Leading Quality
Welcome to Leading Quality, the show that dives into the real-world stories and strategies of healthcare quality improvement leaders at all levels, from Frontline Champions to C-Suite Executives. Each episode uncovers how these dedicated professionals tackle complex topics in real healthcare environments. Discussion range from QI fundamentals, to leadership, technology, AI, and beyond. If you’re passionate about elevating patient care and want practical insights that go beyond the buzzwords, this podcast is for you. Tune in for inspirational conversations, innovative frameworks, and the behind-the-scenes details you won’t hear anywhere else, and discover how you, too, can lead quality improvement from wherever you stand in healthcare.
Leading Quality
How a High Reliability Transformation Cut Preventable Harm by 90%
Safety isn’t a side project. It’s the operating system.
We sit down with Paul Lambrecht, a rare blend of front line paramedic sensibility and executive discipline, to unpack how high reliability organizing moves from idea to front line work. From standing up daily safety huddles to building a just culture where ARCC and SBAR actually get used, Paul explains how to turn near misses into gold, flatten authority gradients, and create a system where performance as intended becomes the norm.
We trace his journey through a post-merger health network that unified on a single EMR and chose safety as its identity, leading to dramatic reductions in preventable harm. Paul breaks down the five principles of high reliability—preoccupation with failure, sensitivity to operations, reluctance to simplify, deference to expertise, and commitment to resilience—and shows how to operationalize each with simple, durable tools. You’ll hear how a 20-minute, whole-house huddle can give real-time situational awareness, how a shared dashboard closes loops fast, and why top-down sponsorship paired with frontline ownership changes behavior at scale.
We also look forward. Human factors is reshaping patient safety by designing systems that make the right action the easy action—clear interfaces, standardized kits, cognitive offloading, and smarter workflows. Paul shares candid lessons on psychological safety and just culture, how to coach leaders who default to blame, and where to start if you’re resource-constrained: round for safety, mine near misses, train in ARCC and SBAR, and build reliability into daily routines.
If this conversation sparks ideas for your team, follow and share the show, leave a review to help others find it, and tell us: what’s the one safety ritual you’ll start this week?
Connect with Paul Lambrecht on LinkedIn
Additional Resources
Foundational Books
- Managing the Unexpected — Karl E. Weick & Kathleen M. Sutcliffe (Wiley). The classic HRO text outlining the five principles.
- The Engaged Caregiver — Joseph A. Cabral & Timothy R. Clark (McGraw-Hill). Discusses the “virtuous cycle” linking safety → engagement → quality → efficiency.
- The Fearless Organization — Amy C. Edmondson (Wiley). Psychological safety as the backbone for speaking up and graded escalation.
Peer-Reviewed / Authoritative Articles & HRO Background
- “High-Reliability Health Care: Getting There from Here” — Mark R. Chassin & Jerod M. Loeb, The Milbank Quarterly (open access). Seminal roadmap for healthcare HROs from the Joint Commission.
- Joint Commission — High Reliability (overview, maturity model, and training).
- NJ Hospital Association HRO Collaborative — origin of the “New Jersey Strong” safety behaviors later adapted locally (e.g., “CooperStrong”).
Practical Tools & Frameworks
- Five Principles of HROs (Weick & Sutcliffe): Preoccupation with Failure; Reluctance to Simplify; Sensitivity to Operations; Deference to Expertise; Commitment to Resilience. (See Managing the Unexpected above.)
- SBAR – Situation, Background, Assessment, Recommendation (IHI tool + PDF).
- ARCC / ARC – Ask, Request, Concern, (Chain of Command) — graded escalation method; overviews and clinical examples.
- STAR – Stop, Think, Act, Review — commonly included in error-prevention toolkits (organizational examples).
- Daily Safety Huddles — Joint Commission HRO guidance for leadership behaviors that enable whole-house situational awareness.
What we find with high reliability is because you're trying to instill a safety culture in an organization, you really have to have the buy-in from the top of the organization all the way through. Otherwise, you're going to have team members trying to deploy and use these skills and behaviors and the leaders of the organization not being on the same page.
