High Reliability Organizations Research Articles

Implementation of a High-Reliability Organization Framework in a Large Integrated Health Care System: A Pre-Post Quasi-Experimental Quality Improvement Project.

The purpose of this quality improvement (QI) project was to evaluate outcomes across Veterans Health Administration (VHA) hospital facilities engaged in an enterprise-wide implementation of a high-reliability organization (HRO) framework. This QI project relied on primary data drawn from 139 facilities nationwide from 2019 to 2023. Data sources included the All Employee Survey Patient Safety Culture (PSC) Module and patient safety reporting data derived from the Joint Patient Safety Reporting system. The project design applied a pre-post quasi-experimental design that examined within-cohort changes at pre-intervention, intervention, and 2 post-intervention follow-up timepoints. HRO interventions included a combination of training, leadership coaching, site assessments, and experiential learning. HRO interventions were initiated at 18 facilities beginning in 2019 (Cohort 1), 54 facilities in 2020 (Cohort 2), and 67 facilities in 2021 (Cohort 3). For between-cohort analyses, the relative degree of change within Cohort 1 sites was compared with all other sites. There were broad positive within-group trends for PSC scores across all sites, and domain-specific between-group differences in PSC Dimension 2-Risk Identification and Just Culture-and Dimension 4-Error Transparency and Risk Mitigation. For patient safety reporting, total events reported, and close calls increased for Cohort 1. The ratio of close calls to adverse events also increased for both Cohort 1 and all other VHA sites at post-intervention year 2. The results of this QI project will inform further refinements to VHA's efforts to implement HRO principles and practices in the nation's largest integrated health system. In addition, the implementation practices may inform other large-scale, multi-level efforts to improve quality and patient safety.

Design Approaches for Developing Quality Checklists in Healthcare Organizations: A Scoping Review.

Quality checklists have demonstrated benefits in healthcare and other high-reliability organizations, but there remains a gap in the understanding of design approaches and levels of stakeholder engagement in the development of these quality checklists. This scoping review aims to synthesize the current knowledge base regarding the use of various design approaches for developing quality checklists in healthcare. Secondary objectives are to explore theoretical frameworks, design principles, stakeholder involvement and engagement, and characteristics of the design methods used for developing quality checklists. The review followed the Preferred Reporting Items for Systematic Reviews 2020 checklist. Seven databases (PubMed, APA PsycInfo, CINAHL, Embase, Scopus, ACM Digital Library, and IEEE Xplore) were searched for studies using a comprehensive search strategy developed in collaboration with a health sciences librarian. Search terms included "checklist" and "user-centered design" and their related terms. The IAP2 Spectrum of Participation Framework was used to categorize studies by level of stakeholder engagement during data extraction. Twenty-nine studies met the inclusion criteria for this review. Twenty-three distinct design methods were identified that were predominantly non-collaborative in nature (e.g., interviews, surveys, and other methods that involved only one researcher and one participant at a given time). Analysis of the levels of stakeholder engagement revealed a gap in studies that empowered their stakeholders in the quality checklist design process. Highly effective, clear, and standardized methodology are needed for the design of quality checklists. Future work needs to explore how stakeholders can be empowered in the design process, and how different levels of stakeholder engagement might impact implementation outcomes.

Building a Learning Management Framework for Patient Safety: Lessons From a Large Multistate System

Background Embracing a learning, transparent, and improvement culture is crucial for healthcare organizations to effectively learn from human errors and deliver safer, higher-quality patient care. However, the application of organizational learning in healthcare has been relatively narrow, necessitating the establishment of learning systems across healthcare organizations. This paper presents a novel learning management framework in a multistate health system, which is also a patient safety organization (PSO), facilitating a transition into a high reliability organization. We also provide initial results, uniquely contributing to the limited literature on healthcare learning management networks for patient safety. Methods We explore solutions for widespread learning from safety events in a large multistate U.S. healthcare system. We discuss the challenges of culture, technology, measurement systems, and barriers to learning from errors. We present our key driver diagram, critical details of implementing a learning network, and our initial findings, including the positive impact of the good catch program and the culture of safety survey. These initiatives have led to improved communication about errors and a growing willingness to learn from them, demonstrating the effectiveness of our learning management network. We also discuss the importance of data in organizational learning. Results From 2021 to 2023, the overall event reporting rate, which includes all severity levels of harm, increased by 22.41%, from 165.15 to 202.16 events per 10,000 patient days (p-value<0.0001). The reporting rate for near-miss events also rose by 20.50%, from 138.09 to 166.41 events per 10,000 patient days (p-value<0.0001). We attribute these improvements to enhanced data sharing and a culture of transparency the learning management network fosters. The “Communication about error” element in the culture of safety survey, with over 55,000 respondents, improved from 69.5% in 2020 to 70.6% in 2022 (p-value<0.0001), indicating better communication and a growing willingness to learn from errors. Feedback from over 1,000 PSO safe table participants highlighted a respectful and supportive atmosphere, acknowledging areas for improvement without blame. Conclusion In conclusion, we emphasize the comprehensive approach to patient safety, utilizing diverse strategies and evidence-backed methods to spread learning and data sources and reinforcing the commitment to “healing without harm.” Looking ahead, we aim to instill essential learning mindsets, create psychologically safe workplaces, and promote high reliability and safety behaviors. We remain optimistic that the maturation of the learning management network will ultimately contribute to a decrease in harm rates, aligning with our ongoing commitment to patient safety and continuous enhancement. Our future research will focus on further refining and expanding the learning management framework to significantly impact patient safety in healthcare organizations.

