High Reliability Organization Principles Research Articles

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.

Implementation of High Reliability Organization (HRO) in the Air Traffic Controller (ATC) Profession in Indonesia

The ATC profession in Indonesia is a profession that has a high risk and workload, this has also been proven by the establishment of the ATC organization as a High Reliability Organization (HRO). The implementation of HRO is very important to be carried out properly because it has an impact on the performance of ATC personnel which also directly affects flight safety. There are also HRO principles and attributes that have a high standard to run. Therefore, the purpose of this study is to determine the application of HRO to the ATC profession in Indonesia. The method used in this study is a mixed-method, with the category of descriptive analysis and the Miles and Huberman model. The results of the study based on the data analysis test using a Likert Scale, showed the results were Enough with a percentage of 59%. Meanwhile, based on the data analysis test using archives/literature studies, HRO's Goals were produced, in which there were 21 (twenty one) goals/targets.

Age-Friendly Health Systems and Meeting the Principles of High Reliability Organizations in the VHA.

The Veterans Health Administration (VHA) is the largest integrated health care system in the US, providing care to more than 9 million enrolled veterans. In February 2019, the VHA identified key actionable steps to become a high reliability organization (HRO), transforming how employees think about patient safety and care quality. The VHA is also working toward becoming the largest age-friendly health system in the US to be recognized by the Institute for Healthcare Improvement for its commitment to providing care guided by the 4Ms (what matters, medication, mentation, and mobility), causing no harm, and aligning care with what matters to older veterans. In this article, we describe how the Age-Friendly Health Systems (AFHS) movement supports the culture shift observed in HROs. AFHS use the 4Ms as a framework to be implemented in every care setting. The 4Ms are used in conjunction with the 3 pillars (leadership commitment, culture of safety, and continuous process improvement) and 5 principles (sensitivity to operations, reluctance to simplify, preoccupation with failure, deference to clinical expertise, and commitment to resilience) that guide an HRO. We also share an HRO case study that is representative of many Community Living Centers involved in AFHS. AFHS empower VHA teams to honor veterans' care preferences and values, supporting their independence, dignity, and quality of life across care settings. The adoption of AFHS brings evidence-based practices to the point of care by addressing common pitfalls in the care of older adults, drawing attention to, and calling for action on inappropriate medication use, physical inactivity, and assessment of the vulnerable brain. The 4Ms also serve as a framework to continuously improve care and cause zero harm, reinforcing HRO pillars and principles across the VHA and ensuring that older adults reliably receive the evidence-based, high-quality care they deserve.

Learning to manage the unexpected: applying Weick and Sutcliffe’s HRO principles to oil tanker accidents

PurposeWeick and Sutcliffe identified five principles that enable high-reliability organizations (HROs) to address environmental complexity and manage unexpected events. The current study aims to adopt this sensemaking perspective to analyze accidents within a typical HRO sector, namely maritime transport.Design/methodology/approachThrough a retrospective case study analysis, this study focused on seven oil tanker accidents, using them as illustrative examples.FindingsFindings show how the five principles contributed to the accidents' occurrence, explaining how failures in sensemaking affected the crew's capability to both prevent errors and cope with their consequences, thus leading to disasters.Research limitations/implicationsOverall, the study offers an applicative contribution showing how this model may provide a reliable framework for analyzing the psychosocial factors affecting an accident. This approach deepens the understanding of how latent factors are enacted and how the prevention and error management phases interrelate within a comprehensive flow of the entire accident sequence. Furthermore, the study emphasizes consistent patterns that emerge across multiple accidents within the same sector, in order to learn valuable lessons to improve safety measures in the future.Originality/valueThis study constitutes an exemplary application in support of how Weick and Sutcliffe’s model is valuable for investigating HROs. It offers a second-order interpretative framework to understand accidents and underscores the interplay among these factors during the dynamic development of an accident.

To err is human: A healthcare organization blueprint towards safety and reliability.

