High Reliability Organization Principles Research Articles

Listening to the Well, Listening to Each Other, and Listening to the Silence─New Safety Lessons from Deepwater Horizon

It is common for accident reports and the analysis of large-scale disasters, such as the Deepwater Horizon blowout, to point to communication failures. This narrow explanation implicitly assumes that accidents could be prevented if employees spoke up about safety. In contrast, the first author of this paper, whose professional experience is introduced in this Commentary to provide context, has frequently observed that there are, in fact, many cases when employees speak up but are not listened to. These patterns of communication (or lack thereof) occur at the intersection of personal, leadership, and organizational factors, which jointly affect how safety issues are recognized, communicated, and addressed. As such, communication problems are at “the tip of the iceberg” of safety problems, not at their root. In this paper, we review research on high-reliability organizations (HROs) with excellent safety records to identify their communication patterns and practices and how they contribute to the ability to enact five principles of HROs: preoccupation with failure, reluctance to simplify, deference to expertise, commitment to resilience, and sensitivity to operations. We then apply this lens to investigate the Deepwater Horizon disaster, based on court documents, expert reports, and personal interviews. Specifically, we investigate how the communication patterns between the onshore experts and the offshore crews compared to the recommendations of HRO theory and how existing discrepancies might help explain the accident. We found that many employees were aware of safety issues and communicated concerns openly, but there was little organizational response to the issues they raised. This failure to listen was largely owed to factors that were not directly related to communication, such as time pressure and lack of resources, and a culture that valued a “can do attitude” and getting things done so much that it got in the way of sensitivity to operations, expert-based guidance, and communication about problems. Moreover, the challenges of the project and its aggressive timeline created an extreme, almost toxic, commitment to resilience. Based on these findings, we discuss recommendations for improving safety in offshore oil and gas production.

Establishment of Elements and Principles of High Reliability Organizations in Neonatal Intensive Care Unit of de Soyza Maternity Hospital, Colombo, Sri Lanka.

Introduction: “High Reliability Organizations (HRO)” is an innovative safety management concept. An effort to transform a health care setting in Sri Lanka to a HRO – management structure is worthwhile to experience the outcomes of this model in Sri Lankan hospital context. Objective: To establish a HRO - management structure in the Neonatal Intensive Care Unit of De Soyza Maternity Hospital Colombo. Design: Pre / post interventional study design was used. Functional status of HRO structure in the NICU was assessed; using 5 HRO principles (ie. Pre occupation with failure, Resistance to simplify, Sensitivity to operations, Commitment to resilience and Deference to expertise) and 5 HRO elements (ie. Process auditing, Rewarding, Avoidance of quality degradation, Risk perception, and Command and control), at pre and post interventional levels. Methods: Practice of HRO principles was assessed using a Self - Administered Questionnaire with a rating scale, with the participation of all the NICU staff. Practice of HRO elements was assessed by a facility survey using a check list. Intervention consisted of a managerial plan with activities to establish the HRO concept. Results: Results showed a statistically significant increase of “response scores” of participants towards HRO structure and the facility survey showed the establishment of planned activities. Conclusion: It was concluded that implementation of this plan, is gradually establishing the HRO management structure in NICU of DMH.

Accident and Emergency Care Made High Reliable: Perception of Staff on Factors Affecting Application of High-Reliability Organization Principles in Accident Emergency Units

