When discussing highly reliable performance with senior managers it is helpful to cite empirical results attributable to high reliability organization design and practices. Since research began with aircraft carriers, nuclear power plants, and air traffic control systems data from these domains has been accumulated and analyzed for years. More recently evidence of improvement possible through adopting high reliability approaches has been obtained from an increasingly larger body of organizational types as discussed in a 2008 essay by Dr. Karlene Roberts of UC Berkeley.
Even with the steadily increasing body of research it is still common to hear the occasional reply of “Yes, but we’re not a _________ (fill in the blank). ” An example where there is some success in overcoming this “we’re different” argument has just been published in an article, “Comparing safety climate in naval aviation and hospitals: Implications for improving patient safety” published in the April-June 2010 edition of the Health Care Management Review. The authors include physicians and social science researchers with extensive experience in health care, Naval aviation2 and other safety significant organizations. This was the first study to compare safety climate in a national sample of hospitals to another industry. What they conclude from their research offers not only insights into the current state of U.S. health care, but also offers empirical support for why “I’m not a ____” has limited validity as a counter to the lessons from highly reliable organizations.
A random sample of health care workers in 67 U.S. hospitals and 30 Veterans’ Affairs hospitals was conducted using questions comparable to those posed at the same time frame (2007) to personnel from 35 squadrons of U.S. Naval aviators. The findings indicated that safety climate was three times better on average among Naval aviators than among hospital personnel. Compared to hospital managers, Naval commanders perceived the safety climate more like front line personnel. In other words the ΔW1 was smaller for Navy aviation than for hospitals.
“Traditional blame and shame modes of operating hinder learning, improvement, and cultivation of an environment in which individuals feel safe to identify concerns, to discuss mistakes and to experiment with small tests of change that can facilitate implementation of innovation and continuous improvement. There is now a growing body of evidence linking measures of better “safety climate” in health care organizations to improved patient and worker outcomes.” Safety climate was defined as the “shared perceptions of practices, policies, procedures, and routines about safety in an organization.” Climate is contrasted with the idea of safety culture as shared beliefs and values. While the two concepts are related, this definition of Safety Climate provides for measurement of opportunities for improvement whereas examination of safety culture is more readily achieved though ethnographic means.
The authors readily acknowledge that Naval aviation is different from health care in mission, structure, and processes. They assert, however, that this does not preclude utility in their comparison. The differences that stem from history or tradition rather than necessary features of health care delivery are “likely to be explained” by deep structural and organizational features. The study results suggest that health care could be improved by creating new structures and processes similar to those in Naval aviation.
“A culture has evolved within the U.S. Navy that focuses on avoiding failure and has embedded processes that promote continuous improvement.”
- Navy aviation makes use of standard operating procedures while retaining flexibility to modify them.
- Standards that could apply to health care include those for pilot qualification, continuous task, team and leadership training, and performance management.
- Safety performance, management and assessment in Naval aviation are systematic, formalized and rigorous. Practices found to work are translated into mandatory self developed standards. Examples include non-punitive close-call reporting, published lessons learned, comprehensive accident investigations, and command structure that reinforces leadership attention to safe performance.
Conclusions and Opportunities:
While the study results showed a significant difference between Navy aviation safety climate and hospital safety climate, there were outlier results for a few hospitals. For some high performing hospitals, responses to several of the 16 survey instrument items were comparable to Navy responses. For one hospital, average responses were equal to those of Navy results, and for one other hospital average responses for all but three of the survey items outperformed those of the Navy benchmark.
This newly reported research supports the idea that high reliability design and practices may be broadly applicable to promote improvement in safety and performance. The key idea is that reliability is achieved by how the organization and its members think about safety and improvement3 and by embedding processes that promote continuous improvement.
So for today’s question, what is the safety climate of your organization, how do you know, and is your organization afflicted with the “But we’re not ____” syndrome?
1 see blog on The Performance Improvement Formula
2 for the original 1987 Navy War College article on high reliability see
3 for a 1993 follow up article by Roberts and Weick see