High Reliability
Background
High reliability organizations are organizations that operate in complex, high-hazard domains for extended periods without serious accidents or catastrophic failures. The concept of high reliability is attractive for health care, due to the complexity of operations and the risk of significant and even potentially catastrophic consequences when failures occur in health care. Sometimes people interpret high reliability as meaning effective standardization of health care processes. However, the principles of high reliability go beyond standardization; high reliability is better described as a condition of persistent mindfulness within an organization. High reliability organizations cultivate resilience by relentlessly prioritizing safety over other performance pressures. A classic example is that of the military aircraft carrier: despite significant production pressures (aircraft take off and land every 48–60 seconds), constantly changing conditions, and hierarchical organizational structure, all personnel consistently prioritize safety and have both the authority and the responsibility to make real-time operational adjustments to maintain safe operations as the top priority.
Characteristics of High Reliability Organizations
High reliability organizations use systems thinking to evaluate and design for safety, but they are keenly aware that safety is an emergent, rather than a static, property. New threats to safety continuously emerge, uncertainty is endemic, and no two accidents are exactly alike. Thus, high reliability organizations work to create an environment in which potential problems are anticipated, detected early, and virtually always responded to early enough to prevent catastrophic consequences. This mindset is supported by five characteristic ways of thinking: preoccupation with failure; reluctance to simplify explanations for operations, successes, and failures; sensitivity to operations (situation awareness); deference to frontline expertise; and commitment to resilience (Table).
Table. Characteristics of High Reliability.
Characteristic | Description |
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Preoccupation With Failure |
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Reluctance to Simplify |
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Sensitivity to Operations |
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Deference to Expertise |
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Commitment to Resilience |
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*HROs: High reliability organizations
Sources: Weick et al 2007; Hines et al 2008; Chassin et al 2013; Rochlin 1999. |
Current Context
It is important to recognize that standardization is necessary but not sufficient for achieving resilient and reliable health care systems. High reliability is an ongoing process or an organizational frame of mind, not a specific structure. AHRQ has outlined practical strategies for health care organizations aiming to become highly reliable in their report of practices employed by hospitals in the High Reliability Organization Learning Network. The Joint Commission suggests that hospitals and health care organizations work to create a strong foundation before they can begin to mature as high reliability organizations. Such foundational work includes developing a leadership commitment to zero-harm goals, establishing a positive safety culture, and instituting a robust process improvement culture. The Joint Commission also provides metrics and tools for assessing the maturity of an organization's leadership, safety culture, and process improvement culture as preconditions to high reliability.