High reliability: truly achieving healthcare quality and safety.

Avoidable INJURIES FROM medication errors, infections, falls, pressure ulcers, and surgical complications should not occur. Problems resulting from poor communication among healthcare providers cost hundreds of millions of dollars each year (Cosgrove et al. 2012). Add to the avoidable injuries the consequences of the inappropriate use of healthcare services (think antibiotics for colds and emergency department visits for primary care needs), and the possible savings are significant.Is creating a truly safe, value-based healthcare system a far-off - some might say unattainable - vision or an urgent, achievable goal? This question defies an easy answer. Transforming the US healthcare system requires a complex, interrelated set of actions that alter both attitudes and behaviors, as Gary Kaplan and John Toussaint articulate so clearly in this issue of Frontiers of Health Service Management. Their stories of transformation share a number of common themes: the implementation of quality improvement tools (such as Lean and the Toyota Production System) used in other industries; a strong vision and strategic plan with a steady and consistent focus on accountability across all levels of the organization; governing body support and sustained commitment; a safety goal of zero defects; collaboration and continual learning to improve; patients at the center of the organizations' definitions of value; and an emphasis on increasing quality to produce greater economic return.These themes are grounded in a patient-centric view of quality; provider convenience is relegated to lower importance. In addition, the two organizations share a genuine sense of humility stemming from the fact that consistently delivering safe, value-based healthcare is a daunting challenge that has yet to be fully realized.Historically, health professionals, government regulators, and private quality organizations have led the way toward identifying the highest-priority healthcare quality and safety issues and developing actions to address them. For example, the Centers for Medicare & Medicaid Services' Value-Based Purchasing Program and The Joint Commission's National Patient Safety Goals and core measures have given hospitals and other healthcare organizations targets for focusing efforts to gain the greatest improvements in specific safety and quality areas. Many hospitals and other types of healthcare organizations already devote sizable resources to address quality and safety improvements. Yet, major shortfalls continue to be seen in numerous areas of safety and quality, which cause significant harm and result in excessive cost. Toussaint and Kaplan assert that only a true transformation can enable sustainable achievements toward zero harm.Creating a Safety CultureOne fundamental element required to move beyond previous efforts and toward a future of better healthcare is creating and sustaining a culture of safety. Practicing mindfulness and striving for perfection - two factors referenced in both articles - help build a culture in which small, point-of-care improvements and attention to details are celebrated. Mindfulness refers to the acute awareness that staff and leaders in a high-reliability organization must have every day. All are mindful that even a small failure in a safety process or procedure can lead to a catastrophically adverse outcome. Originally described by University of Michigan professors Karl Weick and Kathleen Sutcliffe (2007), mindfulness involves the constant searching by staff for the smallest indication of a flaw or hazard that may lead to failure if some action is not taken to solve or prevent the potential problem. Those flaws, or holes in the swiss cheese model described by Reason (2000), can snowball into an adverse sentinel event. Mindfulness leads organizations to find flaws at earlier stages, where they can be more easily fixed, rather than after they have caused harm.Perfection in reliability of care delivery is the standard to which healthcare professionals and healthcare organizations must continually aim. …