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Health Systems and Hospitals in Pursuit of High Reliability

Analysis  |  By Christopher Cheney  
   April 17, 2019

Cleveland Clinic is achieving multiple benefits at the health system by creating a high-reliability culture.

High reliability is a high priority at health systems and hospitals across the country.

For example, recent research identified achieving high reliability as the top priority at children's hospitals. And Novant Health in Winston-Salem, North Carolina, has adopted a culture of zero tolerance for hospital-acquired infections, serious safety events, and any harm to patients while they are hospitalized, says Eric Eskioglu, MD, the executive vice president and chief medical officer.

Another example of a healthcare organization prioritizing high reliability is Cleveland Clinic, which began initiatives in 2013.

"There has been a revolution at Cleveland Clinic over the past several years to emphasize a culture of high reliability and safety, as well as to emphasize a team approach to everything we do," says Edmund Sabanegh, MD, main campus and regional hospitals president at the Cleveland-based health system.

Cleveland Clinic's quest to become a high-reliability organization has achieved a trifecta: improved patient outcomes, boosted physician satisfaction, and reduced physician burnout.

"There is a big problem in healthcare with burnout, which is complex and involves lack of job enjoyment, feeling stressed, and work-life balance challenges. All of those things improve when you have a team working together smoothly to get the best outcomes for patients," Sabanegh says.

The correlation between team-based care and physician satisfaction is direct, he says. "Things that help us successfully treat patients—team approaches, checklists, and spreading of responsibility—improve our engagement and satisfaction with our career field."

High-Reliability Components

Cleveland Clinic's high-reliability initiative has revolved around basic team building, policy standardization, real-time operational management, creating a culture of safety, and sustaining redundancy in the clinical setting.

But inconsistency in administrative and operational policies is a major challenge for health systems seeking to attain high reliability, Sabanegh says.

"One of the challenges for any large healthcare system is there are many sites for delivery of care. A pitfall that you can have is failing to recognize the nooks and crannies of the system, then having different policies and standard operating procedures for different areas," he says.

Cleveland Clinic, which features 19 acute-care hospitals, has made policy standardization a priority, Sabanegh says. "We have worked hard to standardize our policies to make sure that a nurse who works in one ward, then works in another location in our system has a similar expectation and similar understanding of processes."

One of Cleveland Clinic's high-reliability cultural initiatives has upended decades of tradition in the health system's operating rooms. As opposed to the top surgeon dominating discussions and decision-making in the OR, the health system has adopted a team-oriented approach, including operating room pauses, he says.

"If we have a surgery and anyone in the room is unsure of equipment status or a missing supply like a sponge, there can be a pause. Any member of the team can say, 'I want to look at where we are before we proceed any further with this procedure.' It could be the most junior member of the surgical team or it could be the most senior member." 

To achieve real-time operational management, Cleveland Clinic adopted a reporting system based on tiered huddles this year.

"Every morning, on every nursing unit, there is a huddle of the team. They discuss what has gone right, opportunities, and concerns for the day ahead," Sabanegh says.

The discussions at the ward level are reported to hospital leadership, including the president, chief nursing officer, chief medical officer, and chief quality officer.

The hospital leadership's huddle is reported to health system leaders. Information gathered through the tiered reporting allows senior leadership to act quickly at any location in the organization, he says.

"As the hospitals' president, I am hearing every day from every hospital in our system about their challenges and opportunities for the day ahead. What is our workload and how can we balance it? What kind of infrastructure support do we need? What kinds of repairs are needed?"

Gathering timely information from throughout the health system is invaluable from both management and labor perspectives, he says.

"Real-time operational management gives us both an early warning system for problems and challenges for the entire enterprise, and a great venue to communicate up and down the organization. Everybody is hearing about challenges at other places and how those challenges are being solved."

Cultural considerations

Culture is essential to creating a high-reliability organization, Sabanegh says. "We are working very hard to create a culture of safety and high reliability. Every time the leaders of the organization speak, they talk about this theme."

Staff members are encouraged to identify quality concerns with public recognitions such as awards. "We don't want to be in a reactive mode. Our system fails when we have a serious safety event. What we want to identify is the near miss or something that could turn into a serious safety event down the road," Sabanegh says.

Although redundancy is often equated with waste, Cleveland Clinic sees value in redundancy in the clinical setting, he says.

"We still believe some redundancy is necessary. We are leveraging technology to assist in catching things; but, in this generation, technology will not replace the need to have multiple sets of eyes looking at a challenge." 

Education and communication have been key elements of engaging physicians in high-reliability efforts at Cleveland Clinic, Sabanegh says.

Educational programs that support the health system's high-reliability efforts include Solutions for Value Enhancement (SolVE). "Physician leaders learn about high reliability, performance improvement, and tackling processes with risk and opportunity while avoiding risk. We have trained thousands of people in our organization in these areas," he says.

High-reliability benefits

Cleveland Clinic also communicates with clinicians about the benefits associated with high-reliability organizations, he says.

Engaged clinicians have helped Cleveland Clinic achieve significant high-reliability gains. The average 30-day readmission rate has fallen from 14% to 12.65%, which represents 2,100 patients per year who did not require a readmission.

Outpatient hypertension control has increased from 66% to 76%, with 15,000 more patients at prescribed goals. Cleveland Clinic estimates improved hypertension care has saved about 100 lives.

"We have seen a steady improvement in our quality outcomes, a reduction in serious safety events, and improvements in our readmissions—all things that are important to our patients and improve when our care team makes sure we are highly reliable," Sabanegh says.

Christopher Cheney is the CMO editor at HealthLeaders.


Key elements of high-reliability healthcare organizations include a culture with zero tolerance for patient harm and a team-oriented approach to care.

Cleveland Clinic's 30-day readmission rate has fallen from 14% to 12.65%, due largely to high-reliability initiatives.

Establishing a high-reliability organization can ease physician burnout.

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