Fair and just culture, team behavior, and leadership engagement: The tools to achieve high reliability.

BACKGROUND Disparate health care provider attitudes about autonomy, teamwork, and administrative operations have added to the complexity of health care delivery and are a central factor in medicine's unacceptably high rate of errors. Other industries have improved their reliability by applying innovative concepts to interpersonal relationships and administrative hierarchical structures (Chandler 1962). In the last 10 years the science of patient safety has become more sophisticated, with practical concepts identified and tested to improve the safety and reliability of care. OBJECTIVE Three initiatives stand out as worthy regarding interpersonal relationships and the application of provider concerns to shape operational change: The development and implementation of Fair and Just Culture principles, the broad use of Teamwork Training and Communication, and tools like WalkRounds that promote the alignment of leadership and frontline provider perspectives through effective use of adverse event data and provider comments. METHODS Fair and Just Culture, Teamwork Training, and WalkRounds are described, and implementation examples provided. The argument is made that they must be systematically and consistently implemented in an integrated fashion. CONCLUSIONS There are excellent examples of institutions applying Just Culture principles, Teamwork Training, and Leadership WalkRounds--but to date, they have not been comprehensively instituted in health care organizations in a cohesive and interdependent manner. To achieve reliability, organizations need to begin thinking about the relationship between these efforts and linking them conceptually.

[1]  G. Burtless,et al.  Five Years After , 1949 .

[2]  M. Leonard,et al.  The human factor: the critical importance of effective teamwork and communication in providing safe care , 2004, Quality and Safety in Health Care.

[3]  Jeffrey B Cooper,et al.  No myth: anesthesia is a model for addressing patient safety. , 2002, Anesthesiology.

[4]  A. Milstein.  What does the Leapfrog Group portend for physicians? , 2002, Seminars in vascular surgery.

[5]  Erin Graydon-Baker,et al.  Patient Safety Leadership WalkRounds. , 2003, Joint Commission journal on quality and safety.

[6]  The Patient Safety Battles-Put on Your Armor , 2006 .

[7]  Marvin C. Alkin,et al.  What Have We Learned? , 2019, Stumbling Blocks Against Unification.

[8]  C. Denham.  The Quality Choir: From Warm-up to Harmony , 2005 .

[9]  David M. Gaba,et al.  Structural and Organizational Issues in Patient Safety: A Comparison of Health Care to other High-Hazard Industries , 2000 .

[10]  James T. Reason,et al.  Managing the risks of organizational accidents , 1997 .

[11]  D. Bates,et al.  Improving patient safety across a large integrated health care delivery system. , 2003, International journal for quality in health care : journal of the International Society for Quality in Health Care.

[12]  E. Salas,et al.  The science of training: a decade of progress. , 2001, Annual review of psychology.

[13]  Karl E. Weick,et al.  Managing the unexpected: Assuring high performance in an age of complexity. , 2001 .

[14]  Alfred D. Chandler.  Strategy and Structure: Chapters in the History of the Industrial Enterprise , 1962 .

[15]  D. P. Baker,et al.  The role of teamwork in the professional education of physicians: current status and assessment recommendations. , 2005, Joint Commission journal on quality and patient safety.

[16]  Michael W. McGreevy,et al.  Searching the ASRS Database Using QUORUM Keyword Search, Phrase Search, Phrase Generation, and Phrase Discovery , 2001 .

[17]  Susan E. Sheridan,et al.  No Excuses: The Reality That Demands Action , 2005 .

[18]  Geoffrey K Lighthall,et al.  Use of a fully simulated intensive care unit environment for critical event management training for internal medicine residents* , 2003, Critical care medicine.

[19]  R. Helmreich,et al.  Surgery as team endeavour , 2000, Canadian journal of anaesthesia = Journal canadien d'anesthesie.

[20]  R. Helmreich.  On error management: lessons from aviation , 2000, BMJ : British Medical Journal.

[21]  J. Bagian,et al.  The Veterans Affairs root cause analysis system in action. , 2002, The Joint Commission journal on quality improvement.

[22]  C. Denham.  Leaders Need Dashboards, Dashboards Need Leaders , 2006 .

[23]  D. Gaba.  The future vision of simulation in health care , 2004, Quality and Safety in Health Care.

[24]  K. Kizer,et al.  Patient safety: a call to action: a consensus statement from the National Quality Forum. , 2001, MedGenMed : Medscape general medicine.

[25]  L. Kohn,et al.  To Err Is Human : Building a Safer Health System , 2007 .

[26]  C. Denham.  Patient Safety Practices: Leaders Can Turn Barriers Into Accelerators , 2005 .

[27]  P. Pronovost,et al.  Five years after to err is human , 2005 .