High Reliability Organizations (HROs)
Practical Considerations in Formation and Development for Healthcare
May 20, 2016
Aircraft Carrier Flight Decks – A Classic HRO Environment
High Reliability Organizations (HROs) are high-risk workplace environments, designed for and achieving safe and effective operations. HROs avoid catastrophic failure in environments where normal accidents (catastrophic and multifactor) can be expected due to risk factors and complexity. Some of the classic environments that are used as role models of the genre are aircraft carrier flight decks, nuclear power plants and commercial aviation. Today these environments are models of safe and effective operations, while functioning in extremely perilous activities. These HRO environments are built on a unique foundation of teamwork and leadership training, organizational culture focused on safety/learning, and incorporate an intense focus on process improvement and safety.
The US Army, together with The Joint Commission (TJC), have recently adopted programs to incorporate the functional benefits of HROs into their medical standards for operational excellence, based on work done at US Army medical facilities, the Owensboro Medical Health System (KY), Greater Baltimore Medical Center, South Carolina Hospital Association and Sentara Healthcare.
Of all of the work to date, the US Army has the simplest and most direct approach to HROs in healthcare settings, setting the key three components of HRO development as:
- Leadership commitment and effective teamwork,
- A culture dedicated to trust, honest reporting and continuous improvement, and
- Robust use of process and safety tools and methods.
The US Army is a difficult role model for leadership and culture. Since 1975, it has effectively focused on teamwork, leadership and culture as defining elements of its strategic and tactical differentiation and success. Its methods and capabilities are sui generis, and we will return later to more practical examples for leadership and culture in hospital HRO development.
Regarding process and safety tools and methods, the Army has focused its attention on the tools broadly categorized as Lean/Six Sigma for HRO implementation. For most hospitals, the design and development of HROs rests on a more broadly defined combination of safety and process systems and methods including:
- The Safety Matrix developed by William Haddon in 1970,
- The theory of Normal Accidents by Charles Perrow in 1984
- The Swiss Cheese Model of normal accidents developed by James Reason in 1990.
- The concepts of Just Culture,
- The broad range of process tools known as Lean/Six Sigma,
- A broad range of team building tools known collectively as Crew Resource Management (CRM),
- A set of tools for risk analysis and mitigation broadly known as BowTie,
- Existing training and process control tools, including Policies and Procedures,
- Checklists for safety and process control, and
- Overarching quality management systems such as ISO 9001:2015, and Baldrige.
Unlike more defined quality management systems like ISO and Baldrige, HROs have no standardization and no controlling body. HROs have been best described and examined by two professors of organizational behavior, Karl Weick and Kathleen M Sutcliffe; best noted for their collaborative work, Managing the unexpected: Resilient performance in an age of uncertainty. For Weick and Sutcliffe, the HRO is defined by the end-state functional relationships by the people in the organization, broadly described as collective mindfulness. This mindfulness is focused on the possibilities of failure, and how the individual, team and organization can best promote and maintain a safe and effective environment.
What does it Look Like?
Specifically, Weick and Sutcliffe identify five characteristics of HROs:
- Preoccupation with Failure. Any minor detail out of the ordinary can be a “weak signal” of a larger problem. HROs are collectively very sensitive to the potential for failure, and respect the need for all team members to be able to speak up and note potential problems.
- Reluctance to Simplify. HROs operate in complex environment, with the potential for cascading failure. Simplifying loses the detail required to make a complete and well understood situational analyses.
- Sensitivity to Operations. The interface of patient/provider is where care is provided and safety is most critical. Sensitivity to small changes is critical to detect safety risks.
- Commitment to Resilience. Errors will happen – how they are mitigated and limited are critical to patient care and operational continuity.
- Deference to Expertise. Responsibility and authority migrate to those with the greatest expertise and understanding, not based on institutional hierarchy.
Based on these five characteristics, the literature is replete with dozens of examples – good and bad – of what does and does not constitute an effective HRO. First, let’s take a look at obvious failures. Classic studies include studies of Three Mile Island (March, 1979), the disaster aboard the USS Forrestal (July, 1967), and the collision of two Boeing 747s at Tenerife Airport (March 1977). Without going into the detail of each of these cases, they involved terrible communication, inattention to operations and obvious failures and risks, rigid hierarchies that impeded information flow and good decision making, dozens of “weak signals” that the entire operating team ignored, and the inability to deviate from the planned mission until full disaster struck. In each of these cases the ultimate failure was a “normal accident”, in that the ultimate disaster was the result of a series of failures, not a single catastrophic event.
