We Teach High Reliability. But Are We Creating a Culture Where People Can Actually Practice It?

Oct 9

Why healthcare's pursuit of zero harm requires more than education, safety tools, and good intentions.

THE CULTURE PRESCRIPTION™ | THE LEADERSHIP JOURNAL

By Sharra Schewee-Blair

I'm still thinking a lot about the way we approach high reliability in healthcare. We spend considerable time discussing patient safety, psychological safety, speaking up, accountability, and the importance of creating environments where employees feel comfortable identifying risks. We teach the principles. We introduce the tools. We establish expectations. We encourage employees to report concerns, communicate openly, and take ownership of safety. And all of that matters. But there's a question I keep coming back to.

Are we creating workplace cultures where employees can actually practice what we're teaching them?

Because knowing what high reliability looks like and working in an environment that supports it are two very different things. As someone who has spent more than two decades working in healthcare leadership, including frontline operations, I understand how challenging it can be to translate organizational expectations into everyday practice. I also understand that what leaders say they value and what employees experience aren't always the same. And I believe that gap deserves considerably more attention.

We Can Teach People to Speak Up. But What Happens When They Do?

Consider a familiar healthcare scenario. An organization invests in psychological safety education. Leaders attend training. Employees learn the importance of raising concerns, reporting near misses, and identifying potential safety risks. The message is clear. We want you to speak up. Now imagine an employee identifies a concern about a workflow that could contribute to a patient safety event. They bring that concern to their supervisor.

What happens next?

Does the supervisor listen with curiosity?

Does the concern receive appropriate attention?

Is the employee thanked for identifying a potential vulnerability?

Or does the conversation become defensive?

Does the employee feel dismissed, embarrassed, or treated differently for questioning an established process?

That interaction matters, not simply because of the concern itself, but because of what everyone involved learns from the leader's response.

Employees don't determine whether it's safe to speak up based solely on what we teach them. They also learn from what happens when someone actually does.

And those experiences can influence whether the next concern is raised or remains unspoken. This is where high reliability becomes more than a concept. It becomes a leadership behavior.

High Reliability Cannot Depend on Perfect Conditions

Healthcare is complicated. Staffing challenges, competing priorities, interruptions, changing patient needs, operational pressures, and unexpected situations are part of the environment in which we work. We cannot assume those conditions will disappear. Nor can we expect healthcare professionals to compensate indefinitely for weaknesses in organizational systems simply by working harder, paying closer attention, or completing additional education. The science of high reliability recognizes the importance of understanding how complex systems operate, identifying vulnerabilities before they contribute to harm, and maintaining the capacity to respond when circumstances change. But applying those principles requires leaders to look beyond individual performance.

When an error occurs, are we examining the conditions that contributed to it?

When an employee identifies a recurring problem, are we exploring why it continues?

When a process works differently in practice than it does on paper, are we willing to learn from the people performing the work?

Or are we too quick to assume someone simply needs to follow the process more carefully?

I believe these questions are especially important for frontline leaders. We're often the connection between organizational expectations and operational reality. We see where processes work, where they break down, and where employees develop workarounds to accomplish what needs to be done. But seeing those conditions isn't enough. We need organizational environments that allow us to raise concerns, challenge assumptions, and participate in improving the systems we're responsible for managing.

Leadership Behavior Can Reinforce or Undermine Reliability

One of the things I've learned throughout my leadership career is that our reactions teach people just as much as our instructions.

We can tell employees we value honesty. But how do we respond when someone tells us something we don't want to hear?

We can encourage people to take ownership. But do we give them appropriate decision-making authority?

We can talk about continuous improvement. But are we willing to examine processes that we've personally developed or supported?

And we can encourage employee growth. But what happens when someone on our team becomes more knowledgeable, more capable, or more successful?

Do we celebrate that growth? Or do we begin treating their confidence and contributions as a threat?

These aren't small leadership questions. They influence trust, communication, employee engagement, and the willingness of people to share information. In high-reliability thinking, expertise matters regardless of where someone sits in the organizational hierarchy. That means a frontline employee may recognize an emerging operational risk before someone in a formal leadership position does. A newer employee may question a practice that experienced staff have stopped noticing. And someone without management authority may have the most useful insight into how a process actually works. Our responsibility as leaders isn't to protect our position as the person with all the answers. It's to create conditions where the right information can reach the right people and inform better decisions.

A leadership culture that discourages questions, suppresses employee growth, or punishes respectful disagreement can undermine the very reliability principles an organization is trying to establish.

