HRO: Preoccupation with Failure

The first defining characteristic of high reliability organizations (HROs) is a preoccupation with failure.  High reliability organizations do not consider failures as things to avoid at all cost.  Rather, HROs believe that failures represent opportunities to learn and improve their systems.  As Thomas Watson, founder of International Business Machines (IBM) once said,"If you want to increase your success rate, double your failure rate."  Individuals in HROs report their mistakes, even when nobody else is looking!  HROs do not punish individuals who make mistakes.  On the contrary, in many cases, individuals who report their mistakes are often rewarded!

A couple of examples from US Navy aircraft carrier flight operations are illustrative of the kind of preoccupation of failure that is necessary to become a HRO.  Debris and other loose objects can be very dangerous on the flight deck - if a foreign object or piece of debris (or on rare occasions, one of the aircraft mechanics) is sucked up into the aircraft engine, the plane can no longer fly.  For this reason, each and every day while the aircraft carrier is at sea, every single individual on the flight deck, regardless of rank, lines up at the back of the flight deck and walks slowly to the other end, picking up any piece of debris or foreign object along the way (foreign object damage, or FOD walk). There is a popular story of an aircraft mechanic who once lost a screwdriver while working on one of the planes.  He notified his supervisor, who then notified his supervisor (and so on through the chain of command).  The incident triggered a FOD walk, and the screwdriver was found.  Was the mechanic punished?  Absolutely not.  He was recognized by the commanding officer in a ceremony later that same cruise.  The last example of "preoccupation with failure" involves the pilots.  In the early days of naval aviation, pilots were guided back to the flight deck by the landing signal officer (LSO), affectionately known as "paddles".  The LSO was also an experienced pilot.  Today, pilots use advanced technology to assist the landing.  However, the LSO remains as an important part of the landing process.  Each and every landing is graded by the LSO.  Pilots who do not pass muster receive additional training and instruction, and if they continue to have problems, they may be permanently grounded.  The LSO provides the ultimate "peer review" for all the pilots in the squadron.  These landings are also videotaped and broadcast throughout the ship - every one on the ship can watch these landings (PBS once broadcast a special segment on flight deck operations aboard the USS Nimitz - there is an excellent video showing an example of several pilots landing on a rolling, pitching flight deck at night!).

So what would "preoccupation with failure" look like in a hospital?  A hospital on its way to becoming a HRO usually has a "reporting culture" where slips, lapses, mistakes, and errors are reported without fear of punishment.     These hospitals view errors as opportunities to learn and get better.  HRO-like hospitals fully embrace training through simulation - simulation provides a safe, nonstressful environment in which processes can be learned and tested, often using real world scenarios.  Finally, these hospitals fully leverage peer review as a way to identify problems early, so that they can be corrected.  I know of some hospitals that videotape record all of the trauma resuscitations in the emergency department - these videotaped resuscitations are later watched and critiqued in a safe, blame-free environment by all members of the team.  The videotape recording is used as a teaching tool to improve and learn.  The HRO experts Karl Weick and Kathleen Sutcliffe published a short list of questions that hospitals can use to assess whether they are "preoccupied with failure"

There are some experts who feel that "preoccupation with failure" is too pessimistic and focuses too much on events in the past.  These experts suggest that hospitals should be preoccupied with success by focusing on what they need to do in the future in order to be successful.  While I can certainly appreciate this sentiment, I think this view misses the point.  A preoccupation with failure doesn't have to be pessimistic at all.  I think the key (and perhaps Weick and Sutcliffe should have used a different terminology here) is that HROs are focused on LEARNING.