Industry Voices—3 lessons high-reliability organizations can teach us during the COVID-19 pandemic

An abstract image of a hospital hallway
How did these organizations quickly adapt? Years before, they had both committed to becoming high-reliability organizations. (Shutterstock/sfam_photo)

Healthcare leaders around the world have been sharing important lessons about their COVID-19 response. For example, I recently spoke with a hospital in the southeastern U.S. For more than a decade, staff there have conducted structured front-line safety huddles. Every morning, they gather in unit-based teams to talk about that day’s patient safety risks. They have a reliable process in place to escalate problems that need to be addressed by their system leaders.  

When COVID-19 struck, this organization adapted its safety huddles to focus on COVID-19 response. Every day, they discussed the clinical risks associated with the novel coronavirus, assessed personal protective equipment stocks and stores, checked bed availability and ensured safe staffing levels across their system.

A large hospital system in Asia I spoke to recently described how they used a clinical governance mechanism to rapidly formulate and disseminate an initial COVID-19 treatment protocol. In the first two weeks of their COVID-19 response, they changed their protocol more than 30 times; they had built a system capable of rapid iteration based on feedback from their front-line clinicians and the best available science.

How did these organizations quickly adapt amid the worst public health threat in a generation? Years before, they had both committed to becoming high-reliability organizations (HROs). By building systems to identify risks to patients every day, they were able to tackle even bigger threats, like a new and sometimes deadly virus.

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The pandemic has revealed the difference between those who talk about high reliability and those who practice high reliability. Many organizations are familiar with the elements of high reliability—preoccupation with failure, reluctance to simplify, sensitivity to operations, commitment to resilience and deference to expertise—but not all have done the hard work of cultural transformation.

Whether you’re trying to be an improvement-focused organization or a highly reliable one, the method you use is less important than ensuring that your approach to problem solving and learning is embedded in how you run your organization.

Here are three lessons HROs have taught us during this pandemic:

  1. Embed high-reliability principles and behaviors into your organization’s culture. Organizations that have the core operating principles and beliefs of high reliability ingrained in their values, norms and behaviors have managed this pandemic better than others, and I predict they will be well positioned to manage the next challenge we all face. Build daily communication and regular huddle systems. Install a clear escalation process. Develop your problem-solving methods. Consult IHI’s "Sustaining Improvement" white paper where many of these behaviors are described.
  2. Expect the unexpected, and prepare for the worst. If you’ve been talking about high reliability without putting its principles into practice, start now. I’m not the first to say that managing unexpected threats like COVID-19 is going to become increasingly important. More infectious pathogens will cross borders rapidly. We will have more wildfires, hurricanes, floods, blizzards and other natural disasters that are worse than we’ve seen before. We will feel the many effects of global climate change. The unexpected shouldn’t be so unexpected anymore. As IHI board chair and Northwell Health President and CEO Michael Dowling said in a recent interview about his COVID-19 experiences, “Prepare for the worst thing you can possibly imagine.”
  3. Evaluate today’s innovations and design for the “new normal.” Many describe this period of COVID-19 response as a creative time for their systems. They want to preserve their best innovations in the “new normal.” But which ones should be retained? East London NHS Foundation Trust’s Amar Shah recently shared a simple 2 x 2 matrix his organization has used to evaluate changes to its clinical practice during the pandemic. Use a tool like this to identify ideas to amplify and services to resume. Use the same kind of tool to identify the old ways of doing things that should be phased out or terminated.
A graphic examining the pandemic response
(East London NHS Foundation Trust)

Even as we continue to deal with the current pandemic, we have a responsibility to be ready for the next large-scale disasters that come our way.

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Don’t waste the lessons of COVID-19: Listen to what your workforce is saying now about what they need for support and recovery to prepare for future challenges; seize this opportunity to more rapidly translate evidence to widespread practice; if you haven’t developed a way to quickly spread support and the best information throughout your organization, take the time to do it now.

Cultures that have fully embraced high-reliability principles have demonstrated resilience in the face of COVID-19. Developing high-reliability norms and behaviors isn’t the only thing organizations must do to prepare for the next crisis, but it would certainly be a good place to start.

Kedar Mate, M.D., is president and CEO at the Institute for Healthcare Improvement.