High Reliability Organizations - A Very Brief Introduction

We hear a lot about so-called high reliability organizations (HROs) these days.  Regulatory agencies such as the Center for Medicare and Medicaid (CMS), the Joint Commission, and the Leapfrog Group have all embraced the concept that health care delivery organizations should aspire to become HRO's.  HRO theory started with the analysis of three vastly different organizations - the US Navy nuclear-powered aircraft carrier, the USS Carl Vinson, the Federal Aviation Administration's Air Traffic Control system, and Pacific Gas and Electric's nuclear power plant at Diablo Canyon by an eclectic group of investigators - Rear Admiral (retired) Tom Mercer, Todd LaPorte, Gene Rochlin, and Karlene Roberts (all at the University of California at Berkeley).  Additional contributions to the HRO literature have been provided by Karl Weick, Paul Schulman, and Kathleen Sutcliffe.  But what exactly is a "high reliability organization"?  HROs are usually defined as organizations that somehow avoid catastrophic accidents, even though they normally exist in an environment where normal accidents can be expected to occur by virtue of the complexity of the organization and by the nature of the industry.  Examples of HROs have included flight deck operations on US Navy aircraft carriers, nuclear power plants, commercial aviation, NASA, and forest fire fighting operations. 

Interestingly enough, every single HRO has, at one time or another, experienced catastrophic accidents.  For example, NASA has had the space shuttle Challenger and Columbia accidents, while the nuclear power industry has experienced the Three Mile Island and, more recently, the Fukushima Daiichi disasters.  Even the highly acclaimed Toyota Production System (many experts have claimed that Toyota has been one of the more recent examples of a HRO) has experienced difficulties.  As such, there are certainly lessons that we, in health care, can learn from HRO's past successes and failures (I wrote a recent article on this topic, available here).  Karl Weick and Kathleen Sutcliffe have written extensively on HRO principles in their excellent book entitled "Managing the Unexpected".  Weick and Sutcliffe explain that all HROs have five key organizational characteristics in common:

1. Preoccupation with failure
2. Reluctance to simplify interpretations
3. Sensitivity to operations
4. Commitment to resilience
5. Deference to expertise

In the next few blog posts, I plan to discuss in greater detail each specific characteristic.  Whether hospitals can become HROs is debatable - some experts even suggest that hospitals can NEVER become HROs (for example, see the article here).  I would argue that most HROs will never admit that they are, in fact, highly reliable organizations.  In other words, the first characteristic - "preoccupation with failure" suggests (in my opinion) that most prototypical HROs are so focused on failure that they will never claim that they are HROs.  So, beware the hospital that claims to be a HRO!