High-reliability health care: getting there from here

Almost fourteen years have passed since the institute of Medicine's report “To Err Is Human” galvanized a national movement to improve the quality and safety of health care (Kohn, Corrigan, and Donaldson 2000). Isolated examples of improvement now can be found, and some of the results are impressive (Dixon-Woods et al. 2011; Pronovost et al. 2006, 2010). Measured against the magnitude of the problems, however, the overall impact has been underwhelming. Every year, millions of people suffer the adverse effects of health care–associated infections and harmful medication errors (Aspden et al. 2007; Klevans et al. 2007). More people are harmed by errors during transitions from one health care setting to another (Bodenheimer 2008; Forster et al. 2003). Operations on the wrong patient or the wrong body part continue to take place, perhaps as often as fifty times per week in the United States (estimated from: Minnesota Department of Health 2013). Fires break out in our operating rooms during surgery, perhaps as frequently as six hundred times a year, often seriously injuring the patient (ECRI Institute 2013). The frequency and severity of these failings stand in particularly sharp contrast to the extraordinary successes that industries outside health care have had in achieving and sustaining remarkable levels of safety. Commercial air travel, nuclear power, and even amusement parks are pertinent examples. Organizations in these and other industries have been the subject of scholarly study, seeking to understand what characteristics and behaviors create the conditions that produce such exemplary performance or “high reliability” (Reason 1997; Weick and Sutcliffe 2007). Could health care become highly reliable as well? What would health care organizations have to do differently to achieve this goal? To address these questions, a team at the Joint Commission has worked closely with experts in high reliability from academia and industry. We combined this knowledge with an understanding of health care quality and safety that derives from our daily work with the more than 20,000 U.S. health care organizations that we accredit or certify. In an earlier article, we discussed the historical context of the challenge of high-reliability health care and described the broad outlines of a conceptual framework that might enable health care organizations to chart a path toward high reliability (Chassin and Loeb 2011). In this article, we report the further elaboration of that work in the form of a practical framework that individual health care organizations can use to evaluate their readiness for and progress toward the goal of high reliability. The framework describes four stages of maturity that define milestones on this road for each of fourteen specific characteristics of health care organizations. Although some elements of this framework may be relevant to many different kinds of health care organizations, we developed it specifically for hospitals. Indeed, the most serious problems with the quality of health care are found in hospitals, and some hospitals are already working toward becoming highly reliable.