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Three Ways Robust Process Improvement Strengthens Safety Culture


By William T. Choctaw, MD, JD, CSSBB, Physician Advisor
The Joint Commission Center for Transforming Healthcare

In 2013, Dr. Mark Chassin, president and CEO of The Joint Commission, and Dr. Jerod M. Loeb published their landmark study that defined a formal framework for high reliability in health care.

They showed how high reliability science could be practically applied in health care settings through three essential domains: 

  • leadership
  • safety culture
  • Robust Process improvement (RPI)
These three core domains have a dynamic interrelationship with one another, which isn’t well understood. In particular, the Robust Process Improvement (RPI) domain has a particularly strong effect on strengthening or weakening an organization’s safety culture.

Robust Process Improvement was conceived as the most practical and effective set of process improvement tools and methods for adoption by health care organizations. RPI is defined as the blend of Lean Six Sigma plus formal change management. Its purpose is to allow hospitals and other health care organizations to take a definitive first step on their road to become a high reliability organization (HRO). While many organizations have taken initial steps towards becoming highly reliable, a lack of maturity on the RPI domain of the high reliability model inhibits their progress. During my seven years as Chief Transformation Officer at a regional healthcare delivery system, I was responsible for development and deployment of a system-wide RPI program with assistance from The Joint Commission Center for Transforming Healthcare. Based on my experiences, there are three ways RPI strengthens safety culture:

  1. Building Trust – Trust is the oxygen required for all organization leaders to be effective. If trust is not present or lacking, hospital processes will be weak, feeble, ineffective, and unsafe. Trust flows from the executive leaders to the team, not the reverse. Simply put: Leaders must go first. They must walk the talk. The health care team will not trust leadership unless it communicates clear goals supported by clear action. RPI creates a designed framework that is structured and organized. I found RPI particularly helpful with some of our most complex projects like sepsis, patient falls, and emergency room overcrowding.  RPI helps leaders deliver on their promise of better conditions and stronger outcomes to patients and staff, which then strengthens trust.
  2. Road Mapping Process Excellence – Excellent processes keeps our patients safe. The desired goals of any process or system are usually easily defined, such as increasing patient satisfaction or decreasing surgical site infections – essentially eliminating mistakes and defects. Nevertheless, it’s often difficult to choose the best way, i.e. “the process” to reach the desired goals. There may be a hundred processes for each one goal in a particular project. Here, RPI is an ideal methodology for improvement.  Lean Six Sigma is based on the analytical framework at the heart of Six Sigma: 
  • Define
  • Measure
  • Analyze
  • Improve
  • Control 
When used properly, the RPI roadmap can lead to a statistically significant goal or outcome. It is virtually impossible to solve a problem if the problem is not clearly defined to all members of the team. The RPI roadmap helps the team define the problem. Moreover, combining the RPI’s inclusion of change management will ensure that the goal, once achieved, will more likely be successfully implemented with staff members.

Safety culture is defined as the elimination of mistakes and defects based on the team’s culture (beliefs and behaviors). A truism is that when mistakes occurs in a health care organization, it’s often “the process, not the people,” that is the cause. Broken processes are far more common than broken people. However, if broken processes are not fixed, they will eventually begin to destroy the team, leading to a more unsafe environment (e.g. an environment of understaffed and poorly paid nurses). Don’t fire staff when mistakes occur; fix the broken process causing the mistakes, or the mistakes will reoccur.  Use of RPI reinforces the message that it is about improving systems and not about blaming people.  

  1. Improving Physician Engagement – It would be naïve to believe you could create a high reliability organization in the airline industry without engaging pilots. It is equally naive to believe you can have a high reliability organization in the health care industry without engaging physicians. The complexity of physician engagement is discussed almost daily in hospitals nationally, but few actually define it. By following the RPI roadmap, I define physician engagement as:

“Physician-hospital collaboration based on mutual respect, mutual trust, and good communication that improves the patient experience.”

As noted above, the first step to solving an issue is defining it. The above physician engagement definition has three elements: 

  • collaboration
  • relationship
  • patient centered focus

Physicians are a leading cause of disruptive behavior in our hospitals. Disruptive physicians are not engaged physicians. The Joint Commission identified in 2009 that disruptive behavior from anyone in health care as serious, because it undercuts the culture of safety. However, in general people don’t come to work to disrupt.  We must all redouble our efforts to engage our physicians in a sustainable manner. In my experience, inviting physicians and physician leaders to participate in RPI training translates into an invitation to participate the organization’s important improvement initiatives. The language and methods of RPI can then be used as a unifying force for all staff — including physicians.

Finally, it is vital to recognize the strong dynamic relationship between RPI and safety culture. It is imperative we create a sustainably strong safety culture in our healthcare organizations. A strong safety culture requires using the best tools available such as Lean Six Sigma and formal Change management. The success is in the journey!


Bill Choctaw, MD, JD, CSSBB is Physician Advisor for the Joint Commission Center for Transforming Healthcare, where he contributes on a variety of issues. Previously, he was Chief Transformation Officer at Citrus Valley Health Partners (CVHP) where he practiced surgery and was a member of the hospital executive team for seven years. In 2013, Dr. Choctaw launched a Robust Process Improvement/Lean Six Sigma program at CVHP, in partnership with the Joint Commission Center for Transforming Healthcare.