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The underappreciated role of habit in highly reliable healthcare
  1. Timothy J Vogus1,
  2. Brian Hilligoss2
  1. 1Owen Graduate School of Management, Vanderbilt University, Nashville, Tennessee, USA
  2. 2College of Public Health, The Ohio State University, Columbus, Ohio, USA
  1. Correspondence to Professor Timothy J Vogus, Owen Graduate School of Management, Vanderbilt University, 401 21st Avenue South, Nashville, Tennessee 37203, USA; timothy.vogus{at}

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We are what we repeatedly do. Excellence then, is not an act, but a habit.1

Healthcare leaders,2 ,3 academics4–7 and regulators,8 ,9 continue to push healthcare organisations to emulate high-reliability organisations (HROs) like aircraft carrier flight decks and nuclear power control rooms10 to solve long-standing quality and safety problems in healthcare delivery. The nearly error-free performance of HROs in trying circumstances is a function of mindful organising—a set of behavioural and cognitive processes by which their members discern latent and manifest threats to reliability and act swiftly to resolve them.11 ,12 Emerging evidence suggests that processes of mindful organising are associated with lower error rates,13–15 more reliable service performance16 and even lower turnover.17 Yet despite persistent calls by influential leaders and promising empirical evidence, there is little indication of highly reliable performance in healthcare generally.8 ,9 ,18 In other words, the pursuit of highly reliable healthcare through mindful organising has become a problematic improvement to the problem of medical error.19 We ask, ‘why does high reliability remain so elusive?’

Fostering improvement often starts with looking at what successful people and organisations consistently do as evidenced by the continuing popularity of Steven Covey's 7 Habits of Highly Effective People20 or Charles Duhigg's The Power of Habit.21 Similarly, we argue that the continued unreliability of healthcare delivery results from the failure to turn periodic mindful practice into consistent, enduring habit. In other words, we focus on healthcare organisations that either aspire to be highly reliable and/or have attempted to pursue it in some manner but have not achieved reliable performance. For example, hospital executives may consistently emphasise a zero harm goal and frequently talking with frontline care providers about safety (ie, WalkRounds), yet not translate the emphasis into concrete workplace changes.22 In other cases, organisations may make substantial investments in comprehensively training their workforce in a particular practice shown to enhance reliability (eg, crew resource management23), but fail to meaningfully integrate it into everyday practice. In other words, organisations may motivate their people to pursue high-reliability through campaigns and slogans and adopt the surface-level features of HROs like programmes and practices, but struggle to make it stick as new ways of consistently thinking and acting. That is, the complexity of achieving highly reliable performance is underappreciated19 and, as a result, the behavioural, cognitive and workplace infrastructure for high reliability11 is underdeveloped in healthcare.

To better understand the nature and nuances of habit and its application to improve operational reliability, we look to theory24 on habit, especially the foundational scholarship of Dewey.25 Considering habit in a more sophisticated manner helps illustrate how the core of high reliability (ie, mindful organising) is itself habits of thought and action. Foundational theory on habit also provides a more explicit and nuanced view of what it takes to actually create and sustain highly reliable performance and in doing so hopefully reduces incomplete imitation of HROs that fails to reproduce their results.24 Specifically, we use habit as a lens for reanalysing cases of when organisations remain mired in low reliability26–28 or create and sustain highly reliable performance4 ,29–31 and when highly reliable performance collapses.32 ,33


Habit was a central concept in both sociology and psychology in the early 20th century and was especially prominent in the work of John Dewey25 and the American pragmatist movement. According to Dewey, human action is produced by three faculties: habit, ‘intelligence’ (ie, deliberation) and ‘impulse’ (ie, emotion). Of these, habit is primary: ‘Man [sic] is a creature of habit, not of reason, nor yet of instinct’.25 All skilled activity, including perception and deliberation, is shaped by underlying habits.25 ,34–36 In other words, habit was viewed as foundational to human action and the cultivation of habit as paramount to progressive reform. But the prominence of habit faded in the mid-20th century as sociologists further separated from psychology,37 as economists focused on rational or boundedly rational actors and as psychologists engaged in the ‘cognitive turn’.38 Deliberation—the term we use here to signify conscious, rational cognitive processes—came to be viewed as the primary driver of human action. But the inability of deliberation theories to adequately explain behaviours and guide efforts to change them has contributed to renewed attention to the role of habit in human behaviour21 ,39–41 and reinvigorated interest in Dewey's insightful theory.42–45 Dewey identified an important inter-relationship among the three faculties. ‘Emotion is a perturbation from clash or failure of habit, and reflection, roughly speaking, is the painful effort of disturbed habits to readjust themselves’.25 When habituated action is interrupted, typically because something in the environment has changed making the fulfilling of the habit difficult or impossible, emotions are released, serving in part as a useful trigger to engage deliberation in problem-solving. But even that deliberation will rely on habituated modes of problem-solving. In short, habits are crucial for our daily activities, whether routine or unusual, continual or interrupted.

