Where The Culture Prescription™ Meets High Reliability

Sep 6

Translating Organizational Principles Into Everyday Leadership Behaviors

THE CULTURE PRESCRIPTION™ | THE LEADERSHIP JOURNAL

By Sharra Schewee-Blair

Healthcare organizations invest considerable time and resources in patient safety, quality improvement, and high-reliability initiatives. We educate employees, introduce safety tools, establish expectations, develop reporting systems, and communicate the importance of creating environments where patients receive safe, reliable care.

All of those efforts matter.

But after more than two decades in healthcare leadership, I've become increasingly interested in another part of the conversation.

What happens between an organization's commitment to high reliability and the everyday leadership behaviors required to support it?

We can teach employees to speak up when they recognize a potential safety concern. But what happens when they actually speak up?

We can encourage teams to report near misses. But how does their manager respond when a mistake or potential problem is brought forward?

We can teach deference to expertise. But are leaders comfortable acknowledging when someone else has knowledge or experience they don't possess?

These everyday moments influence whether the principles we're teaching become part of how our organizations actually operate.

And that's where I believe leadership development and high reliability intersect.

My Introduction to High Reliability

My introduction to high reliability came through a Vizient learning experience in which I participated in a book club focused on Managing the Unexpected by Karl E. Weick and Kathleen M. Sutcliffe.

Reading the book and participating in discussions about its principles challenged me to think more intentionally about the relationship between organizational reliability, leadership behaviors, and workplace culture.

What particularly interested me was how closely the principles of high reliability connected with leadership challenges I had already experienced throughout my career.

Creating environments where employees feel comfortable raising concerns. Recognizing the expertise of people closest to the work. Remaining attentive to operational conditions. Learning from mistakes and unexpected events.

These weren't entirely new leadership challenges to me. But high-reliability principles gave me an additional framework for understanding their importance and thinking more systematically about how leaders can reinforce them.

That experience also reinforced something I had been learning throughout my leadership career.

We can introduce people to important concepts through education, but understanding those concepts doesn't automatically change how we behave.

The real challenge is translating what we've learned into the decisions we make and the environments we create for other people.

That realization continues to influence my approach to leadership development and the direction I'm taking with The Culture Prescription™.

High Reliability Is More Than Knowing the Principles

In Managing the Unexpected, Weick and Sutcliffe explore five principles associated with high-reliability organizing:

Preoccupation with failure: Remaining attentive to small problems, near misses, and early warning signs rather than waiting for something significant to go wrong.
Reluctance to simplify: Recognizing that operational problems are often complex and resisting the temptation to accept easy explanations.
Sensitivity to operations: Maintaining awareness of what's happening where the work is actually being performed.
Commitment to resilience: Developing the ability to respond, adapt, recover, and learn when unexpected situations occur.
Deference to expertise: Recognizing and involving the people with the knowledge and experience most relevant to a particular situation.

These principles provide an important foundation for understanding organizational reliability.

The Agency for Healthcare Research and Quality (AHRQ) also discusses these characteristics in its Patient Safety Network's overview of high reliability, emphasizing the importance of organizational awareness, resilience, and the early recognition of potential safety threats.

But understanding these principles and consistently demonstrating the behaviors that support them are two different challenges.

Consider preoccupation with failure.

An organization might encourage employees to identify near misses, report concerns, and recognize early warning signs.

But imagine an employee approaching a supervisor to report something that almost went wrong.

The supervisor is busy, dealing with competing priorities, and already frustrated by several operational problems.

Without intending to discourage the employee, the supervisor responds dismissively or immediately begins questioning who was responsible.

What message might that interaction send?

The organization may have communicated the importance of reporting concerns, but the employee's experience with their leader could influence whether they're comfortable speaking up again.

This is why I believe we need to pay particular attention to the everyday leadership behaviors that support high reliability.

Employees experience organizational culture through their interactions with the people around them, including their leaders.

Those interactions can reinforce or undermine the principles we're working to establish.

The Human Environment Behind High Reliability

One of the most valuable lessons I've learned throughout my leadership career is that creating an environment where people feel comfortable approaching you comes with responsibility.

People will bring you concerns, frustrations, questions, and sometimes information that requires further evaluation.

Your responsibility isn't always to solve the problem yourself.

Sometimes it's to listen carefully, recognize the seriousness of what you're hearing, and involve the appropriate people who have the expertise or responsibility to address the situation.

That's where psychological safety, leadership clarity, and deference to expertise can work together.

Amy Edmondson's foundational 1999 research on psychological safety examined how a team's shared belief that it is safe to take interpersonal risks relates to learning behaviors.

Her research helps explain why the interpersonal environment matters when we expect employees to ask questions, acknowledge mistakes, share information, and participate in learning.

