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Unifying improvement through the highly reliable human experience

Liz Boehm, Director of Research, Vocera Communications and Director of Vocera’s Experience Innovation Network

Editor’s Note: This blog originally appeared on the Vocera View blog, which focuses on stories about how to make life better for patients and care teams.

Leaders in healthcare are working to make everything better. They boost safety by adopting best practice bundles and asking patients consistently for two forms of ID to make sure the right care is delivered to the right person. They embrace Lean Management principles and do value stream mapping to strip out waste. They work to improve outcomes by designing new care models that cross traditional silos and undertaking population health initiatives that follow a patient proactively beyond the traditional periodic follow up visits. They seek to improve care experience by teaching communication skills and making sure every clinician introduces him/herself and his/her role to the patient to help build relationships.

Despite continuing efforts to make everything better, healthcare organizations still struggle.

One of the biggest challenges in implementing these changes is that much of the responsibility falls to frontline staff, who are already overwhelmed by increasing demands, regulatory requirements, and the inherent stress of caring for patients. These same physicians, nurses, and frontline leaders are now suffering from initiative fatigue in the face of so many change efforts.

Organizations need greater alignment across improvement efforts so that every new care model, process change, and skill-building effort encompasses all aspects of the Quadruple Aim. They need to rationalize and drive alignment from the top, instead of bombarding frontline staff with dozens of single-issue changes.

Five key traits of high reliability organizations

Since the publication of the Institute of Medicine’s seminal report on safety in the U.S. healthcare system, To Err is Human, in 1999, healthcare systems have doubled down on efforts to boost the safety of care delivery. One of the leading approaches, high reliability, comes from industries such as nuclear power, air travel, and the military – all industries with higher than average risk profiles and lower than expected safety events. High reliability organizations (HROs) exhibit five key traits that allow them to manage extreme hazards with exemplary safety:

1. They’re preoccupied with failure. Individuals and teams within HROs are highly attuned to the inherent risks in the work that they are doing and exhibit vigilance around approaches that mitigate risk, as well as the factors that may undermine those approaches.

2. They’re reluctant to simplify. HRO teams do not accept simple explanations (such as individual failure) when safety events occur. Instead, they perform analyses and look at the systems in which team members operate to see the ways in which they encourage or discourage failure. This allows them to solve for root cause and design more reliable systems.

3. They’re sensitive to operations. HRO teams recognize and examine the upstream and downstream connections that influence the process, behavior, and systems within their immediate areas of operations. HROs design across traditional silos to eliminate breakdowns in handoffs or process disparities that lead to inconsistency and failure.

4. They defer to expertise. HROs seek out the people with the greatest expertise when analyzing systems or designing process improvements. Answers don’t come from the top, but from the people closest to and most familiar with the work.

5. They’re committed to resilience. Rather than dwelling on or getting discouraged by failure, HROs commit to continual improvement and the ability to recover from errors.

Within healthcare and other industries, high reliability has typically been aimed first at safety efforts and then at quality outcomes. At the Experience Innovation Network, part of Vocera, we believe these principles apply equally well to the communication, empathy, and respect that drive experience excellence for patients, families, physicians, and staff.  

At its core, high reliability boils down to asking all physicians, nurses, and staff to take a moment to be mindful that they are entering into a high-risk situation. It asks them to think about and apply the tools and safeguards they can use to mitigate these risks. It calls for them to rely on teamwork and leadership to provide backup and reinforcement. To incorporate the human experience, healthcare leaders just have to expand their definitions of risk: 


By expanding the scope of “risk” to include critical aspects of the human experience, healthcare leaders can elevate the importance of human experience principles while also simplifying thought frameworks for physicians, nurses, and staff. Now, frontline team members can apply the same mental model to managing infection risk as they do to providing clear communication. This approach to building a highly reliable human experience ensures that communication, empathy, and respect are integral components of delivering care excellence.

Hospitals leading the way

Leaders at forward-thinking institutions are already blurring the boundaries between quality and safety, and experience excellence:

Hackensack Meridian Health

Prior to the recent merger with Hackensack University Health System, leaders at Meridian Health system in New Jersey began rolling out a program to teach the highly reliable human experience to all of its staff. The focus is on training the high reliability principles, and aiming them at safety, quality, empathy, and respect.

“The idea is that we haven’t succeeded in delivering exceptional care until we’ve delivered on all four aspects,” said Marty Scott, MD, SVP and Co-Chief Quality Officer. “But we also stress that team members should view them in that order. We can’t compromise on safety out of empathy and we can’t neglect empathy because we’re focused on safe care.”

The rollout is moving steadily through the legacy Meridian Health hospitals, and will soon expand across the entire merged system. “Team members are really embracing this,” said Dr. Scott. “We’re really helping them see how everything fits together.

Providence St. Joseph Health (PSJH)

Over the past five years, PSJH has doubled in size and consolidated significantly, heightening their awareness of the need to drive alignment across the system. Their leadership team knew that providing a safe, reliable patient experience started with enabling a positive caregiver and provider experience. They rallied their teams around key concepts including:

  • Simplifying health wherever possible and reasonable
  • A concept of “know me, care for me, ease my way” that applies equally to patients and families as it does to physicians and staff
  • Understanding they can’t be successful focusing on either patients and families or physicians and staff at the expense of the other

The result has been a journey of aligning practices including hiring, training, mentoring, and even fostering innovation around the delivery of a highly reliable human experience.

“People are burnt out,” said Steve Bucaro, Associate Vice President, Organizational Strategy and Design. “They can’t handle another thing on their plate. We are constantly asking, what can we take away?”

They are hopeful in their more integrated approach. “This is the most engaged we’ve seen our medical staff,” said Marly Christenson, PhD, RN, System Director, Patient Safety.

Intermountain Healthcare

Intermountain Healthcare has been on a high reliability journey for more than five years. In addition to training team members and driving alignment across the quality, safety, and experience disciplines, Intermountain recently launched a program to include engaged family members more fully in the delivery of their loved one’s care during the inpatient stay.

Staff members introduce the voluntary program to family members and invite them to participate as Partners in Healing. Staff members then train interested family members to safely support their loved one by performing designated tasks. Partners track their tasks so the extended care team knows what care tasks have been completed.

“We’re essentially extending the concept of the ‘highly reliable team’ to include care partners,” said Robin Betts, AVP Quality, Patient Safety.

Beth Israel Deaconess Medical Center (BIDMC)

Leaders at Beth Israel Deaconess Medical Center in Boston set a goal to eliminate all preventable harms, and to build a standardized approach to communication, apology, and resolution in cases where preventable harm occurred.

Along the same lines, they committed to a culture of fair and just treatment of healthcare professionals in the analysis and resolution of harms. They used a system to track and analyze preventable physical harms so they could put in place preventive measures as they moved toward their zero harm goal. However, the team quickly realized that there was no commensurate system for tracking and resolving emotional harms. They extended the system and built processes to capture, rate, and quantify emotional harms that patients experience [Lauge Sokol-Hessner, MD, Patricia Folcarelli, RN, PhD & Kenneth E. Sands, MD, MPH, “The Practice of Respect” New England Journal of Medicine, June 23, 2016].

The team’s systematic capturing, scoring, and analysis of preventable emotional harms represents an extension of high reliability rigor for safety to include empathy and respect.

Linking high reliability explicitly to the experience of patients, families, physicians, and staff creates a unifying approach to improvement that addresses all of the crucial elements of the experience (safety, quality, empathy, and respect). It also reduces initiative fatigue and burnout for staff by driving alignment to overcome silos and create cohesion in the work that frontline leaders and staff engage in every day.