Barriers to Achieving High Reliability


The conceptual models being used in healthcare’s efforts to achieve high reliability may have weaknesses, according to Marc T. Edwards, MD, MBA, author of “An Organizational Learning Framework for Patient Safety,” published in the American Journal of Medical Quality. Those weaknesses could explain why controversy over basic issues around the subject remain.

His paper analyzes those barriers to achieving high reliability in healthcare and points to a way forward—specifically, a different framework for identifying leverage points for improvement based on organizational learning theory.

“Organizations learn from others, from defects, from measurement, and from mindfulness,” he writes. “These learning modes correspond with contemporary themes of collaboration, no blame for human error, accountability for performance, and managing the unexpected. The collaborative model has dominated improvement efforts. Greater attention to the underdeveloped modes of organizational learning may foster more rapid progress in patient safety by increasing organizational capabilities, strengthening a culture of safety, and fixing more of the process problems that contribute to patient harm.”

To help bring this about, hospitalists can contribute by “embracing accountability for clinical performance, developing appropriate measures, and engaging in safety improvement activities — the most salient and important of which is reporting adverse events, near misses, and hazardous conditions affecting their own patients,” Dr. Edwards says. “This means taking responsibility for ending the culture of blame in healthcare, which currently blocks physicians from such self-reporting.”

He adds that hospitalists can do this by changing the model by which they conduct clinical peer review: Instead of focusing on whether individual physicians practiced according to standards, they could look broadly at learning opportunities for improvement in the system of care.


  1. Edwards MT. An organizational learning framework for patient safety [published online ahead of print February 25, 2016]. Am J Med Qual. pii:1062860616632295.

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