There is a growing concern regarding patient safety and high reliability which made more intense with this ongoing pandemic.Aim of this study is to assess the organizational factors affecting the practice of High-Reliability Organization (HRO) Principles as perceived by staff in selected Accident and Emergency Units. Methodology: A hospital based cross-sectional study in three Accident and Emergency care setting, among healthcare staff, conducted using a self-administered questionnaire.Results: Out of the five factors affecting HRO practices as perceived by staff, “Organizational Safety Culture” (Mean-4.27., SD-0.49) has the highest mean value followed by Leadership (Mean: 3.96, SD: 0.44) and Teamwork (Mean: 3.95, SD: 0.5). “Work Environment” (Mean: 3.94, SD: 0.46) has the lowest score. All independent and dependent variables have a significant positive correlation with HRO principles (Correlation is significant at the 0.01 level-1-tailed). Multivariate analysis was carried out to assess the proportion variability of the dependent variable. The linear regression model explains 22% of the variability of the HRO practices (dependent variable) by factors affecting HRO practices (independent variables) if all the factors operate together.The distribution of Coefficients, Standardized B value is 0.29 (significant at the 0.01 level), showing if “Organizational Safety Culture” operates together with the other four independent variables 29% of the variability of the HRO practices (dependent variable) can be explained by Organizational Safety Culture.Conclusion: Organizational safety culture shows significant (< 0.01) effect on determining HRO practices.

Clinician Wellness—Self-Care for Staying Healthy: Implementation of a Wellness Calendar and Programming for Health Care Workers in Response to COVID-19

Clinician Wellness—Self-Care for Staying Healthy: Implementation of a Wellness Calendar and Programming for Health Care Workers in Response to COVID-19

Obstetric Care Made High Reliabile: Perception of Staff on Factors Associated with Practice of High Reliability Organization Principles in a Selected Tertiary Care Maternity Hospital

Introduction: Patient safety and high reliability related to obstetric care has become a global concern especially during this COVID-19 pandemic period.Aim of this study is to assess the components of Socio Technical system as the factors affecting while adopting High-Reliability Organization (HRO) Principles as perceived by staff. Methodology: This is a hospital based descriptive cross-sectional study conducted using a self-administered questionnaire.Results: Out of the five factors affecting HRO practices as perceived by staff, "Organizational Safety Culture" (Mean- 4.25., SD-0.454 Significant at <0.01 level), Communication (SD-4.15, SD-0.579), and Teamwork (Mean:3.95, SD:0.499). are having a statistically significant (p <0.05 corresponding to Spearman’s correlation Coefficient positive association with the practice of HRO principles. According to Multiple linear regression model explains 29% of the variability of the HRO practices (dependent variable) can be explained by the factors affecting HRO practices (independent variables) if all the factors operate together. Gender, age, educational level, designation and working experience act as moderating variables to Organizational Safety Culture. There is a significant (p <0.05) difference of HRO practices among female gender, nursing category of staff which is better than other categories.Conclusion: Organizational safety culture, communication and Teamwork and work environment show significant effect on determining HRO practices which is important for policy makers and administrators to pay attention on above three factors to improve reliability. But these five factors (including leadership and working environment) explains only one third of variability of HRO practices), hence need to study other factors affecting reliability of performance.

Crossing Academic Boundaries for Diagnostic Safety: 10 Complex Challenges and Potential Solutions From Clinical Perspectives and High-Reliability Organizing Principles.

We apply the high-reliability organization (HRO) paradigm to the diagnostic process, outlining challenges to enacting HRO principles in diagnosis and offering solutions for how diagnostic process stakeholders can overcome these barriers. Evidence shows that healthcare is starting to organize for higher reliability by employing various principles and practices of HRO. These hold promise for enhancing safer care, but there has been little consideration of the challenges that clinicians and healthcare systems face while enacting HRO principles in the diagnostic process. To effectively deploy the HRO perspective, these barriers must be seriously considered. We review key principles of the HRO paradigm, the diagnostic errors and harms that potentially can be prevented by its enactment, the challenges that clinicians and healthcare systems face in executing various principles and practices, and possible solutions that clinicians and organizational leaders can take to overcome these challenges and barriers. Our analyses reveal multiple challenges including the inherent diagnostic uncertainty; the lack of diagnosis-focused performance feedback; the fact that diagnosis is often a solo, rather than team, activity; the tendency to simplify the diagnostic process; and professional and institutional status hierarchies. But these challenges are not insurmountable-there are strategies and solutions available to overcome them. The HRO lens offers some important ideas for how the safety of the diagnostic process can be improved. The ideas proposed here can be enacted by both individual clinicians and healthcare leaders; both are necessary for making systematic progress in enhancing diagnostic performance.