SPEAKER_00:Welcome to Leading Quality, the podcast spotlighting the people moving healthcare forward from the front lines to the C suite. I'm your host, Jason Meadows. Today's guest, Paul Lambrecht, is a rare blend of frontline sensibility and executive discipline. He's the Vice President of Quality and Patient Safety at Cooper University Healthcare and an assistant professor of medicine at Cooper Medical School of Rowan University. With 30 plus years of healthcare leadership, Paul Nell set strategy for quality, safety, and high reliability at Cooper, overseeing infection prevention, regulatory readiness, medical staff services, documentation integrity, and environmental safety. Before Cooper, Paul spent a decade at Inspira Health, leading system-wide safety, earning consecutive leapfrog A grades and top hospital awards. He sponsored Inspira's high reliability journey and the network's move to Cerner. And he led the COVID response as incident commander. I wanted Paul on the podcast because he's actually made leading with safety work, standing up daily safety huddles and using practical tools like S-Bar, ARC, and Red Rules. First at Inspira and now at Cooper. In this conversation, we'll trace that playbook, talk about the nuts and bolts of culture change, and explore what's next for high reliability in an era of burnout and AI. Let's dive in. Paul, welcome to the podcast. Thank you, Jason. My pleasure. Thanks for having me. I'd love to dive in. Full disclosure, we've known each other for a little while now, and I've really been looking forward to this conversation because it gave me a chance to dig a little deeper myself into your background. But I am curious to know a little more about you having started as a paramedic and maybe among people with your title now, this is uh maybe a less common background. Maybe there's more kind of physicians or nurses in in this world. I'm curious how your journey led you from being a paramedic to maybe a leader of paramedics and then into quality and safety.
SPEAKER_01:Yeah, it was it was definitely a non-traditional start for somebody stepping into uh quality and patient safety work today. While I was working as a paramedic initially, I had the opportunity to do some what we'll call old school quality assurance work, which really amounted to, you know, conducting chart reviews for protocol and regulatory adherence and things of that nature. And then as my work continued in that space, I had the opportunity to step into education. I was involved in educating and precepting new paramedics, and then ultimately had the opportunity to move into a leadership role as a director of the paramedic program. And at the same time, since we were a hospital-based service, moving into that director's position gave me the opportunity to become more involved in other hospital operations, inpatient operations as well. And that's where I actually stepped into the safety world initially from an environmental perspective as the hospital safety officer. And then as patient safety grew, I began to take uh more responsibility on for patient safety as well.
SPEAKER_00:That's great. And I wonder if you you noticed that kind of skills that were forged in the in the fires of paramedic life translate well into this role, or are there any kind of unique features of of the skill set you developed clinically that then translates well into the patient safety world?
SPEAKER_01:Well, it's interesting. What I didn't know then that I know now is that some of the tools that I was using in my clinical practice as a paramedic, such as SBAR three, three we repeat back, phonetic and numeric clarifications, they were all tools that I was using on a daily basis, working clinically, that were actually the initial step into leveraging high reliability tools to keep patients safe. So I was doing it back then and didn't realize that it was actually high reliability tools that I was using. But you know, flashing forward to my current work, I think the skill sets that I bring with me from that time were around critical thinking and communication skills. I think leaders in the healthcare space today have to have solid communication skills for both verbally and written, be able to effectively communicate horizontally and vertically in an organization and across varied audiences. And I find myself speaking to board members, to executive teams, and then to the frontline staff. So leaders in today's space need to be very flexible in their ability to communicate across all of those audiences.
SPEAKER_00:And it's interesting to me, coming from the physician side, that that things like S-BAR and these kind of structured communication tools uh were such a big part of your daily life and and maybe they haven't permeated as as much into your you know usual MD pathway. Yeah, that that's neat that that you know it was kind of foreshadowing what was come what was to come without you knowing it at the time. Exactly. And was this you know intentional that once you started to get into the the quality and safety world that you gravitated in particular? Because I think there's a lot of flavors that that quality improvement work can take. And I'm curious if there's something that led you to uh high reliability in particular. And maybe you can just kind of briefly explain for people who don't know, you know, what a high reliability organization is and then what what made you choose it.
SPEAKER_01:My res my scope of responsibility in quality safety is is really kind of broad. I've got a lot of different areas that kind of report up to me. But what's unique about high reliability is that the principles of high reliability are really kind of foundational that really sets the tone for really all of the work that we do within the quality and safety space. I think what we've found is, you know, like other industries such as commercial aviation and nuclear power, if we lead with safety first and we get that right, everything else is going to follow. So when you look at the scope of healthcare quality and safety, you know, we're focused on quality outcomes, we're focused on patient experience. And, you know, what we found and what the data has shown us is that if you lead with a strong safety culture, you're gonna have strong team member engagement. And together, that safety culture and your team member engagement is really gonna drive the organization's success with respect to quality, patient experience, and ultimately the efficiency of the organization.
