What is a High Reliability Organization (HRO)?

High-reliability organizations (HROs) are those that have avoided catastrophes despite elevated levels of complexity and risk. Researchers Karl Weick and Kathleen Sutcliffe have studied specific examples, including nuclear power plants and air traffic control systems. Recent healthcare organizations have adopted the HRO mentality. Even a minor mistake could have disastrous consequences in each of these cases.

Why are negative outcomes rare?

Researchers at Berkley were looking to identify the characteristics of high-reliability organizations (HRO). Researchers at Berkley conducted extensive research into United States nuclear aircraft carrier, Federal Aviation Administration Air Traffic Control System, and nuclear power operations of Pacific Gas and Electric Diablo Canyon Reactor. Five elements were found to be common among HROs.

These traits are crucial for avoiding catastrophic failures or significant failures despite working in an environment that is hazardous and where lives are on the line. Although your organization may be less complex and face fewer risks, the HRO mentality can help your team achieve its full potential and keep its promises.

Our journey to become a high-reliability organization is focused on improving reliability by better process design, creating a culture that values reliability, and leveraging the human factor through intuitive designs which help people do what they should. Although our desire to become an HRO began with safety, it has evolved into a job that will improve the performance of everything we do.
We also focus on a few principles of reliability science.

  • Designing reliable and standard systems to support staff decisions.
  • Learn to be more aware of your decisions and actions by using the HRO theory.
  • Improving Situational Awareness – the concept that identifies at-risk patients and reduces their risk, escalating the risks until the patient becomes safe.
  • Predicting the future and putting in place robust plans for the expected as well as the unexpected
  • Human factors are important to consider when designing systems. By understanding how people work and interact and taking into consideration their needs, we can better protect patients, employees, and visitors.

Communication skills are essential for solving problems.

Communication is essential for the success of any organization or team. Communication that is clear can reduce stress and anxiety, which in turn improves worker morale. Active listening is one of the ways to improve your communication skills.

Active listening involves more than simply hearing what people say. It also includes paying attention to the tone of their voice and summarizing it so that they understand.

Active listening does not mean that you interrupt someone before they have finished their sentence. Listening half-heartedly can make people think that you’re not interested in what they have to say and may stop speaking altogether.

Communication can be improved by communicating less or, more specifically, selectively. If you communicate with someone who doesn’t work at the same urgency level as you, they may misunderstand your needs and cause you unnecessary stress.

It can be frustrating for a nurse to have five patients in triage waiting for her and then another nurse asks for help moving the equipment.

You might think that they both should just ask each other, but this doesn’t work all the time. People might forget to do so, or not be comfortable asking. So, they pretend everything is fine. If one nurse tells the other, “I have 5 patients waiting in triage,” the other nurse will understand this without having to be told all the details. This can prevent a lot from going wrong.

By communicating selectively, your teammates will know exactly what you want and how long you need to achieve it.

It is essential that all HROs follow the same rules and have a clear leader, to avoid various levels of urgency among teams.

It takes time for HROs to become safe organizations, as they cannot be built overnight. It can take months or years to work together.

High Reliability Organization (HRO) Pyramid Principles
High Reliability Organization (HRO) Pyramid Principles

Core principles for high-reliability healthcare organizations

These organizations are characterized by a set of core values that allow them to be leaders in the healthcare industry and provide the best possible care for their patients. These core principles include:

  • Access to the right information and data
  • Act with the best evidence.
  • Empowering healthcare workers

Access the right information and data.

The optimization and coordination health data can be attributed to many of the healthcare change initiatives dating back over two decades. Until now, much of the essential data was siloed and unstructured. It also remained inconsistent or proprietary.

Many clinicians need to rely on treatment recommendations that aren’t available yet or not clearly described in peer-reviewed publications.

Health Information undermines outcomes.

The World Health Organization calls this a infodemic. The poor quality of data that is used to inform most guidelines that clinicians use as a guide for treatment decisions is not acknowledged by the majority.

Misinformation about health can negatively impact the patient-clinician relationships and adversely affect health outcomes such as medication compliance. High-reliability healthcare organizations prioritize access to data sourced by professionals that can be used in clinical settings to avoid these threats.

How to balance science and speed to translate evidence into action

Every day, clinicians make important decisions about care and management. They need timely access to guidance which synthesizes the best available evidence and is augmented with the wisdom of experts as well as other relevant sources.

If done correctly, presenting the best available evidence in a way that frontline healthcare providers can use it has enormous potential to improve post-pandemic health care and save lives. It is important to deal with complex or unknown conditions, such as cancers and infectious diseases for which treatments are changing rapidly or are still developing.

Transparency and trust are essential for good science, but clinicians must also be able to use the information in a way that is useful. The following are critical components to that balance:

  • Synthesized Evidence
  • Peer review
  • Speed and rigor
  • Recognizable expertise
  • Transparency of data evaluation and recommendations
  • Easy to find information (workflow Integration).