392 Background: In 2019, a comprehensive cancer center was audited by a regulatory agency that identified opportunities to improve the safe delivery of healthcare. Even though the organization has been engaged in multiple continuous improvement initiatives, we found that to run a complex enterprise efficiently, we needed to break silos, learn from the frontline, and educate and train leaders in a psychologically safe environment. The overarching goal is to improve our culture of safety by developing a safety-focused workforce, improving robust processes around high-harm events, increasing transparency/feedback regarding safety events, and advancing the institution towards a High Reliability Organization (HRO)1 with zero preventable patient harm. Methods: Key interventions implemented: 1. Revamped our Root Cause Analysis; 2. Developed a Quality Assurance Performance Improvement (QAPI)2 council with leadership from the enterprise and representatives of the Patient Family Advisory Program, patients of the organization; 3. Implemented a Tiered Readiness Briefing (TRB) 7 days a week; 4. Selection of Serious Safety Event Rate (SSER)3 as the organization's measurement of patient safety and made it transparent; 5. Implementation of a mandatory training program in HRO skills and tools necessary to change behaviour. Training of leadership first goal was to get their buy-in so that the rest of the workforce would comply with the training; 6. Created Priority Focus Areas (PFA) initiatives supported by QAPI, the board, and leadership- providing resources to improve widespread, problem-prone, high-risk issues. Also, a system of accountability. Results: From June 2020 to April 2023- 59% reduction on SSER and sustained rate <0.9; 96% of leaders and 86% of medical faculty trained in HRO; 100% of “Start the Clock” issues identified in TRB are acted on within 24 hrs.; PFA success: the creation of the Blood Shortage Safety Decision Matrix- resulted in no surgery cancellation due to blood shortage. Conclusions: Rigorously implementing HRO principles in a comprehensive and complex cancer center resulted in improved process outcomes and patient safety outcomes that significantly reduced serious safety events.

Reliability-Seeking virtual organizations at the margins of systems, resources and capacity

High reliability organization (HRO) principles have been used to reduce risk and enhance safety, embracing such tenets as high tempo, operational decision-making; clear and repeated communication; an open organizational culture; and the importance of knowledge-sharing and trust. Increasingly, HROs have incorporated remote and virtual organizational structures, where members work in coordinated ways over long distances. These reliability-seeking virtual organizations (RSVOs) apply HRO principles in settings where members are virtual and work is challenging, whether due to geography or operational demands. Research suggests that organizational structuring, trust and knowledge sharing are essential in RVSOs. Yet, as virtualization extends into areas that stress or exceed human capacity, due to the nature of the area (e.g., polar regions or warzones) or speed (e.g., fully-automated contracts), we expect the increasing participation of machines and artificial intelligence in maintaining organizational reliability. This mixed human-AI operation raises questions about the traditional principles of high reliability. This research therefore explores the challenges of applying HRO principles to RSVOs that operate in resource-poor and extreme settings. We explore issues in organizational structure, trust, culture, and communication, in a case study of Arctic emergency response networks and other remote RSVOs at the margins.

Military unmanned aerial vehicle operations through the lens of a high‐reliability system: Challenges and opportunities

AbstractThis study examines the impact of regulations and standard procedures on safety outcomes in unmanned aerial vehicle (UAV) operations, specifically focussing on Norwegian military UAV systems, from a high‐reliability organization (HRO) perspective. By analyzing data from existing regulations, accident reports, and interviews with military drone pilots using thematic analysis, we identify key recurring themes. Our findings highlight the importance of fatigue and exhaustion due to the absence of regulations on resting time for military drone pilots. This poses substantial risks and increases the likelihood of accidents and incidents in UAV operations. Additionally, we uncover gaps in safety reporting and accountability for military UAV pilots, indicating the need for improved reporting procedures that consider the unique operational elements of UAVs. Effective communication between stakeholders, including drone pilots, ground crew, and air traffic controllers, emerges as a critical factor in maintaining situational awareness. This emphasis on communication is consistent with HRO principles and supports the essential safety tasks of UAV pilots, namely sense‐making, decision making, and performance. By uncovering the impact of regulations and operational procedures on safety outcomes and addressing fatigue in UAV operations, this research contributes to enhancing the safety and reliability of Norwegian military UAV systems.

Adopting high reliability organization principles to lead a large scale clinical transformation.

