High Reliability Organizations (HRO): Is This New or Old Thinking in Healthcare?

Healthcare organizations today are facing many challenges, including staffing shortages, financial loss, and safety issues. Many are in search of a way to help them overcome these and feel that working toward being a high-reliability organization (HRO) is the answer.

But is high reliability theory new thinking, or is it a different way of looking at improvement methodologies, something that has been around for decades? Industry and healthcare have been adopting improvement methodologies for many years in the forms of lean, the Toyota Production System, the Shingo Model, and Habitual Excellence.

All of these focus on three things:

1. being the best at what you do,
2. removing waste and preventing errors, and
3. engaging every person in the work.

If you don’t have a framework for organizational excellence, becoming an HRO, adopting TPS, or seeking Habitual Excellence are all proven approaches.

The crux for my thesis is this, if you have one of these proven frameworks and your organization isn’t achieving results, a new framework won’t solve the problem.

Every organization can become Habitually Excellent or Highly Reliable if, and ONLY if, your CEO is committed to and responsible for the success of the framework. And, when your CEO is committed and responsible, your improvement system focus must be on the principles of your framework, not the tools. Your management system focus must be on leader behaviors, not tasks. To change your organizational culture to one of learning and excellence, leaders must be developing reports and solving problems to root, instead of spending more of their time in meetings and focusing on submitting reports.

Listen to some of our podcasts with deeply-committed CEOs

Let’s take a deeper look at the principles and behaviors of excellent organizations, comparing high reliability to other frameworks and focusing on what must be true, no matter your framework.

Preoccupation with Failure

The first high reliability principle, preoccupation with failure, means operating with a heightened awareness of potential risks and near misses that jeopardize safety. There is a strong emphasis on correcting the conditions immediately.

Many other improvement methodologies include a set of tactics and behaviors that create a process to learn from and prevent failure or harm. The Shingo Model recognizes that the pursuit of perfection creates a mindset and culture of continuous improvement. There are multiple lean tactics that focus on error-proofing as well.

At Value Capture, we like to begin teaching this type of thinking by focusing on staff and patient safety. We start there because it is a goal that nobody can argue with; people don’t want to see others get hurt or injured. We also help organizations create processes to learn from others with similar processes or risks, proactively implementing solutions to prevent errors and failures.

Preoccupation with failure can become the motivation and invitation for every person in the organization, everywhere in the organization, to work every day to solve to root the causes of harm, injury, and risk of harm.

Reluctance to Simplify Interpretations

This HRO principle states that people should deliberately question assumptions to create a more complete and nuanced picture of the current situation. When solving problems, refusal to simplify allows us to more completely define all the contributing factors that led to failure and thereby test more robust and complete solutions.

The Rules in Use are the most reliable diagnostic tool for preventing oversimplification. Finding the violation of a particular Rule in Use will provide the greatest clarity for what led to the process breakdown.

Sensitivity to Operations

Sensitivity to operations refers to the sharing of current human and organizational factors to create an integrated big picture so that small corrections can be made to prevent errors from accumulating. 

At Value Capture we teach the importance of listening to those doing the work, creating simple pathways to signal defects or near misses and respond in real-time, solving to root and removing sources of error and risk. Real-time is the key leverage point. Within minutes of the error, going to the place and connecting with those with the facts is the most reliable pathway to effective and efficient problem-solving.

Many improvement philosophies include the adoption and implementation of a management system, which involves daily tiered accountability practices to reveal barriers and risks to physical and psychological safety and an organization’s ability to meet customer needs, creating visibility, urgency, and focus for the leaders.

We believe that highly reliable organizations go beyond the scheduled huddles and connections and build a Help Chain, a real-time pathway of problem-solving responses. Responding to restore the system and care for the injured, and to solve to root in real time to prevent recurrence. To share what was learned and proactively remove risks before they happen elsewhere in the organization.

Commitment to Resilience

According to HRO principles, an organization must also develop capabilities to cope with, contain, and bounce back from mishaps that have already occurred and before they worsen.

Other improvement theories teach us to use visual cues to identify issues. Lean uses things like “pulling the andon cord” (stopping production when things are not right) and error-proofing processes to make it hard (or impossible) to do the wrong things.

This principle is another area where the concepts of real-time problem solving and root cause analysis (referred to in lean, and Toyota Production System) are useful. The Help Chain is invaluable in this immediate response to care for anyone harmed or impacted, restoration of operations, and understanding what went wrong to prevent the propagation of the process error.

Deference to Expertise

The final HRO principle is perhaps the most important principle of them all; decision-making migrates to the person or people with the most expertise with the problem at hand. 

We know that those that do the work are the experts in what they do, what gets in the way of success, and how they resolve issues to win the day. What is needed is a system that supports them and barrier removal to release their problem-solving creativity. This is why many improvement methodologies express the importance of keeping problem-solving as close to the work as possible. Every person, every day should be empowered to solve problems, and when there are barriers, leaders should step in to remove them.

If you need a framework to harness the creativity in your organization toward excellence, choose one. If you have a framework and you aren’t achieving excellence, there is no easy fix. It starts with your top leader and relentless focus on the principles and leader behaviors.

Being better means committing to being the best at what you do, removing waste and errors, and engaging every person, everywhere in the organization, to solve problems in real-time every day.

Each of these frameworks represents what is possible; success comes when every person engages with the principles and behaviors proven to change the culture to one of learning and excellence.