Perception of Nurses Toward Working at High Reliability Healthcare Organizations: The Association to Nurses' Psychological Safety and Intention to Stay

Background: High-reliability organizations (HROs) of healthcare are facing tough challenges to improve nurses’ psychological safety and intent to stay through maintaining organizational resources, work flexibility, environmental safety, and effectively managing stress and anxieties the nurses face in the workplace. Aim: This study aims to identify the relation between perception of working at HRO, psychological safety and intent to stay among Dar Al-Fouad Hospital nurses. Design: A correlational ex-post facto research. Setting: The study was conducted at Dar Al Fouad Hospital. Study subjects: A simple random sample of nurses who are working in Dar Al Fouad Hospital n=225. Tools: Three instruments were used in this study: the instrument one Part (1) - personnel data, Part (2) - Safety Organizing Scale; instrument two - team psychological safety scale, and instrument three - nurses’ intent to stay scale. Results: The total perception levels of HRO was moderate 64.5%, psychological safety was moderate 75.6%, and intent to stay was moderate 89.3% among the studied sample. Conclusion: There was negative statistical significance relation between staff nurses’ total perception level regarding HRO, and psychological safety and intent to stay. Recommendation: Health care managers at HRO work to improve nurses’ psychological safety and intent to stay through providing personal and professional support, encouraging to report mistakes, ask questions, receive effective feedback, and see mistakes as opportunities to learn. Keywords: High reliability organization; Intent to stay; Psychological safety.

(Re)Considering Online Organizations: Communicating and Organizing via New Technology for High Reliability

Tom MacDonald’s success in the music industry can provide valuable insights for leaders and founders, particularly in the context of high-reliability organization (HRO) theory—MacDonald’s approach to music challenges conventional wisdom and societal norms, promoting open communication and adaptability. HROs should prioritize open channels, invest in training, and support continuous learning. Clear communication is crucial for employees to understand the organization’s roles, responsibilities, and goals, facilitating collaboration and problem-solving. It also helps manage change and prevents crises. Investing in communication skills and practices is essential for driving organizational success and resilience in today’s fast-paced business environment.

Learning in the gray zone: Harmful organizational learning from safety deviations in nuclear power plants

Organizations often encounter safety deviations, events that diverge from established safety standards without causing substantial harm. Despite their critical role in preventing severe safety incidents, organizational learning from safety deviations has been understudied. We propose that safety deviations lead to harmful learning due to decision-makers’ self-enhancement tendencies and normalization of these deviations, which facilitates future safety incidents. Our analysis of global nuclear power plants from 1990 to 2017, representing high-reliability organizations, supports this argument. Additionally, we demonstrate that institutional factors significantly mitigate the harmful effects of learning from safety deviations. This study advances the organizational learning literature by distinguishing learning from safety deviations from that derived from safety failures. Finally, we discuss practical implications for fostering safer organizations and societies.

High Reliability Organizations: Safety, Quality, and Ethics.

High Reliability Organizations: Safety, Quality, and Ethics.

The Clinical Nurse Specialist: A Valuable Asset to a High-Reliability Healthcare Organization.

High-reliability organizations aim to achieve zero harm. The clinical nurse specialist (CNS) is an advanced practice RN who adds value to the leadership team. The CNS is proficient in influencing care delivery across the continuum and the master of developing collaborative relationships that aid in the discovery of deficiencies in care and generation of innovative ideas to minimize deficiencies. This column provides some examples of the impact and role of the CNS.