Building high reliable healthcare systems to reduce avoidable patient harm is a global priority. However, there is variability in the application and understanding of the previously identified High Reliability Organization (HRO) principles to make improvements. We describe specific organizational activities exemplifying the five HRO principles during the planning and go-live periods of the new Electronic Health Record (EHR) system at a multi-site academic health sciences centre in Ontario, Canada. Further, we describe a case example where all five HRO principles were exemplified during EHR implementation. Overall, 23 activities exemplifying organizational anticipation and resiliency were identified. Of the 23 activities, 12 occurred during the preparing for go-live and 11 activities occurred during the go-live periods. This article demonstrates how HRO principles can be used in healthcare to detect and adapt to patient safety threats, in order to prevent avoidable patient harm during large scale change.

How the Five Principles of High Reliability Organizations Align with the Five Truths of Special Operations.

Special Operations medicine must provide highly reliable healthcare under intense and sometimes dangerous circumstances. In turn, it is important to understand the principles inherent to building a High Reliability Organization (HRO). These principles include (1) sensitivity to operations; (2) preoccupation with failure; (3) reluctance to simplify; (4) resilience; and (5) deference to expertise. Understanding them is crucial to turning good ideas into sound practical benefit in operational medicine. A prime teaching opportunity involves an interesting coincidence that occurred during the emergence of HROs. Specifically, United States Special Operations Command (USSOCOM) adopted five Special Operations Forces (SOF) Truths that contribute to success in Special Operations, including (1) humans are more important than hardware; (2) quality is better than quantity; (3) SOF cannot be mass produced; (4) competent SOF cannot be created after emergencies occur; and (5) most Special Operations require non-SOF support. These five Truths have more in common with the five HRO principles than merely quantity. They describe the same underlying ideas with a key focus on human performance in high-risk activities. As such, when presented alongside the five HRO principles, there is an opportunity to improve the overall health and performance of SOF personnel by integrating these principles across the range of Special Operations medicine from point of injury care to garrison human performance initiatives. The following discussion describes in greater detail the five HRO principles, the five SOF Truths, and how these similar ideas emerged as more than just a useful coincidence in illustrating the key concepts to produce high performance.

High reliability organizing through an extended crisis: a case study of a U.S. university during COVID-19

ABSTRACT During the COVID-19 pandemic, organizations that had previously operated in low-risk conditions found themselves in environments where failure could be catastrophic. Using the framework of high reliability organizations (HRO), we analyze a specific case of a U.S. university taskforce charged with responding to the pandemic. We argue that the practices employed by the taskforce align with HRO principles, leading to two important theoretical contributions. First, this project highlights the utility of non-HROs using organizing principles reflective of an HRO framework. Next, this project extends HRO theorizing from a set of practices that prevent crisis to a set of communicative principles beneficial during crisis. Finally, the findings suggest practical implications for organizations during various stages of crisis.

Expectant Mothers and Digital Health Interventions: The Application of HRO Principles in Prenatal Care in COVID-19 Era and Beyond

The COVID-19 pandemic expedited the transition of healthcare operations to digital health. The healthcrisis and social-distancing guidelines shifted the in-person health delivery systems to virtual care. Thissudden move to Digital Health exposed the importance of a reliable digital system in healthcareinstitutions to maintain the quality of care. According to recent studies, one of the most affected groupsduring previous global pandemics were expectant mothers. Reports show that previous epidemics wereaccountable for miscarriages, unfavorable fetal and neonatal results, and maternal deaths. Therefore,highlighting the importance of self-isolation for expectant mothers and the need for a digital platform toreceive the care they need. In this study we first identify the key performance indicators for a successfulvirtual visit for expectant mothers, then discuss the application of High Reliability Organizations (HRO)principles as a mechanism to reinforce weak interconnections to achieve systems interoperability and integration.

A Novel Theory-Based Virtual Reality Training to Improve Patient Safety Culture in the Department of Surgery of a Large Academic Medical Center: Protocol for a Mixed Methods Study.

