“HRO’s are those extremely complex organization which effectively leverage culture and science to produce “zero-harm” or failure-free operations over time.”
– Institute for Healthcare Improvement
Examples of HROs include Aircraft Carriers, Military Aviation Units, Commercial Aviation, Nuclear Power, and Amusement Parks. Each one of these industries has leveraged the principles of HRO to bring the catastrophic incident rate to near-zero, while at the same time, operating in a highly efficient and effective manner. The ultimate goal is to translate the principles of HRO, and the myriad of tools used by different organizations to make HRO the standard for healthcare, achieving no harm.
A high-reliability organization (HRO) is an organization that has succeeded in avoiding catastrophes despite a high level of risk and complexity. Healthcare as an industry, and its many aspects, face an extremely high level of risk and complexity, with the ultimate failure being harm or even death to a patient. Unfortunately, the process of getting to a HRO is not as simple as copying what other organizations have done in other industries.
Healthcare for the last several decades has begun instituting a plethora of safety measures with the patient being the focus. The arguments for failure or lack of ability to achieve the desired outcomes for many safety programs has several aspects and can be argued ad nauseam. Some of the most common and most difficult to solve have been, leadership buy-in, middle management buy-in, cost, turnover, difficulty in translating expectations to front-line staff, lack of support, lack of accountability, and concerns with liability.
To understand HRO and how to get there, it takes more than an academic and theoretical approach to the concepts. Proven principles and reproducible results across industries, coupled with a change to system, organizational, and sometimes industrial cultures, has shown that HRO will reduce mishaps, near-mishaps, improve quality, efficiency, and effectiveness, and save resources, money, and lives.
The best individuals to help an organization get to the coveted HRO status are those that have lived it, trained to it, developed it, improved it, and mastered it. It is not enough to know what to do, but one must know how to do it, how to implement it, how to sustain it, and how to measure it.
Principles of High Reliability Organizations
Anticipation:
- Preoccupation with Failure and its Causes
- Reluctance to Simplify Interpretations
- Sensitivity to Operations
Containment:
- Commitment to Resilience
- Deference to Expertise
Principles of High Reliability Organizations
Near misses are viewed as evidence of systems that should be improved instead of evidence of safety. Ex – Pharmacists catches a medicine with significant side effects, which should have been addressed when the doctor went over patient’s medication history.
Reluctance to Simplify Interpretations:
Avoiding overly simple or superficial explanations or solutions. Ex – In healthcare the answer to safety issues has traditionally been universal protocols, education/training, and posters, HROs create complex solutions for complex processes, suspend operations to evaluate and analyze to ensure system integrity, and apply corrective actions.
Sensitivity to Operations:
Heightened vigilance to the state of the systems and processes and how they might support or threaten safety. It takes a system wide buy-in to change the organization, once complete, an organizational culture has shifted and becomes the new standard. Ex – A nurse not reporting a safety issue or concern to a physician for fear of reprisal, being wrong, or being intimidated. HRO organizations requires, 100% involvement, zero tolerance for intimidation, well-defined communication lines, everybody knows roles and responsibilities. Ex 2 – Alarm fatigue!
Commitment to Resilience:
Everybody assumes the system is at risk of failure, leading to a culture of continuous improvement, willingness to experiment and innovate, with an objective to be proactive instead of reactive. Ex – Utilization of LEAN/Six Sigma process improvement. Having dealt with a pandemic over the last year, capture the lessons learned, implement changes to the system, challenge those changes through drills, and continue to improve.
Deference to Expertise:
Expertise, rather than authority, takes precedence in an HRO. When conditions are high-risk, and circumstances change rapidly, on-the-ground subject matter experts are essential for urgent situational assessment and response.
Empowering Frontline Expertise
Consider a situation where infection rates suddenly increase in a hospital without a clear cause. An HRO does not limit the investigation to senior leaders or physicians. Instead, the organization asks frontline staff what they have noticed, observed, or experienced.
In one example, a janitor identifies a potential cause: the hospital ordered the wrong soap for restroom dispensers. The janitor had already notified a supervisor but lacked the authority to order the correct product.
