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Removing Harm from Healthcare – Health Systems and High Reliability Organizations

What do the biggest U.S. Navy ships, airline companies, and nuclear power plants all have in common? Handling advanced military machinery, ensuring airplanes get to and from their destinations, and keeping watch over a nuclear reactor are all essential activities that have no room for error. Each of these entities (and their industries) strive ceaselessly to experience fewer than expected accidents despite operating within complex, high-risk environments – that is the essence of a High Reliability Organization (HRO).

HROs operate around five core principles:


1.) Sensitivity to operations - HROs pay a great deal of attention to how systems and processes operate.

2.) Reluctance to simplify - HROs understand the work they perform is immensely complex and can fail at any time, often in previously unforeseen ways.

3.) Preoccupation with failure - HROs constantly evaluate and near misses are viewed as opportunities to improve rather than proof of organizational success.

4.) Deference to expertise - HROs value insights from staff with the most knowledge of safety procedures over seniority.

5.) Commitment to resilience - HROs provide training for many unlikely but always-possible system failures.


These principles can be adapted to and adopted by other industries. A prime candidate for HRO adoption is the healthcare industry, specifically with health systems. Unfortunately, medical errors are a source of harm to patients and, surprisingly, remain a common cause of death in the United States. Implementing HRO principles across a health system has the potential to not only lower avoidable deaths and health complic


ations, but also bring down costs through standardization. It bears noting that the key goal of applying HRO principles to medical systems is to eliminate harm, not errors. Errors in large organizations are inevitable and can provide meaningful lessons learned. Zero harm to patients, however, is a goal medical systems can strive toward by applying HRO principles.


While the five core principles mentioned above generally apply to all HROs, health systems on the journey to applying HRO principles have at times expanded and broadened these. For instance, the U.S. Military Health System applies two additional principles: Respect for People (fostering mutual trust) and Constancy of Purpose (persisting through adversity towards the goal of zero harm).


But, medical systems do face challenges when deciding to adopt HRO principles. Massive organizational shifts, of course, always present hurdles, and HRO adoption poses some additional specific barriers to health systems. These barriers include organizational reluctance to put safety culture principles into practice, the potential for competition with other large organizational transformation initiatives (like electronic health records), and the effort required to implement new process improvement tools and methods.

Luckily, there are some key strategies that health systems can utilize when implementing HRO principles:


1.) Developing leadership - a health system must be committed to the goal of zero patient harm and a compelling vision must be established.

2.) Supporting a culture of safety - communications and expectations must be clear in order to build a new organizational culture centered on safety.

3.) Building and using data systems to measure progress - data must be tracked to pursue continuous improvement.

4.) Providing training and learning opportunities for providers and staff - all staff must be appropriately trained on process improvements.

5.) Implementing quality improvement interventions to address patient safety - process improvement initiatives must be based on quality of care, safety, and patient outcomes.


As with HRO principles themselves, these strategies can be tailored to individual organizations. For example, the Veterans Health Administration places a special emphasis on “creating a Just Culture,” where staff feel empowered to speak up and address safety issues and target areas that require improvement.


Adopting HRO principles has the potential to lower unnecessary patient deaths, improve care outcomes and patient safety, and increase cost savings for health systems. While the challenges to implement HRO principles may be daunting, a health system can employ the strategies mentioned above along with robust change management and data analysis capabilities to ensure success. HRO principles allow health systems to pursue excellence and treat patient safety with the level of importance it deserves.



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