BackgroundPreventable surgical errors of varying degrees of physical, emotional, and financial harm account for a significant number of adverse events. These errors are frequently tied to systemic problems within a health care system, including the absence of necessary policies/procedures, obstructive cultural hierarchy, and communication breakdown between staff. We developed an innovative, theory-based virtual reality (VR) training to promote understanding and sensemaking toward the holistic view of the culture of patient safety and high reliability.ObjectiveWe aim to assess the effect of VR training on health care workers’ (HCWs’) understanding of contributing factors to patient safety events, sensemaking of patient safety culture, and high reliability organization principles in the laboratory environment. Further, we aim to assess the effect of VR training on patient safety culture, TeamSTEPPS behavior scores, and reporting of patient safety events in the surgery department of an academic medical center in the clinical environment.MethodsThis mixed methods study uses a pre-VR versus post-VR training study design involving attending faculty, residents, nurses, technicians of the department of surgery, and frontline HCWs in the operation rooms at an academic medical center. HCWs’ understanding of contributing factors to patient safety events will be assessed using a scale based on the Human Factors Analysis and Classification System. We will use the data frame theory framework, supported by a semistructured interview guide to capture the sensemaking process of patient safety culture and principles of high reliability organizations. Changes in the culture of patient safety will be quantified using the Agency for Healthcare Research and Quality surveys on patient safety culture. TeamSTEPPS behavior scores based on observation will be measured using the Teamwork Evaluation of Non-Technical Skills tool. Patient safety events reported in the voluntary institutional reporting system will be compared before the training versus those after the training. We will compare the Agency for Healthcare Research and Quality patient safety culture scores and patient safety events reporting before the training versus those after the training by using descriptive statistics and a within-subject 2-tailed, 2-sample t test with the significance level set at .05.ResultsEthics approval was obtained in May 2021 from the institutional review board of the University of North Carolina at Chapel Hill (22-1150). The enrollment of participants for this study will start in fall 2022 and is expected to be completed by early spring 2023. The data analysis is expected to be completed by July 2023.ConclusionsOur findings will help assess the effectiveness of VR training in improving HCWs’ understanding of contributing factors of patient safety events, sensemaking of patient safety culture, and principles and behaviors of high reliability organizations. These findings will contribute to developing VR training to improve patient safety culture in other specialties.

The Perceived Role of Healthcare Providers and Systems in the Development of Secondary Health Conditions among Adults with Spinal Cord Injury

Individuals with spinal cord injury (SCI), with high healthcare utilization rates and costs, require special attention and tailored care protocols to meet their healthcare needs. This qualitative study collected narrative information from adults with SCI and their family members and/or caregivers to examine the perceived role of healthcare providers and systems in the development and treatment of secondary health conditions (SHCs). After personal information was collected, individuals participated in focus groups which were recorded and transcribed; transcripts were then reviewed, cleaned, and uploaded to NVivo10 software to facilitate the analysis. An initial stage of coding was conducted which identified potential categories and themes; afterwards, the perceived role of healthcare providers in the development and management of secondary health conditions (SHC) was prioritized and transcripts were re-coded. Two overlapping themes emerged: (1) Iatrogenic and nosocomial factors; and (2) Relationships with healthcare providers. Iatrogenic and nosocomial factors had three subthemes: (1) Misdiagnosis; (2) Perceived mistreatment or mistakes made during treatment; and (3) Unintended consequences of medical treatment; while three subthemes were identified for Relationships with healthcare providers: (1) Respect; (2) Knowledge and experience; and (3) Patient Expertise. To improve safety, reduce healthcare costs, and facilitate more favorable perceived outcomes for individuals with SCI, healthcare providers, organizations and systems need to implement principles of high reliability organizations to improve outcomes through the treatment and prevention of SHC.

Adaptation of a Lean Tool Across Surgical Units to Improve Patient Experience.

High reliability organizations (HROs) sustain consistently excellent outcomes over time. Health care systems need to eliminate major quality failures to become reliable. Practice variations, unstructured leader rounds, and unfavorable patient experience outcomes with Responsiveness of Hospital Staff prompted leaders to adopt Kamishibai cards (K-cards). Evidence-based practices (EBPs) such as timeliness of answering call lights, purposeful rounding, communication, and engaging patients were used to develop Responsiveness K-cards. Responsiveness K-cards established standard work for staff responsiveness and audited process compliance. Findings determined what areas needed improvement, and leaders engaged frontline staff in practice changes. Percentile rank for Responsiveness of Hospital Staff had a sustained increase. Four of 6 hospital units using Responsiveness K-cards achieved 80% rank or better in every patient experience domain for the entire fiscal year. K-cards use HRO principles to standardize practice and improve outcomes. They encourage continuous improvement, which supports the sustainability of EBPs.

