HRO (15): trust, report, repent, improve

Again according to Chassin and Loeb (citing Reason and Hobbs), in their article on healthcare “[a] culture of safety that fully supports high reliability has three central attributes:  trust, report and improve.”  They outline what this means, stating that organizational trust is developed when individuals trust both peers and management, when errors and opportunities for failure are identified; trust is supported when behaviors that intimidate and suppress reporting are eliminated; trust is sustained when concerns are addressed quickly by management, with clear communication back to those who identified the concerns.  This becomes a cycle where individuals identify concerns and raise them because they are part of an organization that not only encourages reporting but addresses concerns quickly.  “When all three of these components of a safety culture (trust, report, and improve) are working well, they reinforce one another and produce a stable organizational culture that sustains high reliability.”  (again, Chassin and Loeb)

 As Christians, this “trust, report, improve” should seem familiar.  For us, it sounds more like “trust, repent, improve.”  Bear with me—I know that I have two groups of Christian readers, one saying “talking about sin and repentance detracts from the joy of the gospel” and another saying “we are dead in sin; we lack the ability to improve.” 

Our discussion starts with “trust.”  Our “trust” is in Christ Jesus—His love for us, His sacrificial death on the cross, His resurrection in power, His promises for forgiveness, salvation, eternal life in heaven; and strength, righteousness and power on earth He gives us in His service by His Spirit.  The book of 1 John is full of descriptors of God’s character revealed in Christ.  1John 3: 16a says “This is how we know what love is: Jesus Christ laid down His life for us.”  In 1 John 4: 9 - 10 we are told “This is how God showed His love among us:  He sent His one and only Son into the world that we might live through Him.  This is love:  not that we loved God, but that He loved us and sent His Son as an atoning sacrifice for our sins.”   In 1John 3: 1, we are reminded “How great is the love the Father has lavished upon us, that we should be called the children of God!  And that is what we are!”  Our trust is first and foremost in God’s love lived out in Christ Jesus.

It is based on trust in God’s love that we come and “report”—that is, to identify our own sins and repent of them.  We recognized our failings in comparison to God's holiness, but we trust in His love and come to Him confidently.  In 1 John 1: 9, we are advised “If we confess our sins, He is faithful and just and will forgive us our sins and purify us from all unrighteousness.” It should be part of our character and inner routine to reflect upon our thoughts, words and actions and to consider where we have failed to uphold God’s standards, to live in a way that honors Him.  Again in 1 John, chapter 2: 16, we find words to help us understand; John describes “cravings of sinful man”, “lust of …eyes…”, “boasting of what he has or does…”…as “come[ing] from the world.”  When we find ourselves full of sinful cravings, lustfulness, boasting and pride, we must repent.  In 1 John 3: 14 – 20, John tells us that we must love others with the kind of sacrificial love Christ demonstrated, and that anything less is sin from which we must turn away.  We are called to righteous obedience, called to reject sin (1 John 3: 7 – 10); when we fail, Christ calls us to repentance promises His forgiveness.  He also promises us His Spirit, the Spirit which empowers us to live in love and holiness and to cling to Him in faith (1 John 3: 20 – 24).  It is by God’s grace and power that we have the ability to “improve”—to choose rightly, to reject sin (1 John 3: 9).  

Trust in God, have faith in God’s love shown to us in Christ…repent…improve, live in love and holiness.  This will be our pattern on earth.  So the pattern of “trust, report, improve” which is part of a High Reliability Organization should fit like a second skin.  We know that we sin and need to daily repent; we know that we are forgiven in Christ and are to live out His love—so the culture we can inspire can naturally be one of trust, where sins, errors and mistakes are met with the right balance of forgiveness and accountability.  We acknowledge that we are constantly in need of repentance and forgiveness, and yet constantly seeking to improve and do God’s will.  Battling sin and pressing on toward righteousness is the nature of life on earth. 

But I used the word “accountability.”  Chassin and Loeb emphasize “accountability” as part of that culture of trust which leaders develop.  Accountability means that a clear distinction is drawn between “small, blameless errors that people make every day from safe or reckless actions that are blameworthy.”  Understanding how those blameless errors occur is part of the learning and improving that an HRO does; dealing appropriately with blame-worthy actions must also be part of the safety culture of an HRO.  Blameless actions are those which result from our weaknesses as human beings—oversights, slips and lapses due to distraction or fatigue.  Blameworthy actions are those done intentionally, out of recklessness, pride, or laziness.  We should look for ways to prevent blameless actions—developing human-proof processes, ensuring adequate work-rest cycles—while sussing out and disciplining those who commit intentional, blameworthy acts.

Accountability is a team sport for Christians.  In Jude 23, we are told “Be merciful to those who doubt; snatch others from the fire and save them; to others show mercy mixed with fear—hating even the clothing stained by sinful flesh.”  In James 5, we are told “…confess your sins to each other and pray for each other… (vs 16)” and “…if one…should wander from the truth and someone should bring him back…whoever turns a sinner from the error of his way will save him from death and cover a multitude of sin.”  Jesus told His disciples in Matthew 18 “If your brother sins against you, go and show him his fault…if he will not listen, take one or two others along…” (verses 15, 16).  Jesus further tells His disciples to remove unrepentant sinners from church fellowship (vs 17).  Accountability—calling out sin, approaching people in love and with a desire to correct and inspire repentance and change—is essential in every organization.  

Trust, report/repent, respond; hold people accountable.  These are not foreign concepts.  They are reflected clearly in scripture as the way that we live one earth, where we are still living in a fallen world but living in hope and with forgiveness from God in Christ.  As we look to enact principles of trusted care and patient safety, we see the way paved for us in the way that God calls as His beloved children, working with and serving others of His children on earth.

1)      Read 1 John 1: 5 – 10.  How is the pattern of trust, report/repent, respond highlighted here?  In verse 5, God is described as “light” “in [whom] there is no darkness at all.”  How does trust, report/repent, respond honor God’s character as a God of light—both in our personal lives and at work?  In other words, how does trust, report/repent, respond root out darkness and seek the light?

2)      How does 1 John 1: 8—“If we claim to be without sin, we deceive ourselves and the truth is not in us”—represent the opposite of an HRO?  How can our humility as Christians, our acknowledged need for forgiveness in Christ, help set the tone for an organization to become an HRO?  

3)      An HRO sets the highest priority on safety, with a goal of zero patient harm events.  How does this live out the love of Christ in our professional, secular work-lives? (See 1 John 3: 16 – 19).

4)      1 John 5: 4 tells us that it is by faith in Jesus Christ that we “overcome the world.”  Our daily lives are full of exhausting work:  demonstrating love and creating an environment of trust; holding people accountable in a way that represents the justice and love of God; looking for ways to improve systems, processes and training.  Our “overcoming the world” is true regardless of how exhausted we are, because our victory—our forgiveness and salvation—is already accomplished in Christ.  How does this truth energize you when your daily work saps your strength?