Table 2

Reliability framework based on a literature review and analysis

Phase 0: Healthcare as craft; reliability level: 10−1 (<80% of processes are without defects)Phase 1: watchful professional; reliability level: 10−1 (90% of processes are without defects)Phase 2: collective professionalism; reliability level: 10−2 (99% of processes are without defects)Phase 3: highly reliable; reliability level: <10−3 (99.5% of processes are without defects)
Process optimisation and standardisation
  • No articulated processes.

  • Transfers between professionals/processes are ad hoc and therefore error-prone.

  • Lack of routine and lack of experience.

  • Protocols available for essential processes.

  • There is vigilance and a focus on individual discipline.

  • Checklists for processes used by individuals.

  • Decision aids, alarms and reminders built into the care-delivery processes.

  • Desirable outcome is the default modus.

  • Process standardisation and collective checklists lead to complexity reduction.

  • Redundancy in processes, thereby creating fail-safe processes

Outcome measurement and monitoring
  • No structural measurement of process and/or outcome indicators and therefore no insights into quality of care.

  • Registration of adverse events but no insight into trends.

  • Some process or outcome indicators are monitored, but there is no benchmarking. At best, the focus is on mediocre performance elsewhere.

  • Quality monitoring is not part of the planning and control cycles.

  • Structural real-time measurement (statistical process control) of process and outcome indicators.

  • Continue benchmarking with best of class.

  • Continual screening for possible unsafe events before unsafe events occur

Responsibilities and accountability of medical professionals
  • Professionals have individual autonomy.

  • Patient safety is the responsibility of individual professionals; no overall control.

  • Limited individual autonomy.

  • Individual medical professional is responsible for quality and safety of care.

  • Overall control of safety by introduction of meetings, norms and limits.

  • Limited collective autonomy for teams (professionals and managers around one medical condition).

  • Central control and accountability based on process measures.

  • Teams with situational awareness.

  • Very strict control, but at the same time large responsibilities delegated to the ‘front-line’ (decentralised).

Organisational culture
  • No explicit focus on patient safety.

  • Taking risks is equal to high status.

  • Absence of self-critical attitude; ‘denial of vulnerability.’

  • Learning by doing.

  • Respect for each other's roles; addressing safety issues is possible beyond professional boundaries.

  • Individual effort can improve outcomes (from reasonable to excellent).

  • ‘Zero-tolerance’ for violating standards.

  • Teams in which individual performance is of minor importance compared with overall performance.

  • Collective drive to achieve a high-quality and safe environment.

  • Safe introduction of new techniques.

  • Focus on improving safety issues—even when things go well already.

  • A preoccupation with possible failure.