Becoming Highly Reliable: Changing Talk to Induce Transformation

male physician checklist

By: Timothy J. Vogus, PhD, associate professor of management, Vanderbilt Owen Graduate School of Management

Dr. Vogus received his PhD in Management and Organizations from the University of Michigan. His research focuses on the cognitive (mindful organizing), cultural, motivational, and emotional processes through which individuals, workgroups, and organizations enact highly reliable performance. He explores these dynamics at the point of care delivery in health care organizations. His research has been published in top management and health services journals.

Dr. Souba’s recent article on the personal foundations of health care transformation exhibits all the hallmarks of a great commentary. It is simultaneously ambitious, energizing, and provocative. What resonated most to me was his clear definition of transformation as “creating access to a broader range of ways of being, thinking, and acting in order to be more effective in dealing with those challenges for which conventional strategies are inadequate.” I also found compelling the idea that the challenge of transformation is a function of the context we create through the ways we talk.

I want to build on the importance of breaking frames through the words we use and the questions we ask by making the target of transformation more specific—patient safety. Specifically, I want to invoke research on high-reliability organizations (HROs) like aircraft carrier flight decks, air traffic control towers, and nuclear power control rooms that are able to perform in a harm-free manner for an extended period of time, despite operating in extremely trying conditions.1 HROs do so, in large part, due to how they talk.2 Their members consistently talk in ways that prospectively identify what could go wrong, question the assumptions they’re making, continuously refine their understanding of current operations, discuss close calls as sources of learning, and actively seek out relevant expertise rather than formal authority when solving problems. They refer to this mode of acting and interacting as mindful organizing.3 In my research with Kathie Sutcliffe of Johns Hopkins, we’ve consistently found that high levels of mindful organizing are associated with lower levels of medication errors and patient falls in hospital nursing units.4,5

In practice, I’ve turned mindful organizing into a set of questions that can help people break from their existing frames when approaching change and transformation.

  • What are we most worried about? Where are we most vulnerable?
  • What assumptions are we making? What are we missing? Who should we consult to question and refine our assumptions?
  • Do we know where relevant expertise resides? Are we able to draw upon it when we need it?
  • How do we know if we need to adjust what we’re doing? What are the early indicators that we should be learning from?

As a result of intervening with these simple questions, I’ve observed improvements in activities ranging from door-to-balloon time to sustained error-free procurement of histories and physicals prior to cardiac catheterization.

The HRO approach is evident in the linguistic changes implemented by Julie Morath at Children’s Hospitals and Clinics of Minnesota. By changing vocabulary (e.g., moving from “investigation” to “study,” “isolated event” to “system,” “error” to “accident or failure,” “root cause” to “multicausal”), Morath was able to enlarge the inputs to transformation because more data points were considered more completely and openly.6

Even the simple act of relabeling safety issues as reliability issues can be of value. Safety tends to invoke images of careless or unskilled individuals in ways that are identity threatening and cause individuals to hide mistakes. In contrast, reliability focuses on the system of care delivery and tends to evoke more constructive problem solving. When I’ve worked with physicians, there has typically been much more engagement and responsiveness to pursuing reliability. In contrast, safety is often viewed as someone else’s job (e.g., the physician safety officer). The act of analogizing health care delivery to HROs can further fuel the thinking and talk that underlies transformation by infusing new ways of being, thinking, and acting.

In closing, we would all do well to heed Dr. Souba’s view of transformation. I believe work on HROs shows how changing the questions we ask, the words we use, and how we label our tasks provide concrete indicators of how we might begin to transform care delivery to be more reliable.


  1. Roberts KH. Some characteristics of one type of high reliability organization. Organ Sci. 1990;1:160–176.
  2. Schulman PR. The negotiated order of organizational reliability. Adm 1993;25:353–372.
  3. Weick KE, Sutcliffe KM. Managing the Unexpected: Resilient Performance in an Age of Uncertainty, 2nd ed. San Francisco, Calif: Jossey-Bass; 2007.
  4. Vogus TJ, Sutcliffe KM. The safety organizing scale: Development and validation of a behavioral measure of safety culture in hospital nursing units. Med Care. 2007;45:46–54.
  5. Vogus TJ, Sutcliffe KM. The impact of safety organizing, trusted leadership, and care pathways on reported medication errors in hospital nursing units. Med Care. 2007;45:997–1002.
  6. Edmondson AC. Learning from failure in health care: Frequent opportunities, pervasive barriers. Qual Saf Health Care. 2004;13(suppl 2):ii3–ii9.

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