SPEAKER_00:That's great. Uh, I'd like to shift a little bit into some of the background of how you got where you are today and some of the work that you've done, specifically in high reliability and and how you kind of built up this safety, quality and safety career. You joined Inspira in uh 2013, as I understand it. And um, I wonder how you would describe the culture around quality and safety at that time and and maybe how it changed over the time you were there.
SPEAKER_01:Yeah, sure. So in 2013, we were really just a brand new health network at the time. The merger that created InSpear occurred in November of 2012. And I joined, I came from one of the organizations and into uh the new role as the vice president of quality and patient safety. So at that point, uh I would describe the culture as really evolving. You know, we were two, you know, previously independent health systems that have come together. Each had their own culture, each had, you know, very strong work going on within the quality and safety space. And as a new system, we were looking to define who we were going to be going forward. So there was a lot of opportunity to really develop something new when that system was first formed.
SPEAKER_00:And it sounds like there was an appetite to lean into this more. And I think I read in one of the uh an article written, I don't know if it was by by you or about you, but that there was, I guess, a lot of of a sense that there was a lot of good work that had been done within the quality department and that you were looking to to kind of lean into that more. Had the the principles, kind of the the kind of five core principles of high reliability been at all part of the DNA of that system, and and if uh if not, how did you kind of start introducing them?
SPEAKER_01:Yeah, I think they were in part, although many of us maybe not have realized that they were in fact the five principles of high reliability. So what we found was as we got into this new environment, this new health system, we wanted to define who we were as a new system and kind of in a way set us apart from others, so to speak, because we were a very competitive space. There are a lot of health systems around us. So we really were looking to looking for something to define who we were. And there were two things that kind of emerged immediately post-merger that were defining for the new health system. One was the conversion of our electronic medical records from SORI into CERN. So at the time coming together, we had close to 17 different uh or disparate health information systems that were operating throughout each of the facilities and in the inventory environment. So we wanted to bring that all together into the CERN platform, and to do that, it was going to require organizations that previously did things in different ways to kind of come together and do things from a system perspective. So that was the one step that we took into coming together as a system. The second was our work in high reliability. At that time, there were hospitals uh over in Pennsylvania just across the bridge from us in the Philadelphia market who were involved in a collaborative to develop high reliability within their operations. So we had heard about that and we were following that for a little bit. And then around that same time, uh Mark Chasen, who was then the president, CEO of the Joint Commission, had actually published an article about high reliability healthcare. So there was a lot of visibility around this concept of high reliability and how we can begin to apply the learnings from other uh industries into the healthcare industry. So that visibility caught our attention, and we viewed this uh as an opportunity to kind of step into the high reliability journey and begin to develop this new culture of safety uh around error prevention and patient safety as part of a way to develop this new network. It was really hard to argue with that approach. We're trying to focus on enhancing safety culture and minimizing error in this new network. It was really hard to argue with taking a step in that direction. So that was really how we decided to take that step into the high reliability journey.
SPEAKER_00:Yeah, it sounds, it sounds like a theme that I've I've heard elsewhere as well, which is if you start with safety, it's it's such an easy sell for anyone who who decided to devote their life and their career to being in healthcare that it's uh a natural on-ramp to kind of unite people around a common vision. Is that was that your experience?
SPEAKER_01:It it is. And there's actually a textbook called The Engaged Caregiver that actually gets into this idea of the virtuous cycle and how if we lead with safety and utilize high reliability as a lever, together, safety and high reliability will generate positive outcomes in quality, experience, engagement, and ultimately efficiency. So it's uh it's been it's been published in uh in the engaged caregiver.
SPEAKER_00:Yeah, I remember you recommending that one actually uh a few months ago when you give a talk about this. That's uh that's one to check out. We'll keep we'll include that in the show notes. So, you know, I I imagine that there are uh some people in the audience hearing the term high reliability and maybe not sure what that means or uh what the the core principles are underlying it. So this was something um you know published by uh Wyke and Sutcliffe uh back in 2001, uh Managing the Unexpected. And and this is where they define five core principles of high reliability. Can you just walk us through what those five principles are and uh what they mean for healthcare?