Leveraging Consistent Communication Tools and Organizational Values to Promote Accountability Among Health Care Providers.

Teamwork and effective communication between all health care staff members are essential to providing safe, high-quality patient care. High-reliability organizations align behavioral expectations with organizational values and prioritize safety over other performance metrics and pressures. Communication breakdowns, such as inadequate or incomplete information shared between caregivers, continues to be an issue that is linked to errors and staff member dissatisfaction. Initiatives to improve health care communication and improve patient outcomes are well documented, yet communication issues in the health care setting continue. An organization's credo defines its values and behavioral expectations. Educating team members on an organization's credo creates accountability among those teams to align their behavior with the organization's values, policies, and professional commitment. A Coworker Observation Reporting System offers a communication method for providing meaningful feedback on behaviors inconsistent with an organization's credo.

Visual Management Board Implementation to Enhance High Reliability at a Large VA Health Care System.

The US Department of Veterans Affairs (VA) is committed to embodying principles of high reliability organizations and Lean management culture. The practice of making problems readily known to team members and leadership is called visual management, an important tool in the journey to becoming a high reliability organization. Visual management boards (VMBs), or huddle boards, can foster transparency, teamwork, and employee empowerment. A variety of health care teams at the Lieutenant Colonel Charles S. Kettles VA Medical Center within the VA Ann Arbor Healthcare System (VAAAHS) created and instituted VMBs. This article highlights the implementation in a large, diverse outpatient cardiology clinic. The incorporation of a VMB into the daily huddle of the outpatient cardiology clinic team led to increased problem identification among staff and leadership and fostered teamwork as issues were addressed. Feedback from teams across the VAAAHS noted how the boards were helpful in prioritizing areas for improvement, fostering teamwork, and increasing staff engagement, empowerment, and satisfaction. A VMB is a simple, inexpensive, yet potentially powerful tool to bring together diverse health care teams to identify problems in the workplace, engage staff in developing solutions, and enhance communication with leadership. Implementation of VMBs at the VAAAHS may serve as a model for other VA health care systems for the incorporation of visual management into daily workplace culture.

Leadership and the high reliability transformation: A qualitative study at Truman VA medical center.

The Department of Veterans Affairs (VA) has committed to becoming a High Reliability Organization (HRO). The Truman VA Medical Center (VAMC) successfully implemented and sustained foundational HRO elements over a period with several changes in facility executive leadership. We interviewed current and past leaders at Truman to understand how they retained fidelity to the HRO transformation. We conducted 16 interviews with 14 leaders involved in the HRO transformation and identified three themes related to the Truman HRO transformation: (1) Leadership visibly drove culture change through intentional communication and modeling HRO principles; (2) Leadership deferred to frontline expertise and empowered staff to make changes and to fail; (3) Hiring the right team members for the organizational culture and investing in training can support HRO principles and values. Our findings highlight key actions for leaders in the context of HROs: regularly communicate the significance of HRO, demonstrate behavior consistent with what they hope to see from staff, celebrate failure, allocate time and resources to the creation of hiring frameworks that identify employee skillsets conducive to HRO principles, and substantial and recurring investments in employee development. Importantly, successive executive leaders at Truman VAMC modeled these skills to promote and sustain the HRO transformation.

Methods to Increase Reliability in Quality Improvement Projects.

Although many quality improvement initiatives in health care see early and laudable success, 1 of the greatest challenges is sustaining the gains and avoiding the natural tendency of systems to revert to their original state, function, and outcomes. Reliability science describes a mathematical and systematic framework for understanding the level of reliability of interventions, and therefore the anticipated success and failure rate of both the steps of a process and the cumulative process overall. Successful utilization of this framework, along with the mindful organizing principles of high-reliability organizations, will facilitate ongoing and long-lasting improvement in outcomes. In this article, we describe practical methods to increase the reliability of interventions toward achieving and sustaining improvement goals.

From reliability to pragmatism: Hospital management in the context of radical uncertainty

AbstractThe COVID‐19 pandemic presented a scenario of radical uncertainty that hospitals had to manage. Two strands of research can illuminate this management. The first puts forward the high‐reliability organization (HRO) principles that the hospital sector has applied for two decades. The second is based on pragmatism and underscores experimental, trial‐and‐error strategies appropriate for radical uncertainty. This strategy, utilized primarily in the political governance of crises, can be applied in hospital management as well. The results of our qualitative research into French hospitals (109 online interviews over 2020–2021) highlight the importance of pragmatic rationality in crisis management based on organizing collective inquiries. This concept of pragmatic rationality questions the notion of reliability, sticking to pre‐existing performance standards not applicable in such contexts. It invites to propose the concept of high pragmatic organization based on five principles that partially integrate those of an HRO.

