What Is High Reliability?

High Reliability occurs when organizations operate consistently, without harm or catastrophic events over a long period of time. It is a philosophy that organizations adapt that, at its heart, embraces a collective, persistent mindfulness. Organizations and businesses that adapted principles of high reliability are the aviation and nuclear power industries, to name two. Studying these organizations and the principles they put in place for high levels of consistent safety has greatly influenced the adaption of those same principles and characteristics in healthcare quality and safety.

Leaders in a Highly Reliable Organization (HRO) recognize that the key to high reliability is firmly establishing and nourishing a culture of safety. This culture must be the foundation for “whole system safety.”  Often, healthcare organizations put processes in place that encourage communication and team involvement, to push forward specific performance improvement projects. Instead, safety must be part of the overall culture and embraced at a systems level. Every individual in the organization becomes a part of this systems approach to safety. Continuous learning, monitoring and enhancing processes becomes the overall philosophy and frame of mind for the HRO. This systems approach is seen in the strong principles of leadership that encourages teamwork and ultimately, behavior change, rather than focusing just on a particular technology, team or process.

High reliability can be seen in five principles first named by Weick and Sutcliffe,  and are adapted by HROs to achieve consistently high levels of safety. The first three elements or characteristics focus on the anticipation of failure. The last two underline the importance of committing to the containment of errors and failure.

Characteristics of High Reliable Organizations include:

1.        Preoccupation With Failure. Always alert to what might happen, high reliability embraces the constant search for where things might fail or go wrong. Everyone in the organization is vigilant, and attentive to small problems that might become opportunities for improvement.

2.       Resist the Temptation to Simplify. By being reluctant to accept work processes at face value, employees in an HRO understand the complexity and subtle differences that on the surface seem safe, but underneath can challenge safety.

3.       Sensitivity to Operations. It is crucial that all members of an organization are involved in operations and feel empowered to report deviations and feel safe to speak freely at any time.

4.       Deference to Expertise. In a crisis or emergency the people with the greatest knowledge are not necessarily the people with the greatest authority for decision making. Those individuals that have the most understanding of a threat or process are empowered to offer their unique expertise. This characteristic puts less emphasis on the established hierarchy and places importance on the climate of shared responsibility.

5.       Commitment to Resilience. Teams in HROs respond quickly to system failures, understanding that if error does happen, it is recognized quickly, and dealt with appropriately. This both prevents harm at the time of error identification, and prevents further errors.

The goal in attaining high reliability in healthcare means creating a safety culture that informs and drives all operations in an organization. Leadership must be completely committed to the constantly evolving playbook that looks for failure, quickly implements new processes, and rewards committed and involved individuals and teams.

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Chassin, M., Loeb, J. (2013). High-reliability health care: Getting there from here. The Milbank Quarterly. 91(3), p459-490.

Federico, F. (2018). Is your organization highly reliable? Healthcare Executive. 13(1): 76-79.

Brynes, J., Teman, S. (2018). The Need for High Reliability. In The Safety Playbook: A healthcare leader’s guide to building a high-reliability organization. Health Administration Press. 29-33.

Katie Cross, MSN, RNC-OB, LCCE