The Problem Isn't Always a Lack of Training

I believe leadership education is important. I've benefited from it throughout my career, and developing practical education for healthcare leaders is a significant part of the work I'm building through The Culture Prescription. But I don't believe education alone can resolve every leadership or cultural challenge. Consider an organization where employees have completed communication training, but leaders continue responding defensively to concerns. Or a department where managers understand the importance of coaching, but operational demands consistently prevent meaningful development conversations. Or a workplace where employees are encouraged to take ownership, but nearly every decision still requires management approval.

Would another class solve those problems?

Possibly part of them. But we also need to examine the leadership behaviors, organizational expectations, decision-making structures, and operational conditions that may be reinforcing the very problems we're trying to address. Sometimes people need additional knowledge. Sometimes they need opportunities to practice new behaviors. And sometimes the organization needs to change the conditions that make those behaviors difficult to sustain. Recognizing the difference is essential.

Where The Culture Prescription™ Connects the Dots

My introduction to high reliability through studying the work of Karl Weick and Kathleen Sutcliffe helped me recognize connections between reliability principles and the leadership lessons I'd been learning through experience. Their work emphasizes the importance of recognizing potential failures, remaining attentive to operations, resisting oversimplified explanations, building resilience, and respecting expertise. These principles have important implications for healthcare leadership. But I've continued asking myself how we help leaders make those connections in their actual work.

How do we move from understanding psychological safety to recognizing the impact of our reactions during a difficult conversation?

How do we move from learning about sensitivity to operations to genuinely listening when employees describe a workflow problem?

How do we move from discussing deference to expertise to inviting the person closest to the work into a decision?

And how do we make those behaviors part of our leadership routines rather than something we remember only during training?

That's where I believe The Culture Prescription™ can contribute. Not by replacing high reliability science or introducing another competing safety philosophy. But by helping leaders connect established reliability principles with the everyday behaviors and cultural conditions that support their application. The Culture Prescription's five leadership pillars provide a practical way to explore those connections.

CONNECT: Build relationships that make communication, trust, and early identification of concerns more likely.

VALUE: Recognize employee contributions, respect frontline expertise, and create opportunities for people to be heard.

CLARIFY: Establish expectations, decision-making authority, accountability, and shared understanding.

IGNITE: Develop employee capability, encourage learning, and support people as they grow.

LEAVE BETTER: Reflect on our leadership impact and continuously improve the people, teams, and systems we're responsible for influencing.

These pillars don't replace the established principles of high reliability. They provide a leadership lens for examining whether our everyday behaviors are helping create the conditions in which those principles can be practiced.

Making Reliability Part of Everyday Leadership

I don't believe making high reliability more practical requires us to make it more complicated. In many cases, it begins with ordinary leadership moments. How we respond when an employee raises a concern. Whether we ask questions before drawing conclusions. How we approach accountability when something goes wrong. Whether we recognize the expertise of the people closest to the work. And whether we're willing to examine our own leadership behaviors when the culture we're experiencing doesn't reflect the culture we're trying to create. But individual behavior is only one part of the equation. Healthcare executives, organizational development professionals, quality and safety leaders, and frontline operations must also work together to examine the systems surrounding those behaviors.

Are managers supported in making necessary improvements?

Are employees given meaningful opportunities to contribute?

Do our operational processes reinforce the expectations we teach?

And are we evaluating culture through what people actually experience, rather than relying exclusively on whether education has been completed?

Those are the connections I want to continue exploring through The Culture Prescription. Because the goal isn't simply to help leaders become more familiar with high reliability. It's to help make reliability something we can recognize, practice, reinforce, and sustain in the work we do every day.

The Culture We Teach Versus the Culture We Live

I believe healthcare organizations have made meaningful investments in patient safety and reliability. And I believe the pursuit of zero harm remains an essential aspiration. But achieving safer, more reliable care requires us to examine more than whether people understand the principles. We also have to examine whether our leadership behaviors, operational structures, and organizational cultures support those principles when the work becomes difficult. That's a responsibility shared across the organization. And it's one that begins with questions we should be willing to ask ourselves.

Are we teaching people what a high-reliability culture should look like, or are we helping create a workplace where they can actually experience it?

Because ultimately, the culture we create isn't defined only by what we say during training. It's reflected in what happens afterward. In our decisions. In our conversations. In how we respond to concerns. And in the everyday leadership behaviors that tell people what truly matters.

High reliability shouldn't be something we only learn about. It should become something we can live out in the work we do.

That's the connection I want The Culture Prescription™ to help leaders make.

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 emerging professionals, and supporting organizational initiatives focused on leadership development, workplace culture, and high reliability.

She 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™, Sharra develops practical leadership education, mentoring, coaching, and organizational consulting resources that connect established leadership principles with the realities of operational leadership.

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