Considerations for Laboratory Biosafety and Biosecurity During the Coronavirus Disease 2019 Pandemic: Applying the ISO 35001:2019 Standard and High-Reliability Organizations Principles.

Background: Risk assessment is a critical tool for evaluating emerging pathogens such as severe acute respiratory syndrome coronavirus 2 because of the limited available information about pathogens and the diseases they cause. Industries adopt unique frameworks for risk assessment, for example, the ISO 35001:2019 biorisk management for laboratories and other related organizations provide tools to identify, assess, control, and monitor risks associated with hazardous biological materials. Industries such as aerospace are known as high-reliability organizations (HROs) because these must balance high-risk operations with minimal catastrophic outcomes. HROs focus on five core principles: preoccupation with failure, reluctance to simplify, sensitivity to operations, resilience, and deference to expertise to evaluate and manage risk. Results: In the present discussion, practices described in the ISO 35001 standard and the HRO model are applied to the current challenges faced by laboratories worldwide. Laboratories processing known or unknown coronavirus disease 2019 (COVID-19) samples, testing COVID-19 vaccine candidates, propagating severe acute respiratory syndrome-associated coronavirus-2, or validating diagnostic assays benefit from implementing such practices. Principles extrapolated from the HRO also help illustrate the importance of the end-to-end processes to ensure successful outcomes. Summary: Workplace safety is enhanced by the involvement of all stakeholders, from top leadership to front-line workers. High-quality outcomes as measured by a lack of incidents, accidents, injuries, or near misses are the positive consequences of strictly following standard operating procedures and timely communication of risks and pitfalls. Adopting a systematic framework to identify and manage risks posed by emerging pathogens results in increased workplace safety and higher quality processes and products.

Prone during pandemic: development and implementation of a quality-based protocol for proning severe COVID-19 hypoxic lung failure patients in situationally or historically low resource hospitals

BackgroundIntermittent Prone Positioning (IPP) for Acute Respiratory Distress Syndrome (ARDS) decreases mortality. We present a program for IPP using expedient materials for settings of significant limitations in both overwhelmed established ICUs and particularly in low- and middle-income countries (LMICs) treating ARDS due to COVID-19 caused by SARS CoV-2.MethodsThe proning program evolved based on the principles of High Reliability Organizations (HROs) and Crew Resource Management (CRM). Patients with severe ARDS [PaO2:FiO2 ratio (PFr) ≤ 150 on FiO2 ≥ 0.6 and PEEP ≥ 5 cm H2O] received IPP. Patients were placed prone 16 h each day. When PFr was ≥ 200 for > 8 h supine IPP ceased. IPP used available materials without requiring additional work from the bedside team. Changes in PFr, PaCO2, and the SaO2:FiO2 ratio (SaFr) positionally were evaluated using t-statistics and ANOVA with Bonferroni correction (p < 0.017).ResultsBetween 14APR2020 and 09MAY2020, at the peak of deaths in New York, there were 202 IPPs in 29 patients. Patients were 58.5 ± 1.7 years of age (37, 73), 76% male and had a body mass index (BMI) of 27.8 ± 0.8 (21, 38). Pressor agents were used in 76% and 17% received dialysis. The PFr prior to IPP was 107.5 ± 5.6 and 1 h after IPP was 155.7 ± 11.2 (p < 0.001 compared to pre-prone). PFr after the patients were placed supine was 131.5 ± 9.1 (p = 0.02). Pre-prone PaCO2 was 60.0 ± 2.5 and the 1-h post-prone PaCO2 was 67.2 ± 3.1 (p = 0.02). Supine PaCO2 after IPP was 60.4 ± 3.4 (p = 0.90). The SaFr prior to IPP was 121.3 ± 4.2 and the SaFr 1 h after positioning was 131.5 ± 5.1 (p = 0.03). The post-IPP supine SaFr was 139.7 ± 5.9 (p < 0.001). With ANOVA and Bonferroni correction there were statistically significant changes in PFr (p < 0.001) and SaFr (p < 0.001) and no significant changes in PaCO2 over the four time points measured. Using regression coefficients, the SaFrs predicted by PFrs of 150 and 200 at baseline are 133.2 and 147.3, respectively.ConclusionsAn IPP program for patients with COVID-19 ARDS can be instituted rapidly, safely, and effectively during an overwhelming mass casualty scenario. This approach may be equally applicable in both traditionally austere environments in LMICs and in otherwise capable centers facing situational resource limitations.

