For the past several years, there has been a keen focus in healthcare on high reliability, the idea of operating in such a way as to prevent or avoid serious harm or mistakes. But how does the concept translate into actions that clinicians and administrators can use to make progress?

Erika Sundrud, a vice president at Premier Inc., a healthcare consulting firm headquartered in Charlotte, NC, addressed this question during the Institute for Healthcare Improvement’s national forum in December 2019.

“We hear boards saying ‘no harm, that is our vision’ ... but [healthcare organizations] struggle at times to operationalize it,” she noted. “What does it look like for the nurse manager every day in a no-harm environment? What do his or her job duties look like every day as they move forward?”

To learn the answer, it can help to review what the five domains of high reliability are and what they really mean, Sundrud observed.

“If these [five domains] are proven to create a safe environment ... we have to go back and [ask] what does this mean for us, how do we operationalize all five of these things every day, and then continue to have a mindful presence of [high reliability] every day,” she said.

Stay preoccupied with failure. Every adverse event that happens and every near-miss that one catches sends the message that there are further improvements to be made, according to Sundrud.

“I have never met an organization in my 18-year career that does not have any [adverse] events or near misses,” she shared. “For all of us, this is a journey. We need to seek to understand these near-misses [and adverse events], to know them better and move forward.”

Resist the temptation to simplify. When a mistake or near-miss occurs, it is not uncommon for people to immediately reach the conclusion that the problem was miscommunication, the fact that someone lacked the proper skill set, or some other fairly straightforward conclusion.

There is a tendency to oversimplify failure so that a quick fix can be implemented, Sundrud explained. However, in many cases, there are numerous contributing factors to a mistake or adverse event.

For instance, Sundrud recounted the experience of one health system that wanted to understand why patients were experiencing excessive lengths of stay. “Patients were getting hung up in the ICU, and then they were getting hung up in the step-down unit,” she recalled. “We were wondering what was happening here, what was wrong.”

In that instance, the chief medical officer, the hospitalists, and even the intensivists concluded the problem was due to the fact that the organization had just hired new nurses. “Is that a good explanation? It could be, but is it the only explanation? Absolutely not,” Sundrud stressed. “Sometimes, the most simple answer coming forward for some of the events going on in your system is right there in front of you, but [the root cause] can be much more complex than given credit for,” she cautioned

Be sensitive to operations. It is important for leaders and staff to understand what is happening on the frontlines. This includes the specific work, processes, and the system that affects patient care every day, Sundrud said.

“You would think that this would be the easiest thing that we can do because we all know what is happening in every process and every system in our organization that is impacting patient care,” she explained. “Yet, often we are finding that a simple piece alone has variation in it. Understanding that [variation] is important.”

Commit to resilience. Even if there are one or two failures, if an organization can continue avoiding big failures, then employees have achieved something important. Still, leaders must keep pushing, Sundrud noted. “Our job is to uncover things early and often, and to continue to work on them,” she said.

This means periodically fine-turning or redesigning processes so they work more effectively. “Often, we are finding that [this work] slips through the cracks,” Sundrud shared. “That resilience is often very difficult.”

Defer to expertise. “In healthcare, we defer to physicians all the time, which we should, but this is when leaders are deferring to people that know [a specific] process,” Sundrud explained. “They are trusting the insights of people who understand their process and their situation, and then move forward from there.”


  • Premier Inc. Creating a Culture of Optimal Care Delivery. Charlotte, NC; 2018. Available at: Accessed Jan. 22, 2020.