Watching disaster unfold on the Forrestal
Tenerife – A disaster that could have been prevented
Three Mile Island – the worst nuclear accident in US history
Looking at the transcripts from each of these failures, it is clear that the fiascos were preventable at multiple points along the path to disaster. Perhaps most difficult to accept, is that in the cases of Three Mile Island and the Forrestal, the mitigation efforts were nearly ineffective, despite ample opportunity to mitigate the emerging accident. Like wildfires, normal accidents tend to grow in size and damage if mitigation is ineffective.
What is important, is that each of these events served to galvanize the US Navy, US nuclear power industry and the international aircraft control system into development into HROs. Today each of these industries has transformed itself into a model of high reliability and continuous improvement in safety.
Steady reduction in Airline Crashes and Fatalities
Naval Aviation is a model of HRO success
Post Three Mile Island Safety Improvement in Nuclear Power
(Significant events per plant)
Healthcare is unfortunately replete with failures of patient care resulting in harm to the patient or death. NASA’s chief toxicologist estimated in 2013 that between 210,000 and 440,000 Americans die due to medical mistakes per year – putting medical errors in the number three position of total deaths – right behind cancer and cardiac disease.
Dr. Jim Bonnette, EVP of Strategic Consulting at the Advisory Board tells a personal story (here) of how a routine, elective discectomy nearly proved fatal in 1991. It was performed at the hospital with which he was then affiliated, by colleagues on the staff. It is an all too familiar tale of how 10 separate errors on the part of the medical staff in less than a 12-hour period left him nearly dead, requiring emergency corrective surgery, and a stay in the ICU. Only his ability to self-diagnose and work the system from the inside saved his life. Dr. Bonnette took steps after the incident to create an emergency rapid response team to make sure that this never happened again, but the fundamental message is clear – even VIP status will not guarantee safe and effective treatment.
Hospital Treatment remains very high risk
Preventable Death in US Medicine
What is Reliability and how do we measure it?
Donald Berwick and Thomas Nolan did some great work at IHI (here) regarding the definition and measurement of reliability, that is directly applicable to HRO development. First in considering what is reliability:
- The measurable capability of an object to perform its intended function in the required time under specified conditions. (Handbook of Reliability Engineering, Igor Ushakov editor)
- The probability of a product performing without failure a specified function under given conditions for a specified period of time. (Quality Control Handbook, Joseph Juran editor)
- The extent of failure-free operation over time. (David Garvin)
- The measurable capability of a process, procedure or health service to perform its intended function in the required time under commonly occurring conditions. (Berwick & Nolan)
The quantification of reliability must everywhere and always focus on the operations of the organization/hospital. Frequently I see attempts to quantify the success/state-of-development of an HRO based on the aggregate mental state of the participants. This seems to be done, trying to tie HRO status with the descriptive work done by Weick & Sutcliffe – specifically the five characteristics of HROs. Descriptive end state analysis sheds very little light on how an organization got to where it is, where it is going, or the operational success being delivered. HROs come from highly organized teams of well-trained people who consistently deliver expected results in high risk environments. What is ultimately important to a practitioner is how to lead/manage organizations to continuously deliver reliable quality and safety, not the gestalt of the resulting organization. Carl Linnaeus was a brilliant naturalist and taxonomist, but it doesn’t mean that you would use his work to raise a puppy.
Quantification of reliability in medicine can be thought of according to the following construct:
- “Reliability” = Number of actions that achieve the intended result ÷ Total number of actions taken
- “Unreliability” = 1 minus “Reliability”
- It is convenient to use “Unreliability” as an index, expressed as an order of magnitude (e.g. 10-2 means that 1 time in 100, the action fails to achieve its intended result)
- Related measure: Time or counts between failures, for example transplant cases between organ rejection, employee work hours between lost time injuries.
