The concept of high reliability is not new. And much has been written about the promise of partnering with patients and families at the bedside, throughout the care episode, in organizational design and in governance. There is synergistic potential in combining these two strategies: partnering with patients and families to build highly reliable systems. By tapping into the knowledge of patient and family advisers, hospitals can design safer, more efficient and more effective care.

Engaging patients and families in eliminating harm was the main topic of the second annual Quality & Patient Safety Roadmap at this year's Health Forum–AHA Leadership Summit. More than 350 quality and patient safety professionals and nearly 50 patient and family advisers convened to discuss high reliability, governance, and patient and family engagement.

Engaging Teams for High Reliability

Two key strategies to eliminate harm emerged from the Roadmap: (1) hardwiring processes to build high-reliability organizations, and (2) engaging patients and families in quality improvement efforts.

Hardwiring processes. High-reliability organizations share five key characteristics: (1) sensitivity to operations; (2) reluctance to simplify; (3) preoccupation with failure; (4) deference to expertise; and (5) resilience. Notable examples include the commercial aviation and U.S. nuclear power industries. By implementing the principles of high reliability, these industries dramatically have reduced the rate of adverse events. Checklists and other hardwired processes are most often touted as contributing factors to the decline in accidents. According to Gary Yates, president of Healthcare Performance Improvement and of the Sentara Quality Care Network, the hallmark of high reliability is moving beyond simple process design to build a culture of safety and reliability and to implement human factors design.
The key to high reliability is recognizing that success depends on process and people. High-reliability organizations recognize and accept that people make errors and that it is impossible to eliminate human error. In response, these organizations cultivate a reliability culture characterized by core values, vertical integration, behavioral expectations for all, hiring for fit, and a structure that is fair and just and promotes 200 percent accountability. Additionally, high-reliability organizations employ human factors integration; they make it obvious to do the right thing and impossible to do the wrong thing. As a result, processes are immune to inevitable human errors.

When challenged to become more highly reliable or presented with success stories of the airline and nuclear power industries, many health care professionals reply, "but health care is different!" Certainly, health care is different. The provision of health care involves cooperation among multiple, complex teams faced with overwhelming amounts of data and pressure. This complexity provides a compelling case to standardize and design error-proof systems where appropriate.

Yates argues that a high standard is achievable for all health care organizations. He emphasizes the need to monitor performance in seven domains: (1) patient safety; (2) associate safety; (3) clinical quality; (4) patient engagement; (5) associate satisfaction; (6) physician satisfaction; and (7) financial strength. When all of these domains are consistently performing as intended over time, organizations approach high reliability and zero harm events.

Engaging patients and families for quality improvement. Hospitals are engaging patients and families in improvement, but many of these projects revolve around designing buildings, choosing paint colors or providing feedback on food menus. Although these types of projects may be valuable in creating a high-quality experience for patients, the vast majority of hospitals have yet to effectively engage patients and families in strategic quality improvement and patient safety initiatives.

Some patient and family advisers emphasize how their negative experiences during hospital stays inspired them to become active partners in improving safety and quality in their health care organizations. Patients and family members possess intricate knowledge and vastly different perspectives on care processes, communication and coordination systems, all of which are critical in improving care. There is a huge untapped potential to engage knowledgeable and committed patient and family advisers in improving the quality and safety of care.

Eliminating Harm at Vidant Health

In eastern North Carolina, Vidant Health is partnering with patients and families to build a high-reliability organization. Patient and family advisers are involved "from the bedside to the boardroom," says Dorothea Handron, a Vidant adviser. At the health care system, patient and family advisers participate in purposeful rounding, storytelling and education; serve as quality team members; review patient materials; participate in safety rounds; assist with facility design and patient portal development; and become formal advisers to the board. As a result of these efforts and others, Vidant has achieved an 83 percent reduction in serious safety events and a 62 percent reduction in health care-acquired infections, and has received numerous awards and recognitions.

Mark Rumans M.D., CMO, said, "To build a system of care to meet the needs of the people we serve, we must have reliably built-in partnerships with the people we serve." That is, partnership with patients cannot simply be another initiative, but must be fully integrated into the way the hospital operates.

Getting Started on Better Care

Providers across the continuum face steep challenges to improve quality, cut costs, implement new technologies, adapt to changing reimbursement and manage population health. Building high-reliability organizations and partnering with patients and families build a strong foundation to address these challenges. These are recommended steps to get started in eliminating harm:

  1. Find and track the data. Measuring total harm is an effective strategy to reduce and eliminate adverse events. Find more information and templates here.
  2. Identify your processes. Evaluate which processes impact the outcome you are trying to change. Examine, revise and hardwire processes that produce reliable outcomes.
  3. Build a patient and family advisory council. Tap into the knowledge, passion and potential of the patients and families in your community by inviting them to join you in providing safe, high-quality care. Learn more about the benefits of patient and family engagement here.

The effective combination and deployment of high reliability and patient and family engagement holds great promise to build health care facilities that are safe, of high quality and patient-centered. Through this partnership, leaders in quality, safety and patient engagement can transform patient care.

Authors' note: The Quality & Patient Safety Roadmap was hosted by the AHA's newest forum, the Symposium for Leaders in Healthcare Quality. Launched in April 2014, the symposium's mission is to build a community of health care professionals whose work is focused on performance improvement in support of the Institute of Medicine aims of providing care that is safe, equitable, timely, effective, efficient and patient-centered. A key priority for the symposium is building capacity for health care professionals to engage patient and family advisers in quality improvement. For more information on the symposium and to access presentations and videos from Roadmap, visit or contact

Charisse Coulombe is a vice president of clinical quality, Natalie Erb is a program manager and Jessica Blake is a senior program manager, all at the Health Research & Educational Trust.