Although habit is typically viewed as the mere recurrence of specific behaviours, Dewey offers a richer, more expansive view of habit. First, Dewey formulates habits as predispositions or tendencies towards modes of action. While involving mechanisation, repetition is not the essence of habit. Rather, habit is plastic, adaptable and best understood as an action disposition sensitive to particular stimuli.42 ,45

Second, habits are acquired and shaped by prior actions.44 ,46 ,47 The implication is that learning, through both formal training and informal experimenting, plays a crucial role in the (re)formation of habit.

Third, habits are automatic, operating largely below the level of conscious thought.34 ,39 This automaticity, a chief source of habit's value, enables speedy action and conserves cognitive resources for activities that truly demand them like unexpected events.43 It also plays a crucial role in the seemingly effortless skill we associate with the expertise of a renowned surgeon. Automaticity connects habit with system 1 (ie, ‘fast thinking’) in dual processing models of cognition.46 ,48 However, discussions of system 1 automaticity tend to focus unnecessarily on deleterious consequences (eg, biases) that can result in misinterpretations,43 while ignoring how the automaticity of habit can also provide efficiencies, freeing up attention for noticing discrepant cues in unfolding situations.

Fourth, habits are fitted to environment and contextually cued.35 ,40 They form as ways of dealing with environments and recurring situations and, as such, are functionally intelligent.43 The influence may work the other way as well: recurring habituated actions play a part in reproducing situations and environments. By acting in patterned ways, we recreate the social and physical conditions that we and others face. The power of contextual cues to trigger habits may help explain why intentions and explicit goals are often insufficient to change behaviours.40 ,49

Finally, many habits are shared among members of groups, signifying a strong social element to what is sometimes conceived as an individual property.42 Dewey identified two inter-related explanations for shared habits, which he also called ‘customs’. First, people often face similar situations in common environments and act in similar ways to deal with those situations. Second, and perhaps more influential, shared habits ‘persist because individuals form their personal habits under conditions set by prior customs’.25

Advances in neuropsychology have provided support for aspects of habit that Dewey identified nearly a century ago.47 For example, research finds that humans have two separate modes of memory: a declarative mode for storage of facts (ie, ‘know what’) and a procedural mode for storage of skilled activity (ie, ‘know how’).50 ,51 Procedural memory is much more dependent on tacit knowledge and much less subject to decay than declarative memory. In other words, habits are difficult to articulate but highly durable and enduring. Neuropsychology research further reinforces Dewey's notion of enduring ‘habits of thought’ by demonstrating that the ‘habit learning system’ is important for cognitive as well as motor skills.52

Habits and high reliability

In some cases, reliability-enhancing habits can be cultivated through physical redesign of work environments53 (eg, improving handwashing compliance by increasing the availability of disinfectant dispensers),54 but habitual compliance with effective practice is not enough. High reliability requires cultivating more mindful habits of thought and action focused on detecting deviations and identifying weak signals of impending danger to facilitate swift, flexible action (see table 1).11 ,13 High reliability results from processing events in a richer, yet more provisional manner that continually updates what is hazardous55 and managing fluctuations by making the right response at the right time.56 Mindful organising becomes habit through ongoing training on problem-sensing and socialisation through, in part, sharing vivid ‘war stories’.55 ,57 Table 2 elaborates each component of mindful organising and links them to questions that can be asked in everyday practice especially at critical moments (eg, care transitions, considering organisational changes). We focus on questions leaders and front-line staff can repeatedly ask because these questions convey the essential habit of high reliability—a disposition to thinking and acting more mindfully. Thus, while the specific practices outlined in table 1 (eg, collaborative rounding, extensive training, briefings and huddles) can enhance reliability, we argue that the consistency with and manner in which practices are carried out is the key to highly reliable performance. The examples that follow further illustrate the linkages between practices, mindfulness and habit.

Table 1

The components of habit and high reliability

Table 2

The components of mindful organising and implementing them in everyday practice

Mindless habits are difficult to dislodge

Dangerously unreliable organisations like the Bristol Royal Infirmary,28 Mid Staffordshire27 and most recently St Mary's Medical Center in the USA26 all illustrate how entrenched less-mindful habits need first to be dislodged before mindfulness and reliability can result. In all these organisations there was a long-standing history of habitually responding by ignoring or suppressing negative performance information. In other words, based on their histories (poor performance with reprimands from outsiders), they habitually explained away poor outcomes.

