Reliability is often associated with systems or organizations. However, reliability also refers to people as individuals, as collectives, and as the interface with technology and machines. The behaviors expressed as human error and choices in the socio-technical system are the focus to appreciate and understand humans as part of a reliable system.
Consider the individual. You’ve heard the expression that he or she is not reliable. So what does that mean in the context of HCRO: Is the person habitually late? Do they lack sufficient attention to detail? Do they fail to show up when expected? Do they degrade in performance under conditions of fatigue, distraction, stress, illness or discomfort? Are they labile or unpredictable when confronted with challenging or novel situations? Do they lack the mental toughness and focus to manage challenging or unexpected conditions? In other words, are they resilient and can they recover? Resilience is the foundation for improvisation and innovation when conditions or circumstances cannot be sufficiently addressed by standard work of a reliable process design. It is a characteristic of reliability.
These considerations beg the question if reliability can be achieved in the human condition. Can reliability be designed into human behavior and trained and reinforced? We believe that it can through error mitigation and choices. Awareness of vulnerability to risk is the first step to reliability. Design of schedules and practices that become habit enable reliability. Training and monitoring with feedback sustains reliability. We know that people working and living in unmitigated risk defend against vulnerability by losing situational awareness, losing curiosity, and believing “this is as good as it gets.” It is a dangerous place to be.
Consider these questions in the example of a nurse rounding on patients. Is rounding scheduled? Is it structured? Is there a checklist of must do or observe? Is interaction scripted to elicit information and communicate compassion? As with any competency or skill, personal reliability is a rehearsed set of desirable behaviors that become internalized and that are recognized and rewarded for sustainability. Think of reliability as a professional competency.
For example, competencies for achieving reliability include curiosity to develop data to become knowledge, leading to understanding and appropriate action-taking. Reliability also includes the design of processes or systems that allow for vulnerabilities by creating resilience to improvise under uncertain conditions. And, reliability requires mindfulness and continuous assessment to identify and predict barriers that may undermine performance. These can be learned and practiced.
Consider the collective or group. Reliability of the collective can be thought of in terms of culture. Is it a culture of reliability? Are there predictable behaviors and peer monitoring for the collective to stay the course and self-correct to prevent drift, shortcuts in process or denigration in communications and teamwork? As with personal or individual reliability, a culture is created through design, practices, rehearsals, and predictability in schedule, process, team formation and structure, and interdependent behaviors of mutual respect and accountability.
Let’s take the example of rounding again. Interdisciplinary rounds, including patients and families, can be an orchestration of reliable performance. Does the team come prepared and assemble at the appointed time? Do they know each other and introduce themselves to the patient and family? Is the dialogue designed for balanced participation and all voices being heard? Is there a consistent method by which rounds are conducted so that everyone, including patient and family, are oriented and understand their role and contribution? Is the location of position for each rounding member understood? Is there a debrief to examine ways to continually improve teamwork and rounding?
Consider Person-Technology Interface. Reliable person-technology (human-machine) interface requires careful deliberate design, usability testing, training, and vigilance. The belief in the infallibility of technology and instrumentation can promote over-reliance on technology, and the personal judgment requiring choice and action can be subjugated to machine, leading to technology assisted error versus technology enabled reliability.
Reliable performance does not simply happen by using the words. It requires discipline, skill, and continual vigilance. Reliable performance requires humility to acknowledge fallibility and the courage to call it out, become transparent, and mitigate so reliability becomes a continued work in progress.