For most human activity, about 10-3 is about the best level of (un)reliability that can be attained through simple care and vigilance. For HROs, this would be considered the minimum level of acceptable performance for a new organization trying to improve safety and quality. As indicated in the chart from Rene Amalberti below, fully functional HROs can attain levels of (un)reliability up to 10-6.
For those who work in quality, it is helpful to translate this into Deming’s Six Sigma construct:
Translating this construct into meaningful metrics in medicine:
|10-1||Beta blockers for MI
>3 Glycosylated hemoglobin tests/2 yrs.
|10-2||Polypharmacy in the elderly
Deaths in risky surgery
General surgery deaths
|10-4||Deaths in routine anesthesia|
|10-5||Deaths from major radiotherapy machine failures|
|10-6||Deaths from seismic non-compliance|
For further reading, see: McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. New England Journal of Medicine. 2003;348.
Reliability of selected activities
One critical consideration of measurement in HROs, is that the more successful the HRO, the less frequent the failure, and the less that there is to be measured. Since failure is a very infrequent event, and continuous improvement a critical mandate, the measurement of near misses and related weak signals becomes increasingly important to understand reliability of the overall system.
How to get started – and make durable Healthcare HROs
Applying HRO concepts to specific improvement initiatives is what truly matters. If the concepts cannot be used to make specific aspects of hospital care safer, higher in quality, or more efficient, then they are of no value. In all of the examples shown, only small parts of large and complex systems function as HROs – flights decks, not mess halls; reactors, not billing departments; and, flight crews, not TSA staff. HROs are difficult to establish and operate. They involve extensive training and coordination, and are not a generalized management system – they are for high risk areas and procedures where patient safety is critical.
HROs are a critical component in delivering safe and effective medical care, but they can’t exist with C-Suite leadership support and clear economic benefit. Exempla Chief Executive Officer (CEO) Jeff Selberg discussed the importance of supportive executive leadership in achieving high reliability. His observations on what leaders must do reflect many of the HRO principles described above, including:
- Culture is the foundation for vision and strategy. A culture characterized by fear and self-protection will not lend itself to openness, learning, and improvement.
- Transparency is the key to change the culture. An unwillingness to face and share the hard facts is an indicator of denial, and denial is not compatible with a safe environment.
- Safety must be the overarching strategy. Safety should be the root cause of achieving efficiency and effectiveness. If the inverse of this relationship exists, the likelihood of having unsafe yet highly efficient processes increases. Only if safety is the starting point can the correlation among safety, efficiency, and effectiveness remain positive.
- Leaders must take ownership for setting the climate and focusing the work. Generating clarity, setting the example, and demonstrating confidence will help to transform organizational culture. However, without outright acceptance of ultimate accountability for setting organizational direction, a leader’s vision will not be legitimized in the eyes of his or her followers.
- Alignment with your business case. In the past, hospitals could be highly reliable producers of profit without producing high quality/reliability. With all of the value based care payment systems in place and coming, this will no longer be the case. Quality and reliability need to be cornerstones of the business case, and the CFO needs to be involved in the goals and metrics of the system.
Improving quality and safety requires both knowing what to do and how to do it. Many initiatives are excellent ideas but still fail because the approach to implementation is poorly designed. A high reliability mindset must be applied to how your organization plans and implements improvements. If you don’t understand the pressures and challenges facing the people key to your implementation, you probably won’t succeed. You also will not succeed if you oversimplify your implementation strategy, fail to listen to people with the most expertise about what success requires, or fail to constantly consider what can go wrong and work to avoid those challenges.
There are three broad and critical areas to consider in HRO implementation and design:
- Resources and Work
Process Best Practices
If an improvement cannot be integrated into an ongoing initiative or process, do not try it. Until it is integrated it will not be successful. A key to high reliability is simplifying systems and processes so that they can be performed consistently. The more separate initiatives or processes that exist, the less reliable the overall system will be.
Embeds initiatives into the training that they provide to new staff. This creates the expectation that the initiatives are essential and avoids having to retrain staff after they begin work.
Start by simplifying policies and procedures to make it possible for staff to comply. Most hospitals P&Ps are vastly too complicated, and are not risk focused. Gaining buy-in and appreciation for making jobs easier before adding new procedures or processes helps employees to avoid seeing the new things as an extra burden.
