Seeking high reliability in primary care: Leadership, tools, and organization.
BACKGROUND
Leaders in health care increasingly recognize that improving health care quality and safety requires developing an organizational culture that fosters high reliability and continuous process improvement. For various reasons, a reliability-seeking culture is lacking in most health care settings. Developing a reliability-seeking culture requires leaders' sustained commitment to reliability principles using key mechanisms to embed those principles widely in the organization.


OBJECTIVE
The aim of this study was to examine how key mechanisms used by a primary care practice (PCP) might foster a reliability-seeking, system-oriented organizational culture.


METHODS
A case study approach was used to investigate the PCP's reliability culture. The study examined four cultural artifacts used to embed reliability-seeking principles across the organization: leadership statements, decision support tools, and two organizational processes. To decipher their effects on reliability, the study relied on observations of work patterns and the tools' use, interactions during morning huddles and process improvement meetings, interviews with clinical and office staff, and a "collective mindfulness" questionnaire. The five reliability principles framed the data analysis.


RESULTS
Leadership statements articulated principles that oriented the PCP toward a reliability-seeking culture of care. Reliability principles became embedded in the everyday discourse and actions through the use of "problem knowledge coupler" decision support tools and daily "huddles." Practitioners and staff were encouraged to report unexpected events or close calls that arose and which often initiated a formal "process change" used to adjust routines and prevent adverse events from recurring. Activities that foster reliable patient care became part of the taken-for-granted routine at the PCP.


CONCLUSIONS
The analysis illustrates the role leadership, tools, and organizational processes play in developing and embedding a reliable-seeking culture across an organization. Progress toward a reliability-seeking, system-oriented approach to care remains ongoing, and movement in that direction requires deliberate and sustained effort by committed leaders in health care.
Robert R. Weaver, PhD, is Professor and Associate Dean, Research & Partnerships, Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Ontario, Canada. E-mail: Robert.Weaver@uoit.ca. The author has disclosed that he has no significant relationships with, or financial interest in, any commercial companies pertaining to this article.
Robert R
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Weaver
D000884:Anthropology, Cultural; D003299:Cooperative Behavior; D003661:Decision Support Techniques; D005246:Feedback; D006801:Humans; D033183:Interdisciplinary Communication; D007857:Leadership; D008281:Maine; D015279:Organizational Culture; D061214:Patient Safety; D011320:Primary Health Care / Q000458:organization & administration*; D011340:Problem Solving; D058996:Quality Improvement / Q000458:organization & administration*; D012041:Regional Medical Programs / Q000458:organization & administration; D015203:Reproducibility of Results