Establishment of a Perinatal Quality Network

The guiding premise of care at University Hospitals is based on high reliability organization (HRO) principles. With the acquisition of six community hospitals that provided obstetric services and an established regional perinatal leader, the opportunity was created to integrate standardized practice to decrease variation and improve patient outcomes. The establishment of an obstetric network that fosters collaborative inter- and intrahospital efforts and partnerships that promoting HRO principles. These partnerships form the basic governance of the UH OB Network. The foundation of this unique network is the equal ownership of vision and design shared by the chief of systems quality, obstetrics, and the senior quality improvement nurses. This team recruited self-identified obstetric champions (nurses, providers, quality and risk) from each institution to generate consensus and lead process improvement at the local level The adoption of multidisciplinary care guidelines informed by best evidence and internal expert opinion serves as the lynchpin for consensus-driven practice. Customization of the electronic record to reflect care guidelines provides additional crucial support integral to their implementation. The formation of robust local quality assurance committees focused on perinatal care identifies unique risk to drive process improvement. Participation in an online learning and individual risk assessment is required for all nurses and providers. The inception of rigorous quality assurance processes has led to a significant decrease in the rate of patient serious safety events (SSE) using the American Society for Healthcare Management preventable-harm classification system. A reduction in the number of malpractice suits and a decrease in total obstetric litigation costs occurred after the formation of the UH OB Network. Clinician knowledge and judgment scores demonstrated improvement in all modules of the system’s online learning platform. The interprofessional collaborative approach to perinatal care advances the science of health and the art of compassion while maximizing team cohesiveness. The shared partnership model engenders equal ownership of patient care and subsequent patient outcomes. The multidisciplinary approach empowers nurses to advocate and innovate on behalf of patients and their families in achieving best possible outcomes.

Use of an Obstetric Collaborative Council to Support Obstetric Services in a Multihospital Merger

To support the obstetric service in the merger of three hospitals into a single high reliability organization (HRO)–based health care system. To create a three-hospital obstetric collaborative council to promote communication, protocol discussion, and process revision using the HRO core principles of leadership, situational monitoring, mutual support, and communication. Using a monthly meeting platform that was already in place at NYU Langone Health (Tisch), each hospital's core interdisciplinary obstetric group was invited to join the OB Collaborative Council. Merger timeframes were staggered: NYU–Brooklyn, February 2017, and NYU–Winthrop, June 2018. The OB Collaborative Council’s communication was ongoing, with in-person meetings, e-mails, and online conference preparation. Situational monitoring was present and trust and confidence evident initially through professional respect (invitation and accepted invitation) and then by familiarity. Mutual support was shown through active conversation in agenda-filled meetings, regular attendance, sharing expert experience, and brainstorming process change. Leadership was evidenced at the main campus ( NYU Langone–Tisch) initially and then leaders from all of the sites emerged. Physical meeting space, refreshments, agenda, and minutes preparation evidenced system supports. Professional objectives achieved included regular (three-hospital) attendance, regulatory clarification, three hospital–one health care system electronic protocol platform updates, Joint Commission Perinatal Care Certification, and colleague-supported electronic medical record–transition. Interpersonal professional relationships were forged and continue among the three-hospital health care system. The OB Collaborative Council continues to meet monthly. The OB Collaborative Council at NYU Langone Health was and continues to be instrumental in supporting a three-hospital, professional obstetric team within a single, HRO-based health care system. Nursing professionals are the planners and organizers of this interdisciplinary platform and can guide and support small as well as systemwide changes. Awareness of the core HRO principles of leadership, situation monitoring, mutual support, and communication is important to quality and safety in health care.