Explaining away problems and other comfort-seeking behaviour becomes a habit when prior attempts to do otherwise (eg, raise concerns) are unheard, ignored or actively suppressed.27 Consequently, more mindful practice and higher reliability requires abandoning habits of thought and action that buffer individuals and their organisation from uncomfortable realities (eg, deaths are merely anomalies that are a function of uniquely difficult cases).26–28 But the act of buffering through self-serving explanations becomes self-reinforcing and mindlessly habitual.28

These high-profile cases also reflect how less-mindful practice gets habituated more generally. For example, frequently using workarounds creates a habit of seeing recurring problems and workarounds as inevitable and unworthy of the extra (and likely fruitless) effort of reporting. Thus, fixing a problem in the moment and forgetting it rather than fixing and reporting it such that the problem can be avoided in the future becomes habit.58

Creating and sustaining habitual mindfulness and reliability

The Virginia Mason Production System (VMPS)29 and the Comprehensive Unit-based Safety Program (CUSP) at Johns Hopkins4 ,30 ,31 have created and sustained highly reliable performance through new, more mindful, habits of talking and thinking supported by reinforcing contexts that operate independently of any specific leader. At Virginia Mason, the VMPS cultivates mindfulness and fosters reliability through building shared habits of thought and action throughout the organisation that emphasises an improvement orientation and a relentless focus on patients and the patient perspective. The improvement orientation is instilled through training on and frequent use of a shared set of tools (Kaizen, Plan-Do-Study-Act (PDSA) cycles, Value Stream Maps, Andon, etc) as well as immersive experiences (ie, 2 days improvement events) that break people out of old habits of thought and action.29 New, more mindful, habits are reinforced by regular active and supportive leadership presence on the floor.29 In addition, all quality measures are viewed from the perspective of the patient and disciplined by assessing all activities by asking, ‘do they add value from the patient's perspective?’29 Thus, VMPS carefully cultivates and reinforces more mindful habits that foster reliability.

The CUSP approach emphasises more mindful habits in the form of greater collaboration and communication, specifically problem identification, escalation and resolution. The purpose is to get care team members to share more of what they know and ensure that it is heard. CUSP reinforces mindful habits in three ways: carefully constructing diverse improvement teams with the requisite clinical and improvement expertise, using shared language and tools for improvement (eg, process maps, common improvement methodology) and creating feelings of efficacy by formalising prior suggestions into new standards and routines.30 ,31 The latter also frees up attention in a way that enhances mindfulness and the ability to detect and correct the unexpected more swiftly. The results of more mindful habits through CUSP have been impressive as organisational reliability improved across an array of measures.30 ,31

The fragility of mindfulness and reliability

VMPS and CUSP illustrate two possibilities of creating highly reliable performance; however, sustained reliability relies on the continuing active and disciplined application of more mindful habits of thought and action. In other words, mindfulness and reliability are fragile, especially in the face of disruptive events like changes to leadership, organisational structure and physical environment. That means when the context significantly changes, established habits can fail to function effectively. The Loma Linda Pediatric Intensive Care Unit (PICU) illustrates how changing the context, specifically unit leadership, can generate or undermine reliability-enhancing habits. When two hospitalists familiar with high-reliability concepts took charge of the unit, the PICU was able to instil mindful organising. Specifically, the leaders implemented practices derived from research on HROs, including continuously training staff (especially to aid identifying early weak signals of physiological dysfunction) through formal and informal in-servicing, collaborative rounding (ie, joint rounding by all caregivers), empowering the bedside caregiver (ie, giving them more voice and deferring to their expertise on clinical matters) and frequent and inclusive post-event debriefings.32 ,33 Each of these practices became part of a set of shared habits of thought and action that resulted in highly reliable performance. However, when new leadership took over the unit and upended these practices, replacing them with a more ‘traditional’, hierarchical approach driven exclusively by the physicians, the mindful habits were undermined.33 Consequently, staff throughout the unit reverted to passive patterns of practice. In other words, the new leaders created a context that cued less engaged, less-mindful habits resulting in lower levels of reliability (eg, higher mortality rates).


High reliability has remained elusive in healthcare because organisations have failed to recognise the central role of habit. We have articulated the five components of habits and illustrated how mindful organising represents particular habits of thought and action. Specifically, mindful organising means consistently asking—What are ways that a patient (or care process) could break down? What are the dangerous assumptions we are making? How do we know things are going poorly and it is time to reflect and adapt? Are we readily able to draw upon necessary expertise for the problem(s) at hand? Changing to instil the habits of high reliability entails ‘analyz[ing] an act in the light of habits, and analyz[ing] habits in the light of education, environment and prior acts’.25 In other words, jettisoning less-mindful habits, instilling more mindful ways to act and interact and creating a supportive context that cues and reinforces mindful habits.


We would like to thank the late Michael D Cohen for inspiring us to carefully revisit the work of Dewey and apply it to important problems in theory and practice.



  • Contributors Both authors (TJV and BH) have made substantial contributions to the conception and writing of the working including generating ideas, reviewing literature, drafting the work and revising it critically for important intellectual content and in response to editor and reviewer comments. Both authors also approve of the version being submitted for publication, stand behind its accuracy and integrity and agree to be accountable for all aspects of the work.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.