High Reliability Organizations (HROs)

High reliability organizations (HROs) are organizations that operate in complex, high-hazard domains for extended periods without serious accidents or catastrophic failures. According to the Agency for Healthcare Research and Quality (2016), HROs use systems thinking to evaluate and design for safety but they are keenly aware that safety is an emergent, rather than a static, property. New threats to safety continuously emerge, uncertainty is endemic, and no two accidents are exactly alike. HROs work to create an environment in which potential problems are anticipated, detected early and virtually always responded to early enough to prevent catastrophic consequences. Sometimes people interpret the meaning of high reliability as effective standardization of health care processes. However, the principles of high reliability go beyond standardization; high reliability is better described as a condition of persistent mindfulness within an organization. HROs cultivate resilience by relentlessly prioritizing safety over other performance pressures. A classic example is that of the military aircraft carrier. Despite significant production pressures (aircrafts take off and land every 48 – 60 seconds), constantly changing conditions and hierarchical organizational structure, all personnel consistently prioritize safety and have both the authority and the responsibility to make real-time operational adjustments to maintain safe operations as the top priority.

The concept of high reliability is attractive for health care, due to the complexity of operations and the risk of significant and even potentially catastrophic consequences when failures occur. Of course, military aircraft carriers, commercial aviation, nuclear power plants, and other sectors known for high reliability differ from the health care system in critical ways. Concepts and approaches they have used cannot be directly duplicated in hospitals and other health care organizations. Instead, high reliability concepts need to be adapted and contextualized to meet the specific organizational needs and help focus attention on creating a culture of safety that is essential for any improvement approaches to work. Organizations with the strong safety culture maintain continuing alertness, pay close attention to any signals of failure within the system and have shared perceptions of the importance of safety. Weick and Sutcliffe (2007) have identified the five principles of organizational mindfulness that are at the core of HROs. These fundamental principles include the three principles of anticipation (Preoccupation with Failure; Reluctance to Simplify; Sensitivity to Operations) and two principles of containment (Commitment to Resilience; Deference to Expertise). The figure below illustrates the relationships between the five principles of organizational mindfulness and high quality care. Without a constant state of mindfulness, an organization cannot create or sustain highly reliable systems.


High Reliability Concepts


Preoccupation with Failure. HROs are focused on predicting and eliminating catastrophes rather than reacting to them. These organizations constantly entertain the thought that they may have missed something that places patients at risk. Near misses are viewed as opportunities to improve current systems by examining strengths, determining weaknesses, and devoting resources to improve and address them. Near misses are not viewed as proof that the system has enough checks in it to prevent errors, because that approach encourages complacency rather than reliability. Instead, near misses are viewed as opportunities to better understand what went wrong in earlier stages that could be prevented in the future through improved processes.

Reluctance to Simplify. HROs refuse to simplify or ignore the explanations for difficulties and problems that they face. These organizations accept that their work is complex and do not accept simplistic solutions for challenges confronting complex and adaptive systems. They understand that their systems can fail in ways that have never happened before and that they cannot identify all the ways in which their systems could fail in the future. This does not mean that HROs do not work to make processes as simple as possible. They do. It does mean that all staff members are encouraged to recognize the range of things that might go wrong and not assume that failures and potential failures are the result of a single, simple cause. HROs build diverse teams and use the experiences of team members who understand the complex nature of their field to continually refine their decision making methods. Oversimplifying explanations for how things work risks developing unworkable solutions and failing to understand all the ways in which a system may fail, placing a patient at risk.

Sensitivity to Operations. HROs recognize that manuals and policies constantly change and are mindful of the complexity of the systems in which they work. HROs work quickly to identify anomalies and problems in their system to eliminate potential errors. Maintaining situational awareness is important for staff at all levels because it is the only way anomalies, potential errors, and actual errors can be quickly identified and addressed. Sensitivity to operations will both reduce the number of errors and allow errors to be quickly identified and fixed before their consequences become larger. Sensitivity to operations encompasses more than checks of patient identity, vital signs, and medications. It includes awareness by staff, supervisors, and management of broader issues that can affect patient care, ranging from how long a person has been on duty, to the availability of needed supplies, to potential distractions.

Commitment to Resilience. HROs pay close attention to their ability to quickly contain errors and improvise when difficulties occur. Thus, systems can function despite setbacks. HROs assume that, despite considerable safeguards, the system may fail in unanticipated ways. They prepare for these failures by training staff to perform quick situational assessments, working effectively as a team that defers to expertise, and practicing responses to system failures.

Deference to Expertise. HROs cultivate a culture in which team members and organizational leaders defer to the person with the most knowledge relevant to the issue they are confronting. The most experienced person or the person highest in the organizational hierarchy does not necessarily have the information most critical to responding to a crisis. A high reliability culture requires staff at every level to be comfortable sharing information and concerns with others —and to be commended when they do so. A de-emphasis on hierarchy is essential for organizations to prevent and respond to problems most effectively. In many situations, different staff members as well as the patient and family may have information essential to providing ideal care. Deference to expertise entails recognizing the knowledge available from each person and deferring to whoever’s expertise is most relevant to the choices being made.

Although high reliability concepts and principles are very useful, they should not be viewed as conflicting with strategies already being used to promote quality and safety. High reliability concepts are neither quality improvement methodology nor a simple roadmap to help organizations arrive at a permanent state of high reliability in which patients always receive exactly the care they need and the care is provided in systems that have no inefficiencies or waste. High reliability organizing is an ongoing process that is never perfect, complete or total.


Building Highly Reliable Systems