Roll initiatives out incrementally and begin with ones that are non-punitive.
Use Lean/Six Sigma and process mapping approaches to design and roll out initiatives. By drawing together key people and allowing them to spend an extended period of time working together to map out the process and then redesign it, increase the likelihood of redesign efforts that are likely to succeed.
People Best Practices
To involve physicians, avoid systems or procedures that decrease their efficiency. Physicians do not mind changes in how they practice medicine if those changes make them more efficient (or at least do not decrease their efficiency). Involving them in the planning process is crucial toward preventing the implementation of changes that they will perceive as making them less efficient.
Provide resources and expertise that allow physicians to help lead improvement efforts.
Include people from multiple shifts and work units. Including as broad a set of people who will be affected by the initiative is critical.
Encompass multiple staff types in planning.
Avoid having quality improvement staff design initiatives without input from operational staff. The role of quality improvement staff is to serve the teams working on the improvement rather than function as the leads responsible for achieving the change. This consultative role ensures that ownership of the improvement efforts remains with the units and teams that provide patient care. This approach increases staff buy-in as well as the sustainability of improvement efforts.
Resource & Work Best Practices
Resources and labor are always in short supply. Many systems actively monitor the number of priorities to ensure that there are not too many to support. At the microsystem level, several systems use strategies that require managers to list all the things they are trying to do and then to classify these things based on whether they can or cannot do them. Management then must respond to these lists by setting priorities and making decisions about more resources. This task is very difficult for managers but helps avoid starting new things that personnel feel cannot be done.
Simplify work process. If you cannot reduce what you want staff to do into a limited set of clearly defined behaviors, your system will not be reliable.
Daily check-ins. These short, focused meetings of leaders and staff on a unit follow a set agenda and occur at the same time each day. The meetings allow staff to raise questions, give them information that may affect their work, and provide a forum for raising issues, which are delegated and handled outside the meeting.
Executive rounds. Executive rounds enable hospital leaders to retain an awareness of operations that is needed for good decision making. These rounds also create an opportunity for staff to raise issues with leaders and for leaders to model the behaviors they want staff to exhibit, including following up on issues that are raised. They are key to supporting a culture that defers to expertise and encourages staff to speak out about safety and quality concerns. In order for executive rounding to be most effective, however, hospital leadership must follow up on the concerns voiced by staff members in order to ensure receiving continual feedback.
Safety huddles. The huddles are very short but allow people to comment on any safety issues they observed or were concerned about. They also allow people to comment on their own condition so that people can receive extra assistance on days when they may need it.
Performance management. Many systems have very rigorous processes for managing performance and rewarding individual and team accomplishment. These approaches often include behavioral observation of staff by trained supervisors and substantial bonuses. Performance management is key to ensuring that staff are rewarded for desired behavior and discouraged from other actions.
Key Resources and Tools
There are three key foundation level systems/tools that need to be implemented and constantly reviewed to develop and maintain HRO operations:
1) Just Culture. Just culture is a broad term used to define and determine a functional safety culture in a Hospital, and is critical to the success of an HRO environment. Just culture recognizes that the tendency to cast blame for all errors in medical environments is the single greatest impediment to process improvement and learning. Only by reporting errors can the root cause of the problem be determined. Just culture incorporates the reality of system accountability for errors and omissions, as well individual accountability.
The single greatest impediment to error prevention in the medical industry is “that we punish people for making mistakes.”
Dr. Lucian Leape Professor, Harvard School of Public Health Testimony before Congress on Health Care Quality Improvement
“People make errors, which lead to accidents. Accidents lead to deaths. The standard solution is to blame the people involved. If we find out who made the errors and punish them, we solve the problem, right? Wrong. The problem is seldom the fault of an individual; it is the fault of the system. Change the people without changing the system and the problems will continue.”
Don Norman, The Design of Everyday Things
MGH uses the following to define and limit the boundaries and application of just culture:
- Traditionally, health care’s culture has held individuals accountable for all errors or mishaps that befall patients under their care.
- A just culture recognizes that individual practitioners should not be held accountable for system failings over which they have no control.
- A just culture also recognizes many errors represent predictable interactions between human operators and the systems in which they work. Recognizes that competent professionals make mistakes.