The shrinking budgets and staffing shortages are also driving efforts to standardize and digitize healthcare. NHS hospitals, community providers, and mental health services in England are reporting that they have a shortage of almost 94,000 full-time employees. One in ten nursing posts is vacant.

Strategies for Healthcare Workforce

It will be a challenge to develop new strategies for retaining employees, career advancement, and self-care.

Four workforce imperatives to evolve healthcare:

  1. Include training in new delivery models that reflect team-based care and technology-driven care.
  2. Deliver shorter sessions to accommodate new learning styles and integrate emerging digital tools.
  3. Mental health and well-being are addressed, and healthcare workers are actively engaged in improving the workplace culture and practice environment.
  4. Focus on academic and research collaborations that are focused on quality.

Using technology to empower healthcare

When used correctly, technology can improve the efficiency of care delivery and training for HRO healthcare. Download the eBook “Using technology as a way to create a high-reliability health organization” for more information.

5 Principle of High Reliability Organizations (HRO)
5 Principle of High Reliability Organizations (HRO)

Principle 1: Fear of Failure

The Process Failures Are Addressed Completely and Immediately

Some organizations can ignore or work to overcome small process deviations or failures. HROs cannot. HROs don’t ignore failures, no matter how minor, because even a small deviation from the desired result can lead to tragedy. HROs must therefore address all levels of failure, whether they are technical, human, or process-related, immediately and completely. An HRO will even identify and address potential process breakdowns. HROs tend to focus on what could go wrong, even when it hasn’t.

This means, in practice, that each employee of a high reliability organization (HRO) must think about the ways in which their work processes could fail. Shared awareness is always present. This applies to both small inefficiencies and potentially dangerous failures. Employees are encouraged to report any concerns they have about potential failures. This can help develop best practices throughout the organization. Everyone has the language and tools to communicate the culture that supports transparency and information about process breakdowns.

Principle 2: Reluctance to Simplify

Simple Solutions to Complex Problems

High-Reliability Organizations are complex, and they accept that complexity. HROs don’t just explain problems away; they instead conduct root-cause analysis and reject simplistic diagnoses.

HRO leaders must be willing and able to question long-held beliefs. They continually examine data and benchmarks, as well as other performance metrics. Leaders must always seek out information that challenges the beliefs they hold about why problems exist.

Principle 3: Sensitivity towards Operations

Every Voice Matters

HROs know that front-line can give the best view of the situation, particularly if it is unexpected. Frontline employees, who are more in touch with the work than executives, are better placed to identify potential failures and opportunities for improvement. HROs do not make assumptions. Consistently focusing on processes will lead to observations which can be used to inform decisions and create new operational initiatives.

HRO leaders don’t just sit around and wait for employees. They actively encourage them to share their concerns. Communication with employees is frequent and regular. This creates an atmosphere of openness. By taking concerns seriously and giving feedback, they show respect to individuals. The practice is called Gemba Walks.

Principle 4: Commitment towards Resilience

Recovery is Swift

Resilience is the ability to anticipate problems and adapt when they occur. In a dynamic environment, the organization must be able identify mistakes that need to be corrected while innovating novel solutions. They plan for emergencies, and they have clear communication and control methods.

Leaders in HROs stress the importance of multidisciplinary collaboration and removing barriers to it to foster resilience. Team members are encouraged to be flexible to adapt to changes in resources or conditions. They are trained to deal with unexpected events.

Principe #5: Respect for Expertise

Experts can be trusted.

HROs are more interested in expertise than authority. Subject matter experts on the ground are vital for assessing and responding to situations that are urgent and high-risk.

Leaders must be able to defer expertise by knowing who has specialized knowledge within their organization. Also, they must create experts and help skilled employees to keep their skills up to date.

These five principles are the basis for the mindset of High Reliability Organizations (HRO), which is a continuous improvement. There are still lessons to learn from businesses that deal with life-and-death issues. Consider adding these principles to the way you approach improvement.

Benefits High Reliability Organizations (HRO)

HROs have more success in managing errors and near-misses when they use a variety of interconnected mechanisms to control the four principles of error management.

  1. Stay alert and encourage people to do so.
  2. Make sure you have all the relevant information readily available.
  3. Use warning systems to maintain vigilance during operations.
  4. Hold people accountable for their performance and ensure that it is monitored.

It creates an environment that is safety-conscious, where members of the team work together to achieve common goals and adhere to the rules and procedures to ensure optimal performance towards those ends.
HROs can be used to provide a model for managing risk in complex systems.


Summary: HROs can reduce errors and near-misses by providing a protective framework that encourages employees to adhere to rules and Standard Operating Procedures,