High Reliability Organizations: Implications for Nursing Knowledge Development

Abstract

One of the most challenging goals health care organizations face today is how to create practice environments that ensure the consistent delivery of high-quality safe care to all patients. A number of major reports over the past 10 years have documented safety issues in health care. A landmark report of this type is the Institute of Medicine report Keeping Patients Safe (Page, 2004), which focused on the important role nurses play in maintaining safe work environments. While ample evidence exists to document the problems of safety, it is difficult to find strategies or techniques that consistently prevent the occurrence of unsafe care or create environments that promote safety. Other industries face challenges in preventing errors of great consequence from occurring, and research about their experiences has provided insights for health care organizations. For example, on aircraft carriers and in nuclear power plants, errors or failures in critical processes, even if infrequent, can have terrible consequences. Examining these industries and how they try to prevent or reduce failures has resulted in the concept of high reliability. Just as we examine reliability in a research sense, looking for consistency and dependability of performance, organizations that create working environments and processes that reduce system failures are referred to as high reliability organizations (Weick & Sutcliffe, 2001). These types of organizations operate under trying conditions in a nearly error-free manner; they have developed a working culture and processes that reduce system failures and ensure effective response systems when errors occur. The concept of high reliability applies in a number of high stakes industries that face potentially catastrophic errors. Characteristics of organizations that pursue high reliability have been identified through research (LaPorte & Consolini, 1991; Schulman, 1993). These include * Hypercomplexity: environments that depend on multiteam systems working together for safety; * Extreme hierarchical differentiation: clearly defined and differentiated roles that require intense coordination to keep members of the team working together; * Multiple decision makers working in a complex communication network: many individuals working together who make important, interconnected decisions; * Tight coupling: work produced by teams in which the members are dependent on tasks performed across the team, requiring coordination and trust; * High degree of accountability: when errors occur, there are severe consequences; and * Work performed under compressed time constraints: significant time constraints present major challenges, especially from the perspective of training and resources. These characteristics apply to health care organizations as well. However, health care organizations face two additional challenges: care of patients rather than machines and higher workforce mobility (Hines, Luna, & Lofthus, 2008). …