Monday, March 2, 2020

Just Culture, High Reliability, and the Power of Research

Below is the monthly message for the March 2020 edition of the MHRI newsletter, Focus. This month it is a joint message from myself and Dr. Terry Fairbanks, VP of Quality and Safety.

You can view Focus online at

Dear Friends and Colleagues,

Today we jointly write to you about a just culture, high reliability, and the power of research.

Recently, we returned from the annual MedStar Health Leadership Team retreat which was primarily focused on strategic planning for the next several years. At the onset and throughout the retreat, we were reminded about the failure of Boeing’s 737 MAX and why their corporate culture led to the death of 346 passengers and financial hardship for the company. An NPR interview with Cynthia Cole, who worked at Boeing as an engineer for 32 years says that the company’s safety-first culture started shifting and “greater emphasis on maximizing profits over safety caused all kinds of problems.” A recent Forbes article entitled “What Boeing has taught us about not neglecting company culture” gives examples of the tendency to “avoid speaking up so that you don’t get in the way of success of the endeavors of the organization.” There were specific examples of how the problems in 737’s Max’s auto-throttle system were recognized but employees were afraid to tell their managers or worse, their concerns were discounted.

The Boeing story is very sad but telling. The Boeing 737 MAX disaster could have been avoided and Boeing could have saved hundreds of lives and billions of dollars if the employees were empowered to speak up and their voice was heard. Same applies in medicine. Lives can be saved by empowering everyone to speak up, voice their concerns, and have an environment where it is safe to be heard. In fact, our Leadership Team retreat started with a safety moment exemplifying this concept when an adverse event was first discovered.

We are proud that MedStar Health has developed an HRO culture based on speaking up, directly addressing adverse events, maintaining transparency with the patient, and applying systems-based learning from serious safety events. This has led to a nationally funded, AHRQ program (CANDOR) which allowed us to further optimize and scale this model approach. This is just one of many examples of how research has help power the creation of a just culture at MedStar Health. More recently, MedStar Health investigators have studied electronic medical record safety and reporting, working to protect patients and clinicians by advocating for transparency and improvements when it comes to these systems.

Research is the pursuit of truth through formalized investigation. Whether it comes from an academic study or via clinical experience at the bedside, it is the power we all need to learn and improve. Medicine will get better and safer as we share what we know and collectively use that knowledge to learn from for long-term success. This is a learning healthcare system.  This is the essence of a high reliability culture and this is MedStar Health.

Thank you for advancing health, quality, and safety at MedStar Health.

Neil & Terry
Neil J. Weissman, M.D.
Chief Scientific Officer, MedStar Health
President, MedStar Health Research Institute
Professor of Medicine, Georgetown University

Rollin J. (Terry) Fairbanks, MD MS
Vice President, Quality & Safety, MedStar Health
Professor of Emergency Medicine, Georgetown University

Read Focus at

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