High Reliability: A Primer for Athletic Training Educators

Context Health care organizations are integrating employee training and educational programs to designate themselves as high-reliability organizations (HROs). HROs continually strive to evaluate and create an environment in which potential problems are anticipated, detected early, and virtually always responded to early enough to prevent catastrophic consequences. Objective This primer document introduces the concept of high reliability in health care (from a historical and foundational perspective) and establishes a framework for athletic training educators to introduce the concepts at the professional, postprofessional, or residency educational program level. Background While the theory of high reliability is new to athletic training, its quality and origins in health care are established. HROs use systems thinking to evaluate and design for safety and continuous improvement to create an environment where potential problems are anticipated, detected early, and responded to early enough to prevent tragic consequences. Synthesis The HRO focuses attention on emergent problems and deploys strategies to address those problems. HROs behave in ways that seem counterintuitive—they do not hide failures; instead, HROs celebrate them. HROs seek out problems and avoid focusing on just 1 aspect of work to see how all the parts fit together. They expect unexpected events and develop capabilities to manage them, deferring decisions to empowered experts. However, high reliability is only achieved through robust process improvement, which is only achieved with a complementary approach to Lean Six Sigma and change management. Recommendation(s) Given the complexity of patient care in athletic training, the potential for medical error(s), and the need for quality improvement, HROs hold promise for athletic training. Conclusion(s) As future health care leaders, athletic trainers should be educated to foster innovation and improve health care delivery to diverse patient populations. Athletic trainers should want to embrace the principles of HROs. Achieving high reliability can be accomplished with adequate exposure to and training within the classroom and during clinical education opportunities.

Implementing High-Reliability Organization Principles Into Practice: A Rapid Evidence Review.

To promote a safety culture and reduce harm, health care systems are adopting high-reliability organization (HRO) principles. This rapid review synthesizes HRO frameworks, metrics, and implementation effects to help inform health systems' efforts toward becoming HROs. Bibliographic databases were searched from 2010 to 2019. One reviewer used prespecified criteria to assess articles for inclusion, evaluate study quality, extract data, and grade strength of evidence with second reviewer checking. Twenty-three articles were identified: 8 described frameworks, 9 examined metrics, and 9 evaluated implementation outcomes. Five common strategies for HRO implementation emerged (developing leadership, supporting a culture of safety, providing training and learning, building data systems, and implementing quality improvement interventions). The Joint Commission's and Institute for Healthcare Improvement's frameworks emerged as the most comprehensive and widely applicable. The Joint Commission's Oro 2.0 metric for evaluating HRO progress similarly stood out as it was developed through broad stakeholder input and was validated by external researchers. Multicomponent HRO interventions delivered for at least 2 years were associated with improved process and patient safety outcomes. Because each HRO intervention was only supported by a single poor or fair-quality study-none of which contained a concurrent control group-a causal relationship between any HRO initiative and outcomes could not be established. Health care system adoption of HRO principles is associated with improved safety outcomes, yet the level of evidence is low. Priorities for future HRO studies include use of concurrent control groups and examination of specific outcomes measurements.

Manifestations of High-Reliability Principles on Hospital Units With Varying Safety Profiles: A Qualitative Analysis.

To prevent patient harm, health care organizations are adopting practices from other complex work environments known as high-reliability organizations (HRO). The purpose was to explore differences in manifestations of HRO principles on hospital units with high and low safety performance. Focus groups were conducted on units scoring high or low on safety measures. Themes were identified using a grounded theory approach, and responses were compared using qualitative thematic analysis. High performers indicated proactive responses to safety issues and expressed understanding of systems-based errors, while low performers were more reactive and often focused on individual education to address issues. Both groups experienced communication challenges, although they employed different methods of speaking up. Some HRO principles were present in the language used by our participants. High performers exhibited greater manifestations of HRO, although HRO alone was insufficient to describe our results. Mindful organizing, which expands on HRO, was a better fit.