SPEAKER_01:Certainly. So the five principles can really be divided into two buckets. There is what we call the principles of anticipation, which are designed to keep you out of trouble, and then there are the principles of containment, which are going to be used to get you out of trouble when you find yourself in trouble. So when we talk about the principles of anticipation, there are the first three. So we have preoccupation with failure, reluctance to simplify, and then sensitivity to operations. So when we talk about preoccupation with failure, here's where we really focus on studying small errors before they become big problems. We're constantly looking for failure loops and where processes can break down. And that allows us to prevent large errors from happening when we keep our focus on, you know, trying to prevent those small failures from occurring. The second principle is sensitivity to operations. And here's where, you know, as leaders, we kind of have our head on the swivel. Uh, we maintain situational awareness of what's going on in our space at any given time. Uh, we want to make sure we've got a line of sight into what our team members are doing on a daily basis. So that that really encompasses the whole idea of sensitivity to operations. And then the third is reluctance to simplify interpretations. And here, you know, we're trying not to take the first explanation for things when they go right or wrong. It's it's really an idea of digging a little deeper and having diversity of thought and opinion, making sure that we're not just taking the easy answer or the easy explanation for something. So they are the three principles of anticipation that are designed to keep you out of trouble. When you find yourself in trouble, the principles of containment come into play. And those are deference to expertise and commitment to resilience. And deference to expertise, you know, simply stated, is listening to those who are closest to the work. So when you want to understand, you know, why something is the way it is or why an error has occurred, you really want to talk to those at the sharp end, you know, those who are at the point of care delivery doing the work every day, have the clearest picture as to what's going on. So that true deference to expertise, pushing the decision making down to the people who are doing the work every day, they really have the most expertise and know uh how those processes are really working or not working. And then lastly, commitment to resilience. What this simply means is when errors do occur, we don't allow them to paralyze the organization. So high reliability organizing who practices commitment to resilience, they're not going to be paralyzed by an error. They're going to learn from that error, they're going to take those learnings and apply them to make sure that that same error doesn't happen in the future. So there are the five principles. You know, it's it's key to understand those and how they play in a high reliability organization. But then what's most important is how you operationalize those principles using the various tools and skills that we have available to us.
SPEAKER_00:I think that's that's really helpful. And as I'm thinking about these more, you know, the preoccupation with failure, I think a few of these principles, it does take some digging a little bit to internalize what's going on there, what they mean. So preoccupation with failure sounds like almost the opposite of what of what you might want to do if you're if you're trying to succeed in an organization. But uh, but I as I think about it, I imagine things like near misses in healthcare, where something almost went wrong, is what you're talking about there. You're you're preoccupied with finding the ways we could go wrong or we almost went wrong. Is that am I along the right track there? You are.
SPEAKER_01:I mean, near misses are a perfect learning opportunity because you have knowledge of a potential failure that was caught by some strong barrier that you had in place to prevent the failure from getting to a patient. And as long as that near miss is reported, and that is some of the challenge a lot of the times, where team members don't think to report near misses, but they are the premier learning opportunity. We want to know about those near misses so we can dissect them and understand how they happened, and then put the plate the fixes in place to prevent them from actually reaching a patient going forward.
SPEAKER_00:Yeah. One of the others that strikes me as a little counterintuitive, and I think is worth digging into to make sure I understand is you know, deference to expertise sounds different than the way we normally think about expertise, which is very hierarchical. It's very um experts are the people who sit at the top. And I think what you're saying is actually uh very different, that the expertise is derived from doing the actual work. I I remember um I remember a mentor once saying to me something like, the people who do the work know the work better than the people who manage the work. And so how how has that been relevant in your work? How where have you found that to be important?
SPEAKER_01:Well, your your mentor was spot on there. So when you talk about deference to expertise, whenever you are analyzing a safety event that has occurred, you know, part of that process, part of that recause analysis process is the individual interviews that we do with the team members who are involved in the event. And we want to understand from their perspective what made them do what they did that day. You know, is there, you know, a breakdown in a process? Is there a breakdown in training? Is there a breakdown in supervision? And the folks who are doing that work understand where the need for workarounds are, where the need, where the potential uh failure points are in a process because they're living and using it every day. It's nice for us as leaders, you know, we're the ones that are you know designing all these policies and all these workflows and you know, putting in the play for our teams to execute. But at the end of the day, they're the folks that are executing it. So they know the most about what does and does not work on a daily basis.
SPEAKER_00:I I wonder actually if you can share, not to put you on the spot too much, but uh share an example of a near miss that might have surfaced in your, you know, your daily safety huddles at some point in your journey that might be a good example.
