HRO: (3) High Reliability Organizations are Good Stewards of Risk

High Reliability Organizations (HROs) are successful at “achieving and sustaining remarkable levels of safety.”  Beyond safety—and intrinsic to safety—is the idea that these organizations produce incredibly consistent results despite operating in complex, dynamic environments.  HROs are by definition reliable; they have little variation in processes, and by design produce results that do not cause harm or other unintended consequences.  Becoming an HRO is desirable for any organization, as variations with unintended and risk-filled consequences are bad for the bottom-line.  Becoming an HRO also arguably represents being the best steward of all resources entrusted to the operation.  Where risk is anticipated, controlled and mitigated, the valuable human capital, time and the physical and fiscal resources of the organization can be more effectively used to achieve the goals of the organization.  Whether those outcomes are safe, efficient patient care or the safe and efficient production of nuclear power, the principles follow.  If the organization is instead diverting those resources to “clean-up duty”, the result is waste as well as frustration, disappointment and loss of trust.  If hospitals regularly harm and kill patients—and we do—then we are constantly wasting money (repeat procedures, added treatment costs—like caring for a decubitus ulcer in a malnourished patient--litigation, public relations campaigns etc.), as well as all other associated resources.  We waste time—more than just a function of money—on those clean-up efforts, diverting both minutes of the day and emotional energy away from direct, meaningful patient care activities.  We waste the compassion and dedication of our people when they see their caring efforts instead resulting in unintended harm.  I believe we also waste—or outright destroy--the goodwill and the trust of those we are trying to serve and heal, with the end result being a cynical mistrust directed at the science and practice of medicine, placing it in the minds of many at no higher level than unreliable, unpredictable charlatanism and quackery.  By being demonstrably unreliable, we have become unworthy of trust.

Wastefulness and untrustworthiness is the opposite of Godliness.  Good stewardship is intrinsic to God’s nature as our master gardener and Good Shepherd; the bible is full of discussions of Godly and God-pleasing stewardship, of people who act to preserve resources and retain trust.  TheParable of the Talents (or Parable of the Bags of Gold in the newest version of the NIV) tells just such a story.  Three servants are given, respectively, 5 Talents, 3 Talents and 1 Talent.  The servants given 5 and 3 Talents carefully invest the money left in their care and, upon his return, present their master with the money entrusted to them plus interest.  The third servant acted out of fear and, rather than taking both risk and initiative, he simply buried the money in the ground.  The two servants who had demonstrated good stewardship of the money entrusted to them were entrusted with both more resources and with positions of authority.  The third servant, who had demonstrated only timidity, had the money entrusted to his care taken away and was punished for his poor stewardship.  

The phrase “first due no harm”, while not actually part of the Hippocratic Oath, has been linked with the practice of medicine from antiquity.  Those entrusted with the health of the body and the stewardship of human life have a calling to “first do no harm.”  Heard only with timorous ears and comprehended only with a narrow mind, “first do no harm” sounds like the business plan of the third servant—the one who buried the money in the ground rather than risk loss and disappointment.  But medicine is by nature a complex and high-risk affair; in the fight against death and disease, stopping with “first do no harm” means the battle is lost.   As one of my most inspiring bosses was fond of saying: “the only perfectly safe hospital is an empty one.”  Therefore, we must go beyond “first do no harm” and enter the realm of uncertainty and risk.  We cannot emulate the third servant and instead must strive to be like the first two, to be good and worthy stewards by taking risks in the wisest way we know with the goal of being worthy of the trust we’ve been given.  

Based on the response of the master in the Matthew parable, taking risks in God’s service and while doing His will is both pleasing to Him and something He rewards.  In healthcare, as we strive to become more Highly Reliable, to be safer and worthy of the trust of our patients and families, I believe we can clearly and confidently connect those goals with service to God and obedience to His will.  Because of the Fall, “subdue the earth” encompasses activities which directly combat the impact of sin and death in God’s good creation.  Jesus Himself spent significant time healing people during His earthly ministry.  While we can’t confuse the goal of saving souls with the goal of healing bodies, the mission of medicine—to alleviate human suffering—is a noble and God-pleasing one.  Therefore, with our hands holding the Talents we’ve been given, and our goal being to serve and heal God’s people on earth, we can approach this risky business of healthcare with confidence that our efforts will be blessed.

1)      Consider your work-related duties, your role as a professional (in healthcare, in business, in any domain).  The two wise servants—with the 5 and 3 Talents—were blessed for desiring to do their Master’s will, for their good stewardship, and for their risk-taking.  Do you work in such a way as to please God?  Are you a good steward of the resources you control?

2)      What are the innate risks of your work?  How do you work to wisely mitigate the innate risks of your work as a way of being a good steward of human life or God-given resources? 

a.       For example, performing a surgery has innate risk to the patient (blood loss, infection, death), but the alternative—not operating—will nearly certainly result in more harm.  Part of being a good steward in the face of that innate risk is working to control the risks that can be controlled.

b.      As a non-medical example, linemen repairing electrical lines are required to climb to great heights and deal with the innately dangerous power of electricity, in service to those who rely on that electricity for safety and comfort.  Providing that lineman with appropriate training and reliable equipment will mitigate that innate risk.

3)      What are the intentional or chosen risks of your work?  Are you diligent to ensure that you take chosen risks that are God-pleasing; or are you taking risks out of selfish motives?

a.       For the examples above, one might choose to cut corners—skipping handwashing, skimping on training, failing to put appropriate safeguards in place or provide reliable equipment—in a shortsighted attempt to save money or garner efficiency.  How does this represent ungodly risk-taking?  Have you taken such risks and still expected good outcomes, God’s blessing on your work?

b.      Other chosen risks might include an experimental medical treatment, trialing a new piece of equipment, a new training method, a new process or work schedule.  When selecting these optional risks, do you seek God’s wisdom and insight?

4)      Are there risks you should have taken at work—a chance to save a life, improve worker conditions or work efficiency—but you failed to do so, maybe out of fear of failure or lack of initiative?  How can the Parable of the Talents embolden you to take future opportunities?

5)      Read Psalm 130.  The Psalmist speaks of “the depths”:  the despair, anxiety, sadness, frustration and fear that comes from sin and failure.  We may find ourselves in “the depths” as a result of failed risk-taking, neglect of appropriate risk-taking, or failure due to human error despite the best intentions.  As Christians, we know that God offer’s us forgiveness in Christ as we “put our hope in the Lord” because “with [Him] is unfailing love…and full redemption.” (v7)  Contemplate a recent failure and the forgiveness you have in Christ.