1999–2019: Twenty years of watershed moments for patient safety

The case for patient safety is obvious; no one would argue in favor of harming patients. Since the launch of the paper To Err is Human, patient safety has been on the forefront of public health policymakers' priorities. Yet, 20 years later, while progress has been made, harm to patients is still a reality, daily, in health systems over the world. As countries reform their health systems, the national health programs must ensure not only the integration of universal health coverage (UHC) but also that the health coverage provided is safe. To this point, new models of care must be designed and implemented, and organizations should aim to achieve high-reliability care, similar to other industries that keep a solid safety record. This can be achieved by aiming for high-reliability organization principles, ensuring empowerment of patients as codesigners of health care, workforce safety to ensure safety of patients, and UHC without harm and proper regulation of digital health to avoid unintended adverse consequences. Since the past 20 years, the knowledge gap on patient safety has been shortened and therefore the health-care community holds a firm foundation for starting to implement evidence-based strategies that ensure safe care. The Jeddah Declaration on Patient Safety, 2019, is an actionable document that provides guidance to policy- and decision-makers globally that aim to achieve UHC free of harm. Nevertheless, given the high-level of complexity of health-care systems and its vulnerability to error, the question is what is the way forward toward a safer provision of care? How can the year 2019 be the watershed moment for the health-care industry?

The Common Barriers and Facilitators for a Healthcare Organization Becoming a High Reliability Organization

Background: Implementing high reliability organization principles can enhance quality and safety in healthcare. Evidence-based instructions on how to effectively change the organizational culture in healthcare setting are required.&#x0D; Objectives: A systematic review investigating methods, facilitators, and barriers to assist healthcare organizations in becoming a high reliability organization.&#x0D; Method: Literature searches were performed in PubMed, MEDLINE, CINAHL-Complete, EMBASE, and Scopus for articles published between January 2012 and October 2017. The included articles were case reports, case studies, and protocol development studies on implementing high reliability organization principles. The articles were appraised using a modified Critical Appraisal Skills Programme tool. Thematic synthesis was conducted using manual coding. &#x0D; Results: Of the 14 eligible articles nine were case studies, four were case reports, and one was a framework development report. The study populations varied from whole healthcare systems to a single department of a hospital. The most common methods were supportive leadership, staff education, and analysing the safety events and sharing the knowledge. Cost was one of the barriers. Remuneration came in reduction of safety events and costs avoided.&#x0D; Conclusion Implementing high reliability organization principles in healthcare settings is slow and challenging, but doing so improves quality, resilience, and safety, thus increasing productivity.

Mindful infrastructure as antecedent of innovation resilience behaviour of project teams

PurposeThe purpose of this paper is to investigate whether insights into high reliability organizations (HROs) are useful for innovation management teams. HRO teams can keep failure to a minimum level due to high alertness and resilience. Project teams working on innovation management could benefit from HRO principles and thus reduce their chances of failure.Design/methodology/approachA survey among in total 260 team members and team leaders of project teams in innovation management was conducted to study the relation between, on the one hand, organizational features of HROs (“mindful infrastructure”) and HRO principles (adjusted as “innovation resilience behaviour”, IRB), and on the other hand, between mindful infrastructure and IRB and project outcomes.FindingsFrom the results it could be concluded that mindful infrastructure associates with IRB, and that IRB has a mediating role in the relation between mindful infrastructure and project outcomes. Innovation management project teams can thus learn from the practice of HRO teams.Originality/valueTo the authors’ knowledge, HRO-thinking has not been applied to team behaviour in innovation management. A fruitful transfer of insights from the domain of safety and crisis management seems applicable to the domain of innovation.

Using High Reliability Organization Principles in Pediatric Interfacility Emergency transport

Using High Reliability Organization Principles in Pediatric Interfacility Emergency transport

Safety Perceptions of Health Care Leaders in 2 Canadian Academic Acute Care Centers.