SPEAKER_01:One that comes to mind it was a potential medication near mix. There was a unit that had identified that a particular medication was stocked incorrectly within their automated dispensing system. And that was raised uh by that unit on the daily huddle that morning and shared with the others who were who were on that huddle. So we can talk a little bit more about daily huddles, but what the one thing that it does allow you to do is maintain that situational awareness of what's going on in the organization. So as soon as that unit reported that they observed this error in stocking, that prompted all the other nursing units on the huddle, as soon as they completed their huddle, to go and do that cross-check on their units to see if they too had any variance in how their medication dispensing systems were stocked. And the pharmacy team was engaged as well. And we were able to, you know, identify where that error occurred before any dispensing errors occurred that would impact the patient.
SPEAKER_00:Yeah, I can imagine it must be, it must be hard to get the the visibility and the insight into operations like you're alluding to there. And I'm wondering if you can, since you offered, uh, walk us through the uh like what does safety, what do the daily safety huddles actually look like if you were going to design from scratch? What does it look like? Where does the information go? What information is shared? Um, I'm wondering if you can kind of walk us through the nuts and bolts of that. Yeah, sure.
SPEAKER_01:So the daily safety huddle really builds off of the individual unit huddles. So, you know, if you're familiar with the clinical space, you know, nursing units typically have a change of shift report. They have a huddle at the change of their shift to kind of go over what happened throughout the prior shift and what they're faced with on the current shift. So the daily safety huddle kind of builds upon that process, and it's a whole house event. So we have representatives from every department present, so clinical areas, ancillary support, non-clinical areas, and they're really there to report on their current state. So uh at my current organization, that accounts for about 62, 62 different areas that are reporting on that daily huddle. Uh generally takes about 20 minutes, uh, and in that 20 minutes we have complete situational awareness on the state of the house that day. The model that we follow is really a brief statement of the current state of that particular unit or department. We ask them to look back over the prior 24 hours to share any safety issues that may have occurred. They ask them to look forward 24 hours to see if there are any particular challenges that challenges they are faced with and any anticipated safety needs or concerns that need to be addressed. And then the huddle serves really as a forum to resolve problems quickly. So if a unit or a department has a particular issue, they can raise it on the huddle, and you have the benefit of all the other departments and services on the huddle with you, they could jump right in and begin to assist in solving problems. More often than not, issues that are raised during the huddle are typically resolved immediately, same day at the most, and really uh prevents those nagging things that could go on for days to be resolved immediately, and really saves uh particular issues from going on for longer than they need to. So that's really what the construct of the huddle looks like. When we teach it to leaders, we share with them that it's not the kind of thing that you can go from your car to the call and participate. It really does involve the leader getting into their space, getting that debriefing from the night before, what are they faced with for that day, and then coming to the huddle with, you know, their current state and what they might need from others on the call who can assist them in solving their issues.
SPEAKER_00:Gotcha. So you're you're saying that the huddle is occurring with frontline people and senior leaders in the same place, or is there an escalation process that the frontline huddle escalates to uh in order to get those problems resolved? There is both.
SPEAKER_01:So there are senior leaders who are on the call and listening to it and can intervene immediately. And if for some reason there's a particular leader that's not that we need to escalate to, then whoever is facilitating the call that day, the huddle that day, can assist with that escalation.
SPEAKER_00:And so I'm imagining if I'm a frontline person in that huddle, there must be, you know, some template, some format that I'm that I'm given to report on the safety issues such that I can, at the end of that report, it's clear this is going to go to somebody. It doesn't just, I'm I'm imagining a big Zoom meeting and I say there's a problem and it could float off into the ether if we don't have enough structure. Is there is there some specific structure that everyone's following that then causes the escalation?
SPEAKER_01:They do follow a similar report out structure, like I just described. So they're doing that look back, look forward, and current state, and then raising any issues that they have. And then in our particular huddle, uh, the way we construct it, we operate in Teams, Microsoft Teams. So uh during the huddle, one of our patient safety coordinators is actually sharing their screen, and on that screen is a dashboard. So we have you know key indicators for the day with respect to like census and ED volumes, borders, things like that. But then we have a specific area where as reports are being given, the patient safety coordinator who's on is actually capturing action items. So if there's a particular unit that raises a problem, that uh that particular problem is captured by the patient safety coordinator on the dashboard. And we can refer to that through the day to make sure that that event gets resolved. Or we come on for the next huddle the next morning, we're going back over that dashboard to make sure that the issues of the prior day had been resolved.
SPEAKER_00:Gotcha. That sounds like uh like a really robust framework for kind of closing the loop and also making sure that the things get escalated that need to get escalated do get escalated. I'm curious, you had this robust journey, and I don't think we've even touched on it enough, frankly, but at Inspira, where you reduced the preventable harm by 90% over your time there. I wonder what the secret sauce is there, or what were some of the the key components to that success, and and then you know, how did you bring that to a new and and I think a much bigger institution at Cooper?