But I believe there's an important leadership distinction we need to make.

Psychological safety doesn't mean every concern is automatically validated, every interpretation is accepted, or every decision belongs to the person receiving the information.

Leaders must balance approachability with fairness, accountability, and appropriate organizational processes.

An employee should feel comfortable bringing a concern forward while understanding that the leader may need to gather additional information or involve human resources, quality, safety, compliance, or another appropriate resource.

The leader doesn't need to possess every answer.

They do need to recognize when the next step belongs with someone else.

And they need to communicate that clearly.

These may seem like relatively small leadership behaviors, but they can influence whether employees trust the processes their organizations have established.

Where The Culture Prescription Meets HRO

As I developed The Culture Prescription™, I began recognizing how closely my five leadership principles connect with the human behaviors that support high reliability.

The Culture Prescription wasn't created to replace established HRO principles or introduce an alternative safety framework.

It was developed as a practical leadership methodology focused on how leaders connect with people, recognize their contributions, create clarity, develop capability, and strengthen the environments they're responsible for.

When viewed alongside HRO principles, these five pillars provide an opportunity to translate organizational expectations into everyday leadership practices.

Here's what that intersection can look like.

CONNECT: Create the Relationships That Make Speaking Up Possible

Relationships influence communication.

Employees need opportunities to develop trust in their leaders and confidence that their concerns will be taken seriously.

For a frontline manager, CONNECT might mean regularly asking employees what concerns them, following up when someone raises an issue, and demonstrating approachability during difficult situations.

It also means being intentional about how we respond when someone tells us something we weren't expecting or didn't necessarily want to hear.

A leader's reaction today may influence whether an employee approaches them tomorrow.

These behaviors can support preoccupation with failure and sensitivity to operations by helping leaders remain aware of emerging concerns and frontline experiences.

VALUE: Recognize the Expertise Already Around You

One of the most important lessons leadership has taught me is that being responsible for a team doesn't mean knowing more than everyone on that team.

Employees frequently possess knowledge, experience, and perspectives that leaders don't have.

High reliability recognizes the importance of deferring to expertise rather than relying exclusively on organizational hierarchy.

VALUE encourages leaders to recognize individual contributions and create opportunities for employees to share what they know.

That might mean involving an experienced clinical employee when evaluating a workflow concern, asking frontline staff to identify potential weaknesses in a process, or acknowledging when another professional is better equipped to guide a decision.

Recognizing expertise isn't a loss of leadership authority.

It's an important part of exercising leadership responsibility.

CLARIFY: Connect Psychological Safety With Accountability

Creating an environment where employees feel comfortable speaking up is important.

So is helping them understand what happens after they speak.

CLARIFY focuses on expectations, responsibilities, communication, and accountability.

In a high-reliability environment, this might include helping employees understand reporting processes, reinforcing expectations for escalating concerns, and communicating the distinction between listening to a concern and reaching a conclusion.

It also means recognizing when situations require established organizational procedures or specialized expertise.

Leaders should reinforce their organization's safety expectations rather than creating informal processes that unintentionally compete with them.

Clarity helps employees understand both their responsibilities and the resources available to support them.

IGNITE: Empower People to Recognize and Respond to Risk

High reliability depends on people who remain attentive to their environments, recognize potential problems, and take appropriate action.

But employees need more than instructions.

They need opportunities to develop confidence, judgment, and the ability to recognize when additional support is necessary.

IGNITE encourages leaders to develop those capabilities through coaching, meaningful participation, and appropriate empowerment.

For example, a manager might involve employees in identifying workflow vulnerabilities, encourage them to contribute ideas during safety huddles, or provide opportunities to participate in improvement initiatives.

The objective isn't to transfer responsibilities beyond someone's training or authority.

It's to develop employees who understand their roles, recognize potential concerns, and feel supported in taking appropriate action.

These behaviors can reinforce sensitivity to operations, deference to expertise, and organizational resilience.

LEAVE BETTER: Turn Everyday Experiences Into Organizational Learning

I believe one of the most important questions leaders can ask is whether the environments they're responsible for are improving because of their leadership.

In high reliability, learning matters.

Organizations need opportunities to understand what went wrong, recognize what nearly went wrong, examine why things happened, and strengthen their ability to respond effectively.

LEAVE BETTER encourages leaders to contribute to that process.

That might mean recognizing employees who identify potential problems, participating constructively in learning reviews, following through on improvement opportunities, or helping teams understand what changed because someone raised a concern.

It also means recognizing that reporting alone isn't enough.

When employees take the time to identify risks or recommend improvements, leaders should help ensure those concerns reach the appropriate people and that meaningful follow-up occurs.

Employees need opportunities to see that speaking up can contribute to improvement.

And leaders have an important role in helping reinforce that connection.