- Acknowledges that even competent professionals will develop unhealthy norms (shortcuts, “routine rule violations”).
- A just culture has zero tolerance for reckless behavior.
One key attribute and goal of a just culture is a clear cataloging and analysis of all mishaps, including near misses. HROs are characterized by staff preoccupied by faint signals of potential problems, and real time team based analysis of near misses.
We include effective Root Cause Analysis (RCA) as a key attribute of a just culture. It is easy to spot a failed RCA system, because the majority of the “root causes” will be human error or failed training. These are never the majority of causes in any system, and certainly not in an HRO. There are a large variety of tools available for RCA analysis – 5 whys, A3s, etc. – but none of them can work if the culture of the organization prevents real system analysis, and insists on finding human error as the root cause of all system failures.
2) Policies & Procedures (P&Ps). P&Ps are the foundation for process definition/control and training in all medical environments. They are typically required by law and accreditation for hospitals, and may be for physician practices as well, depending on state law and accreditation. Unfortunately, most hospitals use outdated and ineffective P&P systems, that provide inadequate training, poorly executed and vastly too complicated process description and do not incorporate any analysis of risk, cost or revenue. Frequently, we see that process improvement activities live in a parallel universe to the P&Ps that are supposed to describe and control them. The clean-up and re-tooling of P&Ps is frequently a key component of making HROs a durable and extensible solution in hospitals. Audits are the fundamental basis on which training audits, testing and drill take place (see below).
3) Training, audits, testing and drills. Training, audits, testing and drills are legally required for many functions in hospital settings, and are a critical part of the development of a reliable organization/system. These can be coordinated and controlled through a QMS such as ISO, or dealt with individually. All material requirements for these functions should be explicitly included in the P&P system. Compliance for high risk procedures should be included in management reports.
There are two broad groups of “mid-level” tools that are required to build an effective HRO based organization. These are referred to as mid-level tools in that they have broad application throughout the organization, including areas that are not designed to function as an HRO.
1) Process improvement tools including Lean/Six Sigma, TQM, checklists, process bundles, process mapping and value stream mapping. These tools have proven to be durable and vital to the development of process improvement in all process oriented applications – both service and manufacturing. The US Army has specified that learning the application and use of these tools as a key determinant of success for HRO implementation. The most effective and efficient organizations in the world push the understanding and use of process tools out to front line staff, so that they can both understand and design process improvement. Process change always belongs to the front line staff, along with the expertise and accountability for action.
2) Team formation programs – CRM. Neither Just Culture not HROs can function without functional teams. Crew Resource Management (CRM) is a system of team development and management that grew out of the commercial airline business, and has spread to all areas of high reliability. CRM has proven vital in breaching the ramparts of established hierarchies, and creating teams that function based on situational awareness, expertise and functional capability/availability. At its core, CRM separates the concepts of hierarchical position from knowledge – the captain is in charge, but is not always right. It changes the fundamental role of team captain from “decider” to player/coach. Getting the right information and structuring the correct analysis and jointly pursuing the best outcome are team jobs in a CRM based environment.
There are two broad categories of tools and techniques that we recommend for top level tools in the structuring and development of HROs:
1) BowTie based tools and analysis. HRO environments are very specific in any organization. They are always high risk environments which are critical to safe function. Increasingly, we see the use of the BowTie method to Using BowTie methodology in HRO’s.
The BowTie methodology is an increasingly popular approach to assessing and managing risk. BowTie was developed in the 1970’s and quickly adopted by the nuclear and aviation industry. Currently BowTie is the leading method, used by many Fortune 500 companies, to communicate major risks to stakeholders. BowTie is a combination of more traditional fault and event trees with the addition of so-called ‘risk barriers’. A BowTie diagram features a pre-event, event and post-event structure much like Haddon’s matrix. This results in a complete risk picture with room for both prevention and risk mitigation in one clear diagram that is ideal for risk communication.