SPEAKER_01:Yeah, so the the work during my time in Inspira, that was really it was really driven from the top down. And when you think about this type of work or quality improvement work specifically, you always like to think of it from the grassroots, right? You like to have team members really driving the improvement work. And what we find with high reliability is because you're trying to change a culture and instill a safety culture in an organization, you really have to have the buy-in from the top of the organization all the way through. Otherwise, you're gonna have team members trying to deploy and use these skills and behaviors and the leaders of the organization not being on the same page. So the work in high reliability is really driven from the top down to get that buy-in. And in spirit, when we stepped into this path, we had the support of our board. They were fully vested in moving forward with this concept of high reliability organizing. We're fully supported by the president and CEO and the executive team and moving the work forward. It was a significant investment that we were making in our people to train everybody in the organization uh in these high reliability skills and behaviors. So we really had that top-down support to make this work. We trained the executive team, we trained our leadership first, we trained our medical staff, and interestingly enough, uh at InSpira, the medical staff had actually had during a couple of their retreats in the years prior, outside speakers come in and talk about high reliability. So the medical staff leadership was actually already in tune with this concept of high reliability. So when we introduced it as an initiative that we wanted to move forward, we had the support of the medical staff leadership as well. So all of that's important to have out of the gate in order to really gain traction and embed it all the way down uh to the sharp end for the frontline staff.
SPEAKER_00:I remember you giving this talk uh a few months back in a community of quality leaders that that we're both part of. And you were talking about tools that you use in high reliability. So SBAR and ARC. I remember being ARCC being uh two of those. I'm curious to know what those tools are and then how you how you actually use them in what settings do you use them and and what is their their function within this broader framework of high reliability.
SPEAKER_01:Yeah, so the the beauty of the high reliability tools is they could be used in any setting. So one of the greatest misconceptions when you when you hear this work, we hear people talk about this work is that it's just clinical of nature. And that's certainly not the case. I mean, there are errors that can occur in the patient care setting as well as in you know the the non-patient care areas as well. So these tools are tools that could be used in in any setting. They could be used in your professional life, they could be used in your personal life to prevent errors from happening. And in our current organization at Cooper, we utilize a tool set which is known as CooperStrong. And it was born out of work that was done through the New Jersey Hospital Association pre-pandemic, where they convened hospitals across New Jersey into a high reliability collaborative, and everybody stepped in and learned and shared this work together. So out of that came this toolbox known as originally New Jersey Straw, and we have kind of adopted that to CooperStrong for our use at Cooper University Healthcare. And at the highest level, uh Strong stands for speaking up for safety. We have Thinking critically, reliably communicate on task, no harm, and got your back. And when you get into what each of those safety behaviors are and the tools that we have there, when we talk about speaking up for safety, we're talking about team members being able to escalate safety concerns. So we use a tool known as ARC, where we ask a question, request a change, express a concern, and then escalate through the chain of command if necessary. When we talk about thinking critically, we ask a lot of clarifying questions. We validate and we verify when we're unsure of the information that we're presented with. Under reliably communicate, we have tools such as SBAR, which we're very familiar with in the clinical space to help uh focus and make our communications more streamlined. We also have tools such as readback and repeat back and the use of uh phonetic and numeric clarification, for example. When we talk about being on task, we use a tool known as STAR, where we stop, think, act, and review uh with respect to the concept of no harm. Uh we want our team members to be able to stop the line when they're uncertain. And then when we talk about got uh the idea of got your back, that's where we cross-check and coach. And we were able to cross-check each other. And if we have concerns about doing something in a particular way, we've got the ability to cross-check each other and coach each other up uh to prevent errors from happening. So at a very high level, that's the toolbox known as Cooper Strong and some of the tools that we use on a daily basis to uh promote high reliability.
SPEAKER_00:You know, one thing that strikes me uh among many in that description is you you describe the ARCC tool, and this is a tool for escalation, kind of effective escalation with the lightest touch possible, as I understand it. And so thinking about how we how we do that in a healthcare organization, which, like many and maybe more than many, is is intrinsically hierarchical. Um, some, you know, with some institutions being more uh kind of deeply ingrained in these hierarchical ideas, I can imagine this is a hard thing to adopt, hard to kind of get people to escalate if a culture does exist in a hierarchy. And I'm wondering how this, how this went in the in the two, you know, healthcare systems, main healthcare systems that you've worked in, and how much this kind of intertwined with the idea of psychological safety that's been getting you know so much traction in the recent kind of decade or so, uh, with you know Amy Emmonson's book leading the way on this, The Fearless Organization, um, and many other thinkers.
