How can we achieve high reliability in health care?

An international expert on leadership says culture is key

By Julia Dick

March 22, 2018

“Safety is not the absence of bad things happening,” says Gordon Smith. “It is people doing things constantly to make sure that something bad doesn’t happen.”

It’s one thing to preach safety, quite another to create a professional culture where safety is achieved reliably and consistently. This was the crux of Smith’s recent keynote address for the Certificate Course in Patient Safety & Quality Management. Smith has 38 years of experience in high reliability, or safety, leadership in aviation, energy, and health care.

According to “Measuring Patient Harm in Canadian Hospitals,” a 2016 report by the Canadian Institute for Health Information and the Canadian Patient Safety Institute, one in 18 patients suffered from a preventable harm incident in 2014-2015.

Smith used the examples of the aviation and nuclear industries to demonstrate how health care may become a reliable industry with lower patient safety incidents. Smith says the aviation industry encouraged many cultural shifts—such as fostering voluntary reporting of adverse events—to become a highly reliable industry.

The individual error is, he stated, a starting point. To understand why that individual did what they did requires a broader perspective of an organization’s environment and culture.

“Ninety-five per cent of culture change is holding yourselves and each other accountable. Educating and building skill, and then continuing to hold people accountable. And the only way that’s going to happen is if people at the frontline are doing that. They have their own and each other’s best interests at heart,” argues Smith.

By instilling a culture where it is safe for individuals to identify issues with no fear of repercussions, organizations can learn how to avoid mistakes.

“When something happens, you do something about it. You change what you need to change, whatever it takes,” says Smith.

W21C Certificate Course trains new leaders in health care quality improvement

The Certificate Course, which is run in collaboration with the University of Calgary’s Cumming School of Medicine and the Health Quality Council of Alberta (HQCA), trains health care professionals and students to become leaders in quality improvement throughout their careers.

Over its eight years, the course has grown substantially, attracting students from British Columbia, Saskatchewan, Ontario, the United States, and Dubai.

“I think that it’s starting to turn into a career, and people are starting to see that they can do clinical work and lead safety or quality,” says Dr. Ward Flemons, professor in the Department of Medicine at the Cumming School of Medicine, medical director for Health System Improvement at HQCA, and W21C member, who developed the course in 2010. “The only two places that offer a certificate program like this are the University of Toronto and the University of Calgary.”

Dr. Duncan Nickerson is a plastic surgeon and the medical director of the Calgary Firefighters’ Burn Treatment Centre at the Foothills Medical Centre, as well as the physician lead for the Department of Surgery’s Quality Assurance Committee. Through the course, Nickerson says he benefitted from the balance between the basics of patient safety and quality improvement processes as well as leadership in health care.

“Opportunities for quality and process improvement exist all around you in your clinical practice,” says Nickerson. “Rather than letting the ideas die on the vine, you could actually turn them into concrete actions and improve how we deliver care.”

Smith concluded his talk by emphasizing the importance of every member of an organization being leaders. “You don’t just flip a switch and become reliable. It’s now how you behave on a day-to-day basis.”

Echoing this message, Dr. Carissa Beaulieu, a first-year resident in internal medicine at the University of Alberta, believes the course provided her with the intellectual and practical tools to improve processes throughout her career.

“I think that we can and should do better in medicine,” says Beaulieu. “I remember being afraid to speak up and ask questions with respect to patient safety as a medical student, and I don’t think it’s ever too early to question things.”

W21C is a research and innovation initiative based in the University of Calgary’s O’Brien Institute for Public Health in the Cumming School of Medicine, and the Calgary Zone of Alberta Health Services. W21C conducts health systems research to make care better by focusing on improving patient safety and quality of health care delivery.

Photos by Julia Dick