A Mixed Methods Study Exploring Patient Safety Culture at Four VHA Hospitals

BackgroundThe Veterans Administration (VHA) launched an enterprise-wide High Reliability Organization (HRO) transformation effort in February 2019. Yet, many gaps exist in understanding the mechanisms through which HROs achieve positive outcomes. The goal of this paper is to assess content validity of Patient Safety Culture (PSC) scale through a secondary analysis of qualitative data collected from four purposively sampled VHA hospitals concurrently with the employee survey administered in 2019-2020. Methods: We used a concurrent triangulation mixed methods design secondary analysis of the qualitative data collected between 2019-2020 from a larger study that focused on understanding HRO implementation efforts at 4 of the 18 VHA HRO lead hospitals. We combined qualitative data from our summary qualitative reports with quantitative ratings in a cross-hospital matrix to explore the extent and manifestation of each of the PSC factors. Results: Scores were significantly different between the 4 hospitals for all four PSC factors. Twelve of the twenty PSC items (60%) significantly differed across the 4 hospitals. Despite the high rate of statistically significant differences in PSC scores, many differences were small. Qualitative data revealed supporting evidence for 16 of 20 PSC individual items, suggesting good coverage and content validity for the quantitatively derived PSC factors. Conclusions: PSC is a central pillar of HRO maturity. This study shows a newly developed VHA PSC factor had good content validity based on a mixed methods analysis. Future research is needed to better understand the relationship of PSC factors to HRO process and clinical outcomes.

The Role of High Reliability Organization Foundational Practices in Building a Culture of Safety.

High reliability organizations are designed to operate under complex conditions for extended periods by strengthening systems that help serious adverse events for patients. The US Department of Veterans Affairs formally began its enterprise-wide journey to high reliability in 2019. Four foundational practices were identified to advance a culture of safety across all Veterans Health Administration facilities. This article describes these practices, summarizes supporting evidence from the literature, and illustrates strong practices for improving safety. A literature review was conducted from 2018 to March 2023 to identify recent evidence outlining the value of implementing the 4 foundational high reliability organization practices to improve patient safety. This evidence was used to create and implement formal processes for the foundational practices. For each foundational practice, a representative example of a strong practice within the Veterans Health Administration is provided. Effective and sustained application of the foundational organization practices described can support a health care organization's journey to high reliability. Collectively, the 4 foundational practices can be adopted and implemented by other organizations in the continued pursuit of high reliability in health care.

NASA, SpaceX, safety and (Post) bureaucracy. Reinterrogating the past, challenging the present with H. McCurdy.

This article discusses the safety contribution of a public administration scholar specialised in space policy, Howard McCurdy. Its aim is twofold. First, it contends that McCurdy’s research on NASA and (post) bureaucracy has been overlooked in the field whereas it provides a valuable lens to the understanding of reliability, safety and performance of safety–critical systems. This contention requires bringing to the fore McCurdy’ extensive study of NASA and his rationale over several decades. Second, the article argues that McCurdy’s research brings novel and valuable insights to important safety debates. Following a methodological section, the article explains his analysis of the engineering, organisational, and political complexities and challenges experienced by NASA’s employees over more than sixty years of the agency’s lifetime, developing a unique longitudinal and multilevel study of reliability, safety and performance. The relevance of McCurdy’s lens is then illustrated using SpaceX as a case study, an example of the new developments in organising space exploration with their safety related challenges, moving from public to private initiatives. In the discussion, the article explores the value of this author for past and contemporary debates on reliability, safety and performance of safety–critical systems. In “Reinterrogating the past”, it is argued that McCurdy’s research provides a bridge between what was once framed as two opposite theses, normal accident versus high-reliability organisation. In “challenging the present” it is argued that more recent debates and controversies triggered by the “new view” might not be as new as currently thought and advocated.