SPEAKER_01:Yeah, so psychological safety kind of sets the foundation for you to be able to execute ARC appropriately. What's important to keep in mind with a tool such as ARC is it's not a verb, right? So you're not arcing something up. It's a it's a process, it's a framework. So it's it's presenting the team member with a framework to be able to escalate their concern with the lightest touch possible to get the response that they're looking for. So you really, when you start into ARC, you focus on asking clarifying questions and requesting needed changes. And more often than not, simply asking a clarifying question is enough to resolve the safety concern. But if it's not, it gives you that framework to follow where you follow the lightest touch possible to get the response that you're looking for. And the good news is that you know, you get to that chain of command piece, that last C in ARC, that may not always be needed. I mean, you you're we're giving team members the chance to address the concerns on their own before you have to escalate to a chain of command. So it really just provides a nice, easy process for a team member to follow, using, as you said, the lightest touch possible to resolve a safety concern. But at the end of the day, to truly leverage ARC, you have to have that psychologically safe environment for the team to really function. And the way you get there is by leveraging a just culture and building trust. And you build that trust one conversation at a time. So as you interact with team members on a daily basis, you're you're building trust with every conversation you have so that when a team member does come forward and express a safety concern and begin to utilize that art framework, it's accepted more freely, it's accepted more freely. And it kind of flattens that authority grading that we see in so many healthcare organizations and allows team members to operate on equal footing.
SPEAKER_00:Yeah, I can see the theme you mentioned before of top-down or leaders being the, you know, leaders being the leaders being at the helm of this change. I can see how important that would be if one of the things you're trying to promote is giving people this ARC framework where the last step is chain of command and they need to know that that if they get to that step, if they're escalating it up the chain of command, the reception needs to be supportive, positive, warm, such that they are incentivized to keep escalating when they need to rather than being shut down. I'm I'm curious if uh if that was an easy, easy sell in the places you've worked, or if you've needed to, you know, if it's required kind of ongoing, ongoing reinforcement, ongoing coaching of leaders.
SPEAKER_01:I I think it's ongoing coaching of leaders. I mean, I've seen more recently in my in my current organization, we looked at our safety culture results, that we had some challenges with respect to safety culture and uh some team members feeling that they were operating in a, they were not operating in a non-punitive environment, that they felt that they were a little hesitant to speak up or report because of a they felt like there was going to be a punitive response to that. But from that, and we we took those results and we worked with various leaders across the organization who had some challenges and worked with them, coached them up, coached their teams up. And what we found in subsequent surveys was significant improvement in our overall safety culture, especially in the areas where we saw those pockets of concern. So it just goes to share that if if it's a constant topic of conversation, if it's bought in from the top down, you will eventually break down those barriers and uh achieve that environment of psychological safety.
SPEAKER_00:Yeah, I mean, we could talk about this for hours. This is um this is really great stuff. How do you uh people that you've worked with, you know, leaders that you've worked with, have they been tempted to kind of change the idea of it being leader-led or leaders, you know, top-down can sometimes imply that there's not a lot of frontline buy-in. How do you maintain frontline ownership of new processes of the high reliability work while also telling leaders this is going to be top-down?
SPEAKER_01:Yeah, I think just stressing the overall importance as part of their culture. So you can't look at high reliability organizing and the work around that as something that's done in a silo. So, you know, when we talk about it in our organization, we talk about safety and high reliability organizing being the being the foundation upon which we do all of our other work. So our organization, like many others, has a mission and vision statement and values that you know are designed to guide the organization. But at the end of the day, the way that you execute on your mission, vision, and values is from a position of safety and leveraging high reliability organizing as that foundation. So when you talk about what is a high reliability organization, what does that really mean? It's really performance as intended consistently over time. And it's it's the tools and skills and behaviors that allow you to build that consistency into the work that you do. So I think from a team member's perspective, having those tools and building it into their daily standard work as part of the way they consistently do their work allows them to do their best work. And then as leaders, we have the skills that are necessary to lead in a high reliability environment so that we are constantly keeping safety first. We're messaging on safety on a regular basis, we're providing feedback through routing on our team members. And I think together that allows both the leaders and those at the sharp end to see it as an important uh piece of work for the organization.