Towards high reliability in national pathology education: Evaluating the United States and Canadian Academy of Pathology educational product

The United States and Canadian Academy of Pathology (USCAP) leadership undertook a high level, global review of educational product outcomes data using high reliability organization (HRO) principles: preoccupation with failure; reluctance to simplify; sensitivity to operations; commitment to resilience; and deference to expertise. HRO principles have long been applied to fields such as aviation, nuclear power, and more recently to healthcare, yet they are rarely applied to the field that underpins these—and many other—complex systems: education. While errors in education are less calamitous than in air travel or healthcare delivery, USCAP's educational products impact over 15,000 learners a year, and thus have important implications for the future practice of pathology. Here we report USCAP's experiences using HRO principles to evaluate our keystone educational product, the “USCAP Short Course.” Following this novel method of data review, USCAP leadership was able to better understand diverse learner needs based on practice venue, training level, and course topic. Unexpected lessons included the identification of specifically challenging educational topics, such as molecular pathology, and a need to focus more resources on emerging fields such as quality and patient safety. The results allow USCAP to assess educational product performance using HRO tools, and provide strong data-driven decision support for future national pathology education strategy.

From HRO to HERO: Making Health Equity a Core System Capability.

As many health systems have been working to become high-reliability organizations (HROs), health equity has been largely absent from discussions and applications of HRO principles. This is a serious oversight. Disparities in health and health care represent systematic failures to achieve reliable outcomes for certain groups. Acceptance of disparities is antithetical to the essential HRO goal of "zero harm." We propose adding Equity to HROs in the most literal sense by designating it as a key component and achieving High Equity Reliability Organizations. We describe how equity should be a crucial element of all 5 HRO core concepts: sensitivity to operations, preoccupation with failure, deference to expertise, resilience, and reluctance to simplify.

Implementing High-Reliability Organization Principles at Biological Diagnostic Laboratories: Case Study at National Institute of Health, Islamabad.

Healthcare organizations are complex systems where healthcare professionals, patients, biological materials, and equipment constantly interact and provide feedback with highly consequential outcomes. These are the characteristics of a complex adaptive system. Healthcare delivery requires coordination but it necessarily relies on delegation of essential functions. It is thus essential to have an engaged workforce to ensure optimal outcomes for patients. Thus human performance factors play a key role in ensuring both the presence of excellent healthcare provision and the absence of outcomes that must be avoided-"never events." The commitment of management was a precondition for the implementation of the high-reliability organization (HRO) principles. A team from middle management was engaged and provided with appropriate management tools for identifying, prioritizing, assessing, and applying solutions for the safety concern in their operating systems. This article documents efforts at the National Institute of Health (NIH) to adapt the principles of HROs to diagnostic laboratories and vaccine production facilities at its campus in Islamabad, Pakistan, and seeks to draw some lessons for how this approach can be usefully replicated in such facilities elsewhere. Public health institutes such as NIH deliver vital products and services that are inherently risky to produce, where the consequence of failure can be catastrophic. Adopting the HRO principles is an approach to improving not just safety, but also the overall organizational performance in any setting, including low-resource settings, and can serve as an implementable process for other institutions.

High Reliability Organization Principles Improve VA Workplace Burnout: The Truman THRIVE2 Model.

Provider burnout is a significant health care concern. It is unclear whether high reliability organization (HRO) practices can prevent it. The Truman Veterans Affairs Medical Center (VAMC) undertook an initiative implementing HRO principles and assessed for impact on burnout metrics. This became known as the Transformative HRO Initiative Via Employee Engagement (THRIVE2) model. THRIVE2 consisted of Just Culture training, Clinical Team Training, and continuous process improvement through Lean. Truman VAMC was compared with other Veterans Health Affairs (VHA) facilities regarding burnout and employee satisfaction metrics. Truman VAMC saw significant changes in multiple HRO metrics (P < 0.001) as well as improvements in work group psychological safety and employee exhaustion (P < 0.001). High burnout rates decreased by 52% (6.2%-2.95%; P < 0.001). Truman VAMC went from 75th to the No. 1 ranked VHA facility regarding Best Places to Work. These findings have significant national policy implications given the effects of burnout.

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.