Q&A with High Reliability Expert Dave Marshall: Goal-Setting and How to Ensure HRO Success

In this follow-up to Studer Group’s June 2017 webinar, *High Reliability in Healthcare: Creating the Culture and Mindset for Patient Safety, Huron high reliability expert Dave Marshall goes deeper with insights, tips and recommendations on how to lean into the HRO journey.

Q: How can hospitals and systems benchmark or measure success in the beginning to ensure they are on the right track?

A: From the beginning, HRO performance measurement involves collecting, reporting and benchmarking data. Measuring clinical as well as operational performance creates buy-in for improvement work and enables an organization to track its improvements over time. This information can also be used to identify and prioritize improvement goals and to track progress toward established HRO goals.

When it comes to goal-setting for an effective high reliability strategy, there are several key factors to consider. Before you start, ensure you understand the systems that are in place within your organization to plan, execute and maintain an HRO program. Those are critical to setting appropriate goals and achieving error-free performance and operation.

In a typical year, I visit dozens of healthcare organizations. In some organizations, these systems have been carefully and intentionally developed; they have received significant investment, and are sophisticated and effective. In others, they have evolved without much strategic planning and, at best, are ineffective; at worst, they are harmful and result in catastrophic outcomes.

Also, I recommend you organize HRO goals around five key areas that have worked effectively in other industries. These include: leadership, culture, patient safety, quality improvement and process improvement. It’s important to continuously analyze, evaluate and improve in each of these so they align to HRO goals and objectives.

Q: Many organizations are facing limited resources and a shrinking budget at a time when there’s a high degree of change in the industry and competing priorities. What’s the best way to approach high reliability when facing these kinds of constraints?

A: It’s a common challenge. That’s why it’s so important to build consensus and strategy from the top down. I recommend three things: First, if this describes your organization, work with your board, community and executive team members to set up a comprehensive strategy and overarching mission for becoming a high reliability organization (HRO). If high reliability is an organization-wide strategy, use that framework to prioritize and mesh competing priorities.

Second, you’ll need an in-house expert. With competing priorities across the organization, you’ll want to identify someone who is steady and passionate; moreover, that person should be a dedicated HRO specialist so you move forward without getting derailed. Many leaders have a quality, safety and process improvement background so identify someone with those skillsets.

And third, approach your HRO strategy with milestones and concrete objectives. Your board and community members can help to keep you accountable for these targeted activities.

Q: Can you share a few examples of success in organizations you work with?

A: Organizations across the U.S. and Canada have made major advancements in a number of areas. One organization Studer Group worked with reduced incorrect drug and patient events by more than 90 percent in just over two-and-a-half years. Another maintained zero percent for targeted hospital-acquired infections (HAIs) for three consecutive years. A third reduced lost time injuries by 95 percent.

However, it’s important to recognize that while some efforts may not be officially labeled “high reliability,” many organizations are setting goals that are improving patient safety and gaining momentum toward zero patient harm. For example, there’s a substantial ripple effect from organizational work on engagement that benefits high reliability.

Dramatic increases in physician, employee and patient engagement are driving zero defects in specific targets, as well as better clinical outcomes, lower readmissions and lower turnover. Those, in turn, improve both safety and financials. It’s a virtuous feedback loop…high reliability organizations feed engagement through a strong sense of teamwork and vice versa.

In the HRO webinar, for example, we talked about five common traits of HROs (see sidebar). Let’s consider how one of them, sensitivity to operations, boosts engagement.

When leaders and frontline staff maintain constant awareness and call attention to a colleague for doing something against protocol–or taking short cuts–that becomes part of the culture. In other words, it’s no longer viewed as a negative behavior, but instead, it’s applauded because it identifies and mitigates threats to patient safety. It feeds engagement as it naturally spreads to other leaders and other employees. Since what gets rewarded gets repeated, the result is both higher engagement and better patient safety.

5 Common Traits of HROs

1. SENSITIVITY TO OPERATIONS: Maintaining constant awareness by leaders and frontline staff of the state of systems and processes that affect patient care — thereby identifying threats and preventing them.

2. RELUCTANCE TO SIMPLIFY: Avoiding overly simple explanations of threats and failures is essential in order to better understand the true reasons and causes that lead to patient harm.

3. PREOCCUPATION WITH FAILURE: Rather than viewing near-misses as proof that the system has effective safeguards, they are viewed as symptomatic of areas in need of more attention.

4. DEFERENCE TO EXPERTISE: Leaders and supervisors must be willing to listen and respond to the insights of staff who know how processes really work and the risks patients really face.

5. RESILIENCE: Leaders and staff are trained and prepared to know how to respond when system failures occur and rapidly correct the process that led to the bad outcome.