SPEAKER_00:Taking a step forward or a look forward into the future, you've been doing this kind of uh quality and safety, high reliability work for a while. Is there a change in the safety landscape or a safety practice that you see emerging, you know, maybe tech enabled, uh, that you think will be transformative in the future?
SPEAKER_01:What I see currently, and when I've been uh diving into myself more recently, is the concept of human factors in healthcare and how looking at process and system design intersects with safety and designing best practices or designing safe practices. So when we do cause event analysis, we try to look at things through a human factors lens to see how the system was designed, how the process was designed. Was the work carried out as intended? Are there different things that we can do in that design process to make it easier for the human to do the work? Can we design the system differently so that the humans can operate differently and make it safer? So I think this whole concept of human factors in healthcare uh is emerging and becoming more embedded in some of the patient safety work that we're doing.
SPEAKER_00:I can imagine over this journey you've uh you've learned a lot of hard lessons too. And I wonder what advice you would uh you would impart to uh your younger self or or someone else who is uh looking to start on a high reliability journey in their healthcare system or is looking to lead with with safety as a strategy for for engagement of staff and working towards high reliability. What kind of advice would you share?
SPEAKER_01:So the times are different now. A lot of the work that a lot of the learning that I did was on-the-job learning, basically, because at the time we didn't have various degree programs and certifications out there specifically around quality and safety. And that has changed dramatically today. So there are a lot of undergraduate and graduate degree programs, certificate programs specifically in quality and safety. We have them designed for both the physician world and the non-physician world. So there are members of the medical staff where I work who have pursued uh degrees in quality and patient safety to further their knowledge. Uh, and then like I said, there's various certification programs now, whether it's the certification in healthcare quality, the certification as a patient safety professional, and now more recently, a certification in human factors and healthcare. So there's a lot of learning opportunities that are out there where you can really dig deep and dive into uh to this work. So to the younger me coming into this world, I would encourage them to take advantage of those opportunities and get that formal education to do this type of work. And then just leverage the processes that you have in place. I mean, today with healthcare being what it is, resources can be kind of tight. Not all organizations have a lot of resources at their disposal, but leverage what you currently have in place. You know, I'm sure that most, if not all, organizations do a unit huddle of some type. So leverage that unit huddle. Talk to the team members, make safety a topic during those unit huddles. Leader rounding is another good uh good topic where I know leaders are out rounding on their team members and talking to their team members on a regular basis. We can always manipulate our time and utilize our time to get out there and talk to our team members, talk about safety, ask them what their challenges are, what's making it hard to do things the way they need to be done. And then most importantly, listen. And when you get that feedback, be prepared to act on it and try and break some of those barriers down. The daily safety huddle is a great tool. Uh, if you can leverage your unit huddles and get an organization to put a daily safety huddle in place, that's a great way to give you situational awareness and begin to solve problems uh in a timely fashion. And then the last thing I would say is begin to look at your harm. You know, take a look back over your harm events to see what trends, what themes are emerging, and how you begin to adapt some of these tools that I talked about earlier to address some of those harm events and begin to build out your high reliability toolbox. So there's a couple of thoughts for folks that are stepping into this work now on how they can uh how they could get themselves started.
SPEAKER_00:I mean, I think we could go on for for a long time with this. You you opened up the human factors door just a moment ago, and I thought, oh, this is a whole new episode. And maybe it will be. I I think it's uh I'm hearing more and more about that as well. I know that there are more and more certificates for human factors in particular. Um, and uh, and as you said, degree programs and uh and much many more resources to uh to dive deeper into these areas. So I do really appreciate your time and and us chatting today. I think you're a bit of a social media guy. Where can people find you on social media? You have a LinkedIn, I think. LinkedIn is the easiest way.
SPEAKER_01:My LinkedIn profile is out there and up to date, so feel free to uh to reach out and connect. Networking is a huge part of this work. We've learned so much uh in the 10 plus years that I've been doing high reliability work by simply networking with organizations and folks all across the country with similar interests. So happy to network uh with anybody who wants to reach out.
SPEAKER_00:That's a great place to end. I appreciate it. Paul, thank you uh so much for sharing your insights on leading quality, safety, and high reliability. Thank you, Jason. It was uh it was a fun time. Appreciate it. Thanks so much for listening to today's episode of Leading Quality. If you enjoyed the show, please take a moment to like, subscribe, and share it with someone who might find it useful. You can find all our episodes at leadingquality.bugsprout.com or in your favorite podcast app. The show is written and hosted by me, Jason Meadows, edited by Milan Milostafievich, and produced by Thrive Healthcare Improvement. See you next time.
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