare leaders, we must address disparities in care with the same intensity and passion with which we have unequivocally embraced patient safety and quality,” Lynch says.

Unmistakably STEEP

One patient at a time—that’s how they meet the challenge at MLH, according to Lynch. While inequities in the country’s healthcare system lead to disparities in patient care, healthcare leaders cannot and should not consider this problem insurmountable, in Lynch’s view. By adopting the National Academy of Medicine’s STEEEP principles and holding all employees accountable for ensuring that each patient receives care that is safe, timely, efficient, effective, equitable and patient centered, MLH is committing to achieve their vision of equitable care for all by 2020.

Culturally correct

When ethnic disparities in patient safety occur, often they can be traced to a lack of cultural competence—a blend of cultural knowledge, attitudes, skills and resources—on the part of the healthcare providers (Suurmond, Uiters, de Bruijne, Stronks, & Essink-Bot, 2010, p.S116). Healthcare leaders today have a moral and financial imperative to invest in cultural competence education for their staff.

AT MLH, managers participate in a Diversity, Respect and Inclusion workshop over 2 days; the hospital intends to roll out similar training to all staff in 2019. In his article, Lynch mentions several national organizations that can help healthcare organizations improve their teams’ cultural competency. One such resource is the ACHE’s Leading a Culture of Safety: A Blueprint for Success, which helps leaders build a safety culture grounded in trust, respect and inclusion.

 Speaking up for safety

“At MLH, we have worked diligently to create a culture in which everyone feels empowered and encouraged to speak up for safety and ‘have each other’s back,’” says Lynch, though he shares that the organization, like others, has much work to do. Such an environment is an essential precondition for patient safety. Human error is unavoidable in healthcare, as everywhere. For this reason, healthcare leaders must cultivate a culture of respect and trust, where staff members feel empowered and emboldened to admit to, to report, and to stand up to impending error.

“If we can establish trust and respect in our organizations, we can then be sure every healthcare worker will be that much more committed and sensitive to providing compassion, respect, and an equitable experience to every individual who gives us the privilege to serve and care for them,” promises Lynch.

Jack Lynch was a key speaker at the 2018 Congress on Healthcare Leadership, which just wrapped up in Chicago. Join us as we lead with intent, lead for safety and lead toward zero harm.

How To Lead For Safety

There is nothing more important for healthcare providers than ensuring the safety of their patients and workforce. And, ACHE is committed to catalyzing healthcare leaders around safety.

We contacted three of our nation’s leading safety experts,  Tejal K. Gandhi, MD, CPPS, Chief Clinical and Safety Officer at Institute for Healthcare Improvement and President of its NPSF Lucian Leape Institute; John “Jack” Lynch III, FACHE, President/CEO of Main Line Health; and Doug Salvador, MD, Vice President of Medical Affairs at Baystate Health.  Each of them emphasized that the journey to a zero-harm environment begins with creating a safety culture.

“A culture of safety is the foundation for all work, from day-to-day operations and care to improvement initiatives in safety and beyond,” offers Gandhi.

But, culture often remains unchallenged because it’s seen as the way things have always been. According to Salvador, there is a mountain of evidence linking disrespectful and dismissive behavior by healthcare providers to the harm of patients. For this to change, Lynch stresses that there can be no compromise on quality of care and patient safety. It must be “embedded as a non-negotiable,” a core value for all healthcare organizations.

How To Get Started

“The most important first step is to measure the safety culture in your organization using a validated safety culture survey instrument,” says Salvador. This includes leadership, communication and interactions right at the front lines. Often, this is where cultural issues exist but are never talked about.

Gandhi points out that it is nearly impossible to sustain improvement without a clear vision for the future. Leaders should set the vision and model aligning behaviors to demonstrate an expectation of trust and respect across all levels of an organization. Lynch agrees. For an organization to lead for a culture of safety, it must also “ensure a supportive, inclusive and respectful environment so that each member speaks up for safety … and feels empowered to do so.”

ACHE, in partnership with the IHI/NPSF Lucian Leape Institute, launched Leading a Culture of Safety:  A Blueprint for Success, including an organizational self-assessment and best practices to help healthcare leaders build a sustainable culture of safety.  “Though creating a culture of safety is not easy, our new tool, provides a framework for leading an organization toward the ultimate goal of zero harm,” says Gandhi.

Common Obstacles Faced By Organizations

Lynch reminds healthcare leaders to expect challenges—and embrace them. These are essential to discovering an organization’s strengths and weaknesses, and how to make necessary improvements.  He suggests, “Leaders must be relied upon by all levels of staff … to address changes when they need to be made,” especially when focused on error prevention and safety.

It’s also important to remember changing organizational culture is an “ongoing journey,” indicates Gandhi. Salvador suggests leading these shifts in culture can be “extremely hard and often lonely.”  He emphasizes that support for creating a culture of safety has to come from the top because “setting new expectations for safe behaviors will be met with push-back from powerful places.”

