Preoccupation With Failure

A preoccupation with failure is a proactive approach to prevent failures from occurring. In a high-reliability system, all employees at all levels are encouraged to think of ways in which work processes might break down or accidents occur. This shared mindfulness includes the full spectrum of failures, from small inefficiencies to catastrophic system failures, and allows for development of best practices within organizations. Errors that are detected are ideally corrected before any harm occurs, and employees are encouraged to report any near misses to further safe-proof systems and practices. It is important to destigmatize failure and see it as an opportunity for improvement. Evaluating and addressing the root causes of near misses throughout the chain of steps that lead to a potential failure are critical for increasing the reliability of a system. High-reliability organizations must also combat complacency with the status quo and embrace aggressive troubleshooting and continuous improvement.

Within radiology, the staff needs to be well prepared prior to beginning examinations or procedures. All necessary supplies should be readily available with extra supplies if necessary. Care providers should take ownership of their processes and actions and be prepared for potential complications. Radiology leadership should be committed to long-term process improvement and lead employees to see that success is attainable and borrow best practices from other successful operations within their department or others within the healthcare system.

Reluctance to Oversimplify

A reluctance to oversimplify is a principle of high-reliability organizations and systems that ensures problems and processes are deeply examined and appropriately managed. Although it is advantageous to simplify work processes whenever possible, high-reliability organizations see the risks inherent in a superficial approach. It is critical to respect the complexity of processes and problems and to explore problems deeply to find the root cause or true source of a problem so a meaningful solution can be formulated. Leaders of high-reliability organizations should constantly seek information that challenges their current beliefs as to why problems exist. They should also question explanations that may seem reasonable or obvious unless they are backed by data. This principle is applicable to radiology, which is a very complex field involving different types of imaging studies, techniques and protocols, acuity of examinations/procedures, reporting structures, and a wide range of diseases. A respect for these nuances is required when solving problems or redesigning radiologic systems or procedures.

Commitment to Resilience

A commitment to resilience is a hallmark of highly reliable systems. High-reliability systems account for failures and are prepared to respond when they occur. Flexibility in a system is essential in mitigating failures and potential harm. According to Ashby’s law of requisite variety, a system must be more complex than its set of inputs to adapt appropriately to changes. Some level of redundancy should be built into a high-reliability system to provide flexibility during unexpected events or larger system failures. Radiology groups may have a backup physician or technologist available to cover for another’s unexpected absence. Radiology groups should develop a backup process when there are RIS or PACS failures for emergency interpretation and reporting. Large system redundancies are inefficient, but small redundancies are critical for resilience in times of failure. Highly reliable organizations are resilient and will bend without breaking when a large problem occurs.

Highly reliable organizations also see failures as critical learning opportunities. System failures occur within a matrix of processes and the causes are not always readily apparent. Once the immediate threats of a failure are neutralized, a longer-term analysis can begin. System failures are an opportunity to closely examine problems and processes to improve or replace them if necessary and increase future reliability. It is also important to evaluate how leadership responds to problems to drive future improvement and create a shared sense of resilience throughout an organization.

Deference to Local Expertise

Deference to local expertise is a fundamental principle of high reliability. It acknowledges that those in management and authority roles within an organization are not always the most experienced or knowledgeable. This is important when considering highly reliable performance in complex situations and settings. Although leaders will determine the overall organizational strategy for improvement, the frontline staff possesses vital knowledge about their work. Highly reliable systems encourage staff feedback and minimize the power distance between employees and management. For example, a first-year resident may have a more advanced degree and perceived rank than a senior ultrasound technologist; however, the experience of the technologist brings more value to the team. Deferring to the expertise of the most qualified individual regardless of title demonstrates respect, builds an environment of trust, and improves patient care. When working in healthcare and radiology, the vast and varying expertise of staff and complexity of clinical scenarios necessitates the empowerment of all staff members to improve care. Another important source of expertise is the prior work experience of all staff. Many healthcare workers have experience in other systems and leaders in high-reliability organizations encourage employees to share their prior experiences and incorporate foreign successful processes and systems whenever possible.