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American College of Physician Executives

The Science of High Reliability: Building Better Health Care

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Overview / Abstract:

Errors, delays, and waste are the results of inefficient and poorly designed work processes. High reliability is the study of human performance in complex systems and includes: systems thinking, analysis of serious safety events, techniques to minimize mistakes, techniques to minimize waste, and tactics to move your people to a culture where patient safety is at the core of the business. This new course delivers skills and competencies in patient safety and high reliability organizations. Physician leaders will learn to improve team performance at both the bedside and in the C-suite. You will identify the types of waste and inefficiency in work processes and hear techniques to streamline inefficient processes and techniques for better performance.

The terminal objective of the program is to improve patient care (safety, clinical quality, cost, and time) through applying best practices from High Reliability Organizations. The course is organized in the three modalities of improving system reliability: Prevention, Detection, and Correction (PDC).

  • Define reliability, and describe how reliability can be measured and expressed
  • Describe, using Reason's Swiss Cheese Effect, how human error and latent system weaknesses combine to cause loss events in health care
  • Describe, using Cook and Wood's Sharp-End Model, how culture can shape behavior and prevent human error that contributes to loss events
  • Know, and be able to provide examples for each of, the five (5) behavior-shaping factors of reliable systems: structure, protocol, culture, process, and intuitive environment
  • Know, and be able to apply in the context of Patient Safety Culture, the three steps to culture change
  • Describe the process for selecting Patient Safety Culture behaviors for a hospital or a service line or a single unit
  • Be able to identify safety behaviors, and describe the use of each behavior, for each of the three (3) human error types in the Generic Error Modeling System (GEMS)
  • Be able to identify Leader behaviors, and describe the use of each behavior, for high reliability organizations
  • Creating the Learning Organization. Understand the cultural background of Toyota and how it directly relates to your HealthCare organization. Be able to connect behaviors and culture
  • Data Transparency: Be able to describe several different models for making problems visible including: incident reporting, stopping the line, visual control, and simplified data presentation. Learn how to move data closer to the source and the impact this has on the speed of correction. Understand the common patterns in building a culture which stops to fix problems
  • Models of Human Behavior Related to Change. Demonstrate understanding of several research based models for organizational change and the impact they have on making change. Models include: Everett Rogers, Tuckman Form/Storm/Norm/Perform, Demming 14 Points and IHI's Model for Transformational Change. Be able to apply the models for various situations
  • Making Everyone an Active Agent. Organizations today require everyone to be engaged in solving problems. The Toyota Production System/Lean provides many tactical & practical tools and techniques to make this a daily occurrence. Through a rapid cycle of Education, Case Study and Exercises, learn how to use several different tools for change


Dec 31, 2011


Physician CME, Nursing CNE




575 - 675

Credits / Hours

10 CME Credits

Is This Activity Certified for "Live" Credit?


Presenters / Authors / Faculty

  • Craig Clapper, PE, CQM/OE -Healthcare Performance Improvement
  • Jeff Norton, MSME -Center for Enterprise Quality and Safety, University of Kentucky

Activity Specialities / Related Topics

Public Health / Community Health

Keywords / Search Terms

American College of Physician Executives The Science of High Reliability: Building Better Health Care

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