An estimated 7.4% of patients admitted to acute care facilities in Canada experience injury or death due to health care mishaps, and 38% of these events are deemed preventable. Commitment of executive leaders to a culture of safety is important for the reduction of risk to Canadian patients. The purpose of this study was to examine the safety climate from a leader's perspective in 2 Canadian acute care settings, with attention paid to high reliability organization (HRO) principles. The Patient Safety Culture in Healthcare Organizations questionnaire was administered to leaders in 2 acute care hospitals in Ontario between June and January 2009. The primary outcome measures were senior leadership support for safety and supervisory leadership support for safety. Misalignment between the safety climate and HRO principles was defined as greater than 10% of respondents reporting problematic or neutral leadership support for safety. Of the 142 respondents (67% response rate), both medical/nursing leaders and tertiary care clinical leaders were significantly more likely than board/administrative leaders to report problematic/neutral responses. Overall, executive leadership perceptions of the safety climate were not aligned with HRO principles. The significant differences in response between board/administrative leaders and those involved in frontline patient care suggest that a weak safety culture exists in these 2 health care organizations. The cultivation of a stronger organizational safety culture, in alignment with HRO principles, could lead to lower rates of preventable mishaps and support risk identification and mitigation in perioperative settings.

Use of High Reliability Organization Principles in the Onboarding of New Graduate Nurses to Labor and Delivery

To provide an orientation experience built on comprehensive experiences, didactic content, socialization and cultural assimilation to improve retention of new graduates. High reliability organization (HRO) principles were used to develop a holistic, multidisciplinary method of onboarding new graduate nurses to labor and delivery. A multiphased approach was used to coordinate didactic content with preceptor orientation. The new onboarding process was based on the five high reliability principles that underscore the organizations commitment to excellence. The first principle, Preoccupation With Failure, was addressed by revamping the hiring process and developing a quality orientation program. The orientation and didactic timeframes changed from 12 weeks to 22 weeks and from zero to 80 hours, which addressed Reluctance to Simplify. Sensitivity to Operations necessitated a collegial environment through personalized gifts and welcome lunches; simulation was used to prepare new hires for clinical experiences. The use of biweekly meetings with managers, educators, preceptors and orientees emphasized the Commitment to Resilience principle. The use of multidisciplinary speakers during didactic content highlighted the final principle, Deference to Expertise. One to two year retention rates improved from 33% to 100% after implementation. Use of the five high reliability principles helps to ensure high quality orientation, which results in high nurse satisfaction and retention of new graduate nurses.

Learning how to cope with uncertainty

PurposeManufacturing companies increasingly have to deal with uncertainty and complexity without being sufficiently prepared for it. High-reliability organizations (HROs) successfully deal with dynamic and unknown situations. The authors ask the question whether learning concepts of HROs can be a role model for manufacturing companies and if their learning principles can be successfully applied there. The paper aims to discuss these issues.Design/methodology/approachThe authors’ research is based on high-reliability theory and former qualitative empirical studies on learning and development of mission-based HRO. The authors compare their learning practice with learning and development demands of the own empirical cases studies of three manufacturing firms.FindingsLearning concepts in the manufacturing firms are disconnected from their practical demands. In HRO in contrast, learning and development follows a distinct choreography, with a focus on collective reflection. Manufacturing firms can learn from HROs about learning principles especially with respect to collective reflection-on-action in order to develop situational awareness. However, the HROs’ learning should not be seen as a strict role model as their work organization differs significantly from that of manufacturing firms.Research limitations/implicationsThe research is based on in-depth case analyses (e.g. interviews and observation). The outcomes are case specific and focus on manufacturing firms. Hence, only patterns or principles can be generalized. To gain a more complete picture, the authors suggest further case analyses in different industries.Practical implicationsManufacturing firms can benefit from learning principles of HROs, like combining formal and informal learning and collective reflection on practice.Originality/valueThe paper connects previous research on HRO with original empirical research on manufacturing firms. Through the matching of data, the authors contribute to the discussion on whether the concept of HROs can be seen as a role model for learning and development in manufacturing firms.