Achieving the status “High Reliability Organization (HRO)” is now the gold standard for healthcare organizations, but there is little agreement on how to achieve it. To help you move your organization toward this important goal, let’s try to make that term clearer. Authors Weick and Sutcliffe first used the phrase in their 2001 book, Managing the Unexpected, now in its 3rd revision (Weick, K. E., & Sutcliffe, K. M., 2015 Managing the unexpected, John Wiley & Sons).
They defined 5 principles that define a HRO:
1) Preoccupation with failure
Translation: Accidents or errors can happen at any time
No central line bloodstream infections (CLABSIs) for x weeks? Great, but your team needs to continue to be vigilant, because the next infection can happen anytime, and new threats are always present (e.g., different brand of catheters, new interns, different patients, etc.).
Useful strategies: Before acting, always think ahead of what could go wrong. As a team, use huddles or simulation exercises to prepare for possible scenarios. As an organization, monitor and prepare for potential disruptions, like hurricanes, medication shortages, staff shortages, cyber threats, and more.
2) Resistance to simplify
Translation: The first answer is rarely the full answer. Broad, rational excuses can be attractive when processes don't work well, but while it is beneficial to simplify some work processes, there is a risk of painting with broad strokes and failing to dig deeply enough to find the real source of a particular problem.
Example: “CLABSIs could be avoided if everybody just washed their hands.” Yes, handwashing is important, but so are decreasing line entries by eliminating or bundling labs, switching IV medications to oral, observing good patient mouth hygiene, and decreasing the clutter in rooms, etc.
Remember the Swiss cheese model! It takes more than one hole to let an error happen, i.e., there is usually more than one simple explanation for an event.
3) Sensitivity to operations
Translation: The earliest indicators of threats typically appear in small changes in organizational operations
Example: HROs would report that that hand gel feels “stickier” than before, leading to decreased use. If not reported: Handwashing compliance decreases from 100% to 60%. Frontline workers are often the first ones to observe a change/potential threat.
Any action can have unanticipated consequences, caring for patients is never “routine,” nor does care follow a cookie-cutter approach.
Example: Susie was discharged without a discharge order and had to be called back to the ED. The root cause was found to be the fact that nurses now prepare for discharge early to expedite process, but this leads to an assumption that, “Everything is ready.”
4) Commitment to resilience
Translation: Bad things happen to good people with good intentions, but we can learn from it and get better.
Example: Baby on ECMO, intubated. In order not to risk any accidental dislodgement of tubes, baby stays in same position for prolonged periods of time and then develops a pressure injury.
Despite all best efforts and past successes, errors will occur, and safety will be threatened. HROs learn from mistakes instead of being paralyzed by them, and also observe and learn from actions that go right!
5) Deference to expertise
Translation: Identify the person with greatest expertise, instead of expecting the most senior person to come up with answers.
Example: Environmental services observed that patients and staff put regular trash in the trash bin reserved for biological waste. Since the hospital has many Spanish-speaking patients, new labeling was designed to include writing in both English and Spanish to indicate for what each trash bin is to be used.
Frontline staff members and patients and their family members often have useful insights! The most experienced person should be given authority to make changes, regardless of their title or place in the organizational hierarchy.
Although some industries, such as nuclear power plants or aircraft carriers, have achieved something close to high reliability, it still represents an ongoing improvement process and exercise in vigilance, even for them. Healthcare is, in some respects, even more complicated and unpredictable, and it may take longer to become a true HRO, but the principles described above apply to every level, from the individual person to the entire healthcare system.
To learn more about how ECRI can help your team become a HRO, contact ECRI at clientservices@ecri.org.