Q: Every organization will have unique challenges. How can these best be addressed in the HRO strategy and rollout?

A: Leaders of organizations adopting an HRO strategy must ensure that the strategy is aligned with their specific organizational goals and consistently executed; both are needed to achieve success and sustainability in a journey toward zero harm and operational excellence. One proven strategy I recommend is the use of Evidence-Based LeadershipSM (EBL). It provides a framework that helps leaders build a sustainable culture that fosters innovation and consistently delivers the best quality outcomes. That’s because it’s essentially an operating system that provides the foundation for organizational alignment and accountability. This is especially critical with an HRO strategy in place.

Through continuous and standardized rounding, communicating and daily reporting, organizations drive results at all levels. In my experience, those that use Evidence-Based Leadership achieve faster and more sustainable improvements related to HRO compared to organizations without this type of operating strategy.

EBL is the “engine” for results. Frequently at Studer Group, we meet leaders at organizations that haven’t been able to realize the gains they anticipated from various process improvement initiatives (e.g., Lean, Six Sigma). What they are frequently missing is the chassis or operating strategy piece that EBL brings to the process.

It’s the best way to manage competing priorities and drive integration so the sum is greater than the parts. So many organizations today are working on improving engagement, quality and safety. A hardwired HRO strategy happens at the intersection of processes to succeed in all three of these areas. EBL drives that through an aligned, accountable team.

Q: The cost of measurable medical errors is a big problem. In fact, an August 2017 Health Affairs article pegged it at $17 billion in 2008. How can we mitigate these costs?

A: I wish I could say there was a quick fix to prevent and change the causes of medical errors. Unfortunately, there isn’t. The fastest path toward organizational alignment and dedication to zero harm goals is communication. That’s why it’s so critical to train and teach all frontline staff members (including physicians, nurses, administrators and support staff) about the benefits and skills needed to work as teams with defined communication protocols and methods.

As high reliability is becoming increasingly important in the world of healthcare, many fail to recognize the crucial piece that teamwork plays within the HRO journey.


Effective teamwork increases communication, allows team members to realize potential errors before they happen, and increases both patient safety and employee satisfaction.


Teamwork is the process of collaborating as a cohesive unit committed to achieving a shared goal. High reliability teamwork accomplishes this stated objective while constantly maintaining an elevated level of quality and safety.

As a high-performing team, each member understands:

  • the plan or course of action for a routine outcome,
  • the plan for contingencies, should unexpected issues arise,
  • how to share all the information the team needs to work together prior to beginning an activity or procedure,
  • how to identify and openly address the shared goals and expectations for each individual as well as the team with all team members,
  • how to identify available and necessary resources and ensure they are accessible in a timely manner, and
  • the need for continuous communication, awareness and cross monitoring.

Q: How do you specifically help organizations with the high reliability journey?

A: We begin to help organizations on their HRO journey with six key elements. First, we start with an organization-wide diagnostic or assessment of current conditions that will influence the ability to adopt high reliability strategies. Second, we work closely with the leadership team to plan the rollout of the most effective HRO strategy, based on our findings. Third, we select the clinical areas that are best prepared to adopt and hardwire HRO principles. Fourth, we train managers, frontline staff and team members on HRO specifics as well as process improvement activities and methodologies. Fifth, we work with organizations to continue the spread of high reliability protocols. Sixth, we focus on continual improvement measures and benchmarking data reporting.

Organizations often accelerate the launch of their identified strategy through initial team training, planning and practice. The goal is to integrate three important processes into the foundation of their strategy:

  • Communication requires individuals to speak candidly with others and use standardized models to send and receive information efficiently.
  • Coordination requires individuals to give and receive support for the team’s effort(s) and assume roles and responsibilities according to shared team expectations.
  • Collaboration requires individuals to trust in and respect teammates, monitor situational awareness at all times, and apply collaborative problem-solving and conflict management techniques.

Training and practice in these skills occurs while also acquiring the specialized knowledge, skills and abilities to ensure HRO success.

And finally, physician engagement is also critical to HRO performance. Success can only occur if the relationship between administration and physician leaders is collaborative, with a focus on the shared mission and vision of the organization.

Rounding on physicians is a powerful way to engage physicians because it provides opportunity for them to offer input into quality, safety, service and other areas that matter most to them. Because effective follow up is so critical to building a relationship with physicians, we recommend the use of the stoplight report to communicate outcomes of rounding and close the loop with physicians on what leaders have taken action on, what is still in process and what is not possible (and why). When the medical staff and administrative team are working together in pursuit of shared goals that feel realistic and tangible, the sky is the limit!

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*Adapted from the article, High Reliability in Healthcare: Creating the Culture and Mindset for Patient Safety, published in the Canadian College of Health Leaders Healthcare Management Forum, March 2017.

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