Push Decision-Making to the Front Line
An HRO uses situations like this to strengthen its systems. Leaders can improve the ordering process and give frontline employees the appropriate authority to address safety concerns quickly.
The goal is not simply to identify the person who noticed the problem. The goal is to create a system that allows employees with relevant expertise to act before a small issue becomes a larger safety event.
Barriers to High Reliability
If transitioning an organization to HRO status were easy, more organizations would have done it by now. Common barriers include high variability, failure to respect unexpected events, unwillingness to acknowledge shortcomings, inadequate root-cause corrective action, and an overreliance on the “expert” mindset.
Why Variability Creates Risk
Several factors contribute to high variability, including a lack of hospital-wide, system-wide, or industry-wide standards; a “we are different” mentality; personal preferences; competing goals and objectives; and limited process thinking.
Building a Culture of High Reliability
Strong leadership support provides the foundation for change. The Board and executive team must fully support the HRO initiative and establish clear expectations for implementation.
Leaders can then introduce the appropriate processes and tools, provide training, implement changes based on risk analysis, monitor results, and document progress. These efforts can create pockets of high reliability that gradually influence the broader organizational culture.
Measuring the Results
As organizations strengthen their reliability practices, leaders can track outcomes such as incident rates, liability exposure, insurance costs, HCAHPS scores, employee retention, and employee satisfaction. Most importantly, these efforts should focus on reducing preventable patient harm.
Author:
LCDR Stephen Hartz, USN (ret), FACHE is a Principal at H & H Leadership Solutions and President of Leadership and Executive Recruitment. He has greater than twenty-five years of experience in military service, leadership development, implementation, and executive healthcare recruitment. Steve previously served as Chief Operating Officer at COORS Leadership Capital, a retained executive search and healthcare solutions firm. In that role, he led the organization through the COVID-19 pandemic, increased revenue by 200%, and expanded its services to include operational transformation. Steve created the HROrx “Prescription for Safety Culture,” system to help improve culture, safety, and quality in hospitals and health systems.
Steve retired from the Navy in December of 2020 after servicing twenty years in the United States Navy as an officer, helicopter pilot, and leader. During his twenty years of service Steve had the opportunity to lead various groups through a myriad of highly complex and diverse challenges with exceptional results, centered on the core principles of integrity and service. Steve’s experience includes budget development, resource requirements, risk mitigation, resource management, conflict resolution, acquisition, personnel management, and integrated operations.
Throughout his career Stephen has taken every effort to educate himself receiving an MBA in Information Technology, an MS, in Orbital Mechanics, and multiple certifications focused on process improvement and leadership. In 2022, Steve became a Fellow in the American College of Healthcare Executives. Steve is committed to the principles, mission and vision of H & H Leadership Solutions, People, Process, and Purpose.
FORMC (ret.) Chris Engles, USN is the current Director of Recruitment and Training at COORS Leadership Capital. Chris has over 36 years of leadership experience; 32 years in the Navy, two in sales training and over two in the Oil & Gas industry. His distinguished military career includes tours in Special Weapons, Conventional Weapons, Recruiting, and numerous Senior Enlisted Advisor positions. These positions include Command Master Chief tours of an Aviation Squadron, Missile Cruiser, Nuclear powered Aircraft Carrier, Overseas base, and Force Master Chief for all 72 Naval Installations with 85,000 people around the globe.
During the last two years Chris has trained hundreds of personnel in North America, the Gulf of Mexico, and
throughout Europe on the principles and implementation of High Reliability Organizations. He is the person who gets the best out of people because he gives his best all the time. He is recognized as an exceptional leader who can work in any environment.
References:
- Mark R. Chassin, Jerod M Loeb; High-Reliability Health Care: Getting There from Here (The Joint Commision).
- RDML Bruce Gillingham (MD), MC, USN; LT Joshua D. Corbridge, MSC, USN; CAPT Howard C. Warner III, USN; CAPT (ret.) Curtis Shaub, USN; LCDR (ret.) Richard Hoffman, (Ed.D), USN, High Reliability Health Care: Lessons From the Fleet (2016). Linda T Kohn; Janet Corrigan; Molla S Donaldson, To Err is Human: Building a Safer Health System (Washington, DC: The National Academies Press, 1999).