From Organizational Principles to Leadership Development

This intersection between leadership and high reliability has influenced the direction I'm taking with The Culture Prescription.

I believe healthcare organizations have an opportunity to strengthen their existing HRO initiatives by intentionally developing the everyday leadership behaviors that support them.

Consider how organizations typically introduce high-reliability expectations.

Employees participate in education, learn safety tools, review organizational principles, and receive information about reporting and escalation processes.

Managers and supervisors are then expected to reinforce those expectations while navigating the operational demands of their departments.

But how intentionally are we developing the leadership capabilities required to do that?

Are we helping managers practice responding constructively when employees raise concerns?

Are we teaching them how to recognize when to involve additional expertise?

Are we helping them balance psychological safety with accountability and established organizational processes?

And are we providing ongoing coaching and reinforcement after their initial education is complete?

These questions connect directly to the leadership development philosophy behind The Culture Prescription.

My approach follows a continuous development pathway:

DIAGNOSE → LEARN → APPLY → MENTOR → REFLECT → REINFORCE → MEASURE

Rather than treating leadership education as an isolated event, this approach connects learning with practical application, mentoring, reflection, reinforcement, and evaluation.

Within a high-reliability environment, that could mean helping managers identify leadership behaviors that need development, providing targeted education, and creating opportunities to practice those behaviors through everyday operational activities.

Safety huddles, employee rounding, one-on-one conversations, recognition opportunities, and routine problem-solving can all become meaningful opportunities for leadership development.

Mentoring and coaching can help managers reflect on challenging situations, recognize opportunities for improvement, and strengthen their judgment.

Organizations can then evaluate whether those development efforts are translating into observable leadership practices.

The goal is to complement existing organizational development, education, quality, safety, and HRO infrastructure.

Not to introduce competing expectations.

And certainly not to suggest that leadership development alone can address every factor influencing patient safety or organizational reliability.

Reliable healthcare requires effective systems, appropriate resources, sound processes, professional expertise, and coordinated organizational commitment.

Leadership development is one important part of that larger responsibility.

Building the Conditions Where Reliability Can Thrive

I've spent much of my leadership career learning that the way we lead influences what other people experience.

Our reactions matter.

Our communication matters.

Our willingness to listen, recognize expertise, provide clarity, and develop others matters.

And in healthcare, those everyday behaviors can have implications beyond employee engagement or workplace satisfaction.

They can influence how comfortable employees feel identifying concerns, how effectively teams communicate, and how consistently organizational expectations are reinforced.

That's why I believe the intersection between leadership development and high reliability deserves greater attention.

The Culture Prescription is my contribution to that conversation.

Through practical leadership education, mentoring, coaching, and organizational consulting, my goal is to help connect established leadership and high-reliability principles with the realities of everyday operational leadership.

Because teaching people the principles of high reliability is important.

Developing leaders who consistently reinforce the behaviors that support those principles is equally important.

High reliability is how we strive to operate. Leadership helps create the human environment where reliability can thrive. And culture is what helps make it stick.

References & Further Reading

The perspectives shared in this article draw on my professional leadership experience, participation in a Vizient high-reliability learning experience, and established research on high-reliability organizing and psychological safety.

Weick, K. E., & Sutcliffe, K. M. (2015). Managing the Unexpected: Sustained Performance in a Complex World (3rd ed.). Jossey-Bass.

This book provided the foundation for my introduction to high reliability through a Vizient book club. Its exploration of high-reliability organizing continues to influence how I think about leadership behaviors, organizational culture, and operational reliability.

Edmondson, A. (1999). Psychological safety and learning behavior in work teams. Administrative Science Quarterly, 44(2), 350–383.

This foundational research examines psychological safety and its relationship to learning behaviors within teams.

Agency for Healthcare Research and Quality (AHRQ). (2019). High reliability. Patient Safety Network. Last reviewed in 2024.

This resource provides additional information about high-reliability principles and their application within healthcare organizations.

About the Author

Sharra Schewee-Blair is the founder of The Culture Prescription™, an author, and a healthcare operations leader with more than 20 years of leadership experience.

Her professional background includes ambulatory healthcare operations, frontline leadership development, mentoring, and organizational initiatives focused on workplace culture and high reliability.

Her participation in a Vizient high-reliability learning experience, including a book club focused on Managing the Unexpected, helped shape her understanding of the relationship between leadership behaviors, organizational culture, and high reliability.

Sharra is the author of The Culture Prescription: Leadership Practices for Connecting, Valuing, Clarifying, Igniting, and Leaving People Better Than You Found Them

Through The Culture Prescription™ LLC, she develops leadership education, mentoring, coaching, and organizational consulting resources that connect established leadership principles with the everyday realities of operational leadership.

Sharra Schewee-Blair https://www.cultureprescription.com