Determinants for the acceptance of emergency response information systems: Ethnographical insights into the digitalization of a voluntary fire department

Fire departments are one of the most versatile and widespread emergency management organizations. To support their digitalization, innovative firefighter information technologies such as emergency response information systems (ERIS) are suggested. Despite theoretical potentials like raised situation awareness, however, these technologies seem to disseminate only slowly in practice. As existing acceptance models cannot sufficiently explain the acceptance of novel technologies in this special domain, literature calls for increased contextualization. To get insights into the domain-specific acceptance factors, we conducted an ethnography and observed a voluntary fire department's multi-year project to introduce an ERIS. We identified seven factors, like revealing events and error management culture, which acted as triggers for different adoption stages. From overarching characteristics of a voluntary fire department, we derived six additional acceptance factors, like situational adaptability and self-determination. The identified factors can help firefighters in conducting successful digitalization projects, and policy makers in supporting voluntary emergency management organizations. Moreover, the results provide numerous avenues for future research, can be linked to various research fields and contextualize existing acceptance models. Beyond fire departments, the results may be transferred to similar high-reliability organizations.

Ensuring Patient Safety in Pediatric Dental Care

This review aims to examine safety concerns in pediatric dental care and underscore the need for comprehensive patient safety initiatives within the Korean Academy of Pediatric Dentistry. Drawing insights from the prevailing patient safety policies of the American Academy of Pediatric Dentistry, case reports, and systematic reviews, this review elucidates issues such as dental fires during sedation, ocular complications from local anesthesia, and surgical emphysema. This review highlights the significance of safety toolkits encompassing infection control, medical error reduction, dental unit waterline infection, and nitrous oxide safety in pediatric dental settings, underscoring the need to foster a safety culture. Furthermore, this study explores the curriculum for pediatric dentistry residency programs, emphasizing concepts such as high-reliability organizations and mortality and morbidity conferences. The study suggests the need for initiatives to enhance patient safety, including establishing safety committees, expanding reporting systems, policy development, and supporting research related to patient safety. In conclusion, this study underlines key messages, emphasizing the utmost priority of patient safety, acknowledging the inevitability of human error, promoting effective communication, and cultivating a patient safety culture. These principles are vital for advancing patient safety in pediatric dental care and improving outcomes among pediatric patients.

Priority Competencies for Designated Education Officers in the Veterans Health Administration.

Designated Education Officers (DEOs) at Veteran Health Administration (VHA) hospitals are senior educational leaders tasked with oversight of all clinical training at a particular facility. They prioritize dozens of tasks and responsibilities each day, from educational policy and strategy to staff management, financial planning, onboarding of trainees, and facility planning and management. Clarifying priority competencies for the role can help executives recruit, appoint, and evaluate capable personnel and promote effective, efficient performance. Using a federally developed method of competency analysis, researchers consulted a panel of subject-matter experts to identify priority competencies for DEOs, using data from a 2013 study that operationalizes competencies for more than 200 federal jobs. The research identified 25 primary competencies within 6 leadership domains. Five of the primary competencies cut across all leadership domains. Veteran Health Administration subject-matter experts in educational leadership say the identified competencies are urgently needed, critical for effective leadership, and valuable for distinguishing superior DEO performance. The competencies are relevant to VHA and perhaps other senior academic leaders who develop health professions education programs, oversee clinical training, and manage educational change. In military training facilities, attending to these competencies can help Designated Institutional Officials responsible for graduate medical education become more credible partners to other hospital leaders and contribute to becoming a high reliability organization. Executives identifying, recruiting, and appointing VHA DEOs and Designated Institutional Officials at military training facilities should consider these competencies when assessing candidates.

Development and implementation of local pediatric anesthesia performance metrics at a Canadian children's hospital: a technical report.

In this project, we sought to develop and implement pediatric anesthesia metrics into electronic health records (EHR) in a hospital setting to improve quality and safety of patient care. While there has been an upsurge in metric-driven health care, specific metrics catering to pediatric anesthesia remain lacking despite widespread use of EHR. The rapid proliferation and implementation of EHR presents opportunities to develop and implement metrics appropriate to local patient care, in this case pediatric anesthesia, with the strategic goal of enhancing quality and safety of patient care, while also delivering transparency in reporting of such metrics. Using a quasi-nominal consensus group design, we collected requirements from attending anesthesiologists using Agile methodology. Forty-five metrics addressing quality of care (e.g., induction experience, anesthesia delivery, unanticipated events, and postanesthetic care unit stay) and provider performance (e.g., bundle-compliance, collaboration, skills assurance) were developed. Implementation involved integration into the EHR followed by transition from PDF-based feedback to interactive Power BI (Microsoft Corporation, Redmond, WA, USA) dashboards. We introduced and implemented customized pediatric anesthesia metrics within an academic pediatric hospital; however, this framework is easily adaptable across multiple clinical specialties and institutions. In harnessing data-collecting and reporting properties of EHR, the metrics we describe provide insights that facilitate real-time monitoring and foster a culture of continuous learning in line with strategic goals of high-reliability organizations.