Learn More About How To Lead For Safety

ACHE is committed to supporting the Leading for Safety journey for all healthcare leaders.  As a result, it is offering a variety of learning opportunities, including:

How Leaders Can Engage & Make Organizations Safer Across the Care Continuum

Recently, the National Patient Safety Foundation released its report, “Free from Harm: Accelerating Patient Safety Improvement Fifteen Years After To Err is Human” which offers eight recommendations to lead to patient safety. A decade-and-a-half after the Institute of Medicine initially brought to the public’s attention the issue of medical errors, the NPSF is partnering with ACHE to urge healthcare executives to take a pledge to commit to creating a culture of safety for patients and providers.

Following this recent report, Tejal Gandhi, MD, NPSF’s president and CEO, breaks down how “there’s a variety of ways that executives can make their organizations safe for patients and providers… our report really highlights different strategies that organizations can take to drive towards that goal of safety.”

Leaders drive the culture in healthcare organizations

“One of the biggest messages from our report is really that leaders in organizations drive the culture in organizations,” explains Gandhi, “And we need to create a culture of safety in organizations where safety is a top priority.” For her, some indications of a healthy culture of safety mean creating a workplace environment where both clinicians and patients “feel comfortable” being vocal about any issues or concerns. But beyond being able to speak up, it’s crucial that they “feel that those concerns are being listened to and lead to actual improvements.”

“There are lots of ways for executives to measure this culture,” says Ghandi. In partnership with NPSF, the ACHE’s Patient Safety Self-Assessment allows executives to honestly analyze their current safety measures then prioritize targeted areas of improvement to implement a culture of safety, building from the six fundamental domains outlined in “Leading a Culture of Safety: A Blueprint for Success.” 

By identifying and developing “interventions,” Ghandi says leaders can then “try to create that culture, but it really has to come from the Board to the C-suites all through the organization. Our expert panel felt that creating this culture change was critical.”

Safety extends across the care continuum

The patient experience extends beyond an intake center or an imaging lab. It can involve follow-up appointments, outpatient treatment, testing and so on, and Ghandi says healthcare leaders need to be thinking about delivering “safety across the entire care continuum.” She says, “as organizations are now becoming much more widespread and have facilities outside of hospitals, safety needs to be part of the conversation regardless of the setting.” In order to implement change across the board, having an up-to-date and clear understanding of current safety practices in every setting is a must in order to create a cultural shift in a proud, meaningful way that the patient and clinician can feel regardless of the site.

Why implementing workforce safety matters too

“We think workforce safety is actually a pre-condition of patient safety,” Ghandi explains. In working towards zero medical errors, healthcare leaders should not forget the importance of the safety of their own workforce too. This sets the tone, impacts clinicians’ mood, productivity and comfort levels, and has a residual effect on the ability to deliver the best care.

“Executives need to really focus on the safety of their workforce from a physical standpoint and a psychological standpoint,” says Ghandi, who adds that this can include mindfulness of issues like “burnout, stress, disruptive and bullying behavior…as well as the physical harms, workplace violence, etcetera, [they] need to be at the top of the attention of boards and senior leadership.”

To create a culture of safety, start by engaging patients at all levels

One of the report’s most significant takeaways is the essential need for leadership to value patient’s opinions, needs and concerns, and to engage with and learn from the real “users” of healthcare systems.

Ghandi says this means “really ensuring that patients are truly partners in their care, and having patients and the patient voice throughout the organization.”

This involvement can take different shapes and forms including most basically, shared decision-making between providers and patients.

“At the organizational level,” Ghandi stresses the significance of “having patients on boards, on quality committees, on quality improvement projects and even on things like root-cause analysis.” Overall, she believes that in order to create a culture of safety, “it’s really critical to have that patient partnership in all activities of your organization.”

ACHE’s John Buell interviewed Tejal Gandhi, MD, president and CEO, National Patient Safety Foundation, to learn healthcare executives can make organizations a safer place for clinicians to practice and patients to receive care.

Webinar on Leading A Culture of Safety

This webinar highlights the partnership between The American College of Healthcare Executives (ACHE) and the IHI/NPSF Lucian Leape Institute (IHI/NPSF LLI) and its commitment to helping healthcare leaders adopt best practices for building and sustaining a culture of safety. Learning objectives include:

  • Learn best practices for building and sustaining a culture of safety from leaders at exemplary organizations.
  • Discuss strategies that can drive culture change in health care.
  • Learn how the partnership between ACHE and IHI/NPSF LLI is spearheading the discovery of leadership practices, informed by a series of roundtables.

Speakers include:
Deborah Bowen, FACHE, CAE

Former Chair, IHI/NPSF LLI
Chairman and CEO, Virginia Mason Health System

Charles (Chuck) D. Stokes, RN, BSN, FACHE
Chairman, ACHE
President & CEO, EVP & Chief Operating Officer, Memorial Hermann Health System

Tejal K. Gandhi, MD, MPH, CPPS
Chief Clinical and Safety Officer, IHI/NPSF LLI

View Webinar