A BowTie diagram
Risk barrier thinking is an important part of the BowTie approach. Think of a BowTie as a collection of adverse event scenario pathways. A risk barrier intervenes in a scenario and stops the scenario flow or deals with the consequences. The Swiss cheese concept is integrated in BowTie risk barriers through the addition of so-called ‘Barrier Defeating Factors’. These factors can undermine the reliability/effectiveness of prevention and risk mitigation barriers. BowTie takes into account the organizational context and its effects on critical risk management controls. This is an indispensable component of an effective safety culture.
In healthcare BowTie complements existing risk tools like FMEA and RCA because it addresses needs that are currently not met by existing tools. BowTie focuses on risk relevant day-to-day operational activities and how the organization affects them. BowTie is a proactive risk assessment tool.
Due to its visual nature BowTie is ideal for use in a multidisciplinary group working on HRO development. Staff, physicians and others involved can all see the same model and add their specific experience and expertise to it. Used this way BowTie also provides a shared mental model and terminology for thinking about risk, and takes advantage of CRM efforts.
The risk barrier concept is now also incorporated in the new ‘Root Causes and Barriers’ method (RC&B) for incident analysis. This method creates a regular RCA event structure but it adds risk barrier units to focus on their reliability / effectiveness when intervening in the event flow.
Developing a BowTie typically takes place in three distinct phases:
- Create an understanding of the risk (building of core diagram, no barriers)
- Understand how the risk is managed (adding control framework)
- Knowing and managing the weaknesses of the control framework (control context)
Many hospitals use BowTie to assess and manage a subset of risks that have a low frequency but severe catastrophic consequences. The low frequency means that not much is known about such events. BowTie is also a powerful gap analysis tool especially when used with the BowTieMED software package and its document linking capabilities.
HROs particularly benefit from the BowTie and its risk barrier concept. Especially when used in multidisciplinary workshops tangible results can be delivered fast, and with the right facilitation results are also deemed very relevant by workshop attendees. This is the result of BowTie showing the complete risk picture but also putting the prevention and risk mitigation efforts in the correct order. Because of this many users also hail its heuristic abilities. They frequently mention that BowTie enabled them to look at particular risks from a completely different and new perspective.
Developing a BowTie is all about selecting, defining and implementing prevention and risk mitigation barriers. The BowTieMED software supports barrier definition with its own framework focused on operational activities, accountability and documentation. Overall accountability for barriers and separate responsibilities can be defined supporting a just culture.
Finally, the BowTie allows for planning for mitigation of Critical Events when they happen. The resilience of an HRO depends on understanding the alternatives available.
2) Root Cause Analysis (RCA), Corrective & Preventive Actions (CAPAs). RCA analysis and CAPA plans and implementation are central to any functional QMS or HRO. There are a large variety of RCA tools – 5 Whys, A3s, etc. – and consistency of application is as important as method. RCAs should invariably lead to corrective and preventive actions, typically using the mid-level process management tools. As a rule of thumb, if more than 35% of RCAs and CAPAs point to training or human error as root cause and remediation, then that organization is not operating as either a Just Culture or HRO.
3) Integration with Value Based Care. Until the development of the major value based care programs through CMS (Value Based Purchasing and MACRA/MIPS), reimbursement offered perverse financial incentives to maximize volume at the expense of quality. These programs, together with the various hospital rating systems, clearly favor the integration of financial and quality goals. The easiest way for hospitals to intelligently evaluate the impact quality and safety today, is through the financial and regulatory (rating) impact analysis.
Three Levels of Tools for HROs
Design Considerations of HROs
Berwick and Nolan refer to three distinct Levels (stages) of HRO development, based on the maturity of the system, tools that are used and expected levels of reliability. This is an effective explanatory construct, but reality tends to be a bit scruffier. There are no smooth transitions or definitions from one stage of HRO development to another. Furthermore, HROs tend to operate as small, complex, very high performing systems in organizations which are generally held to much lower standards of quality and safety. Finally, HROs use tools and methods that work for them, and always rely on an obsession with outcome by all participants as the first and last line of defense against failure.
Nevertheless, the three level model of development is worth consideration as a well-organized method to look at the temporal development of HROs:
|Characteristic||Tier 1||Tier 2||Tier 3|
|Design||Intent, diligence & hard work||Design informed by reliability science and research in human factors||Design of high reliability organizations (Weick)|
|Methods||Standardized protocols, feedback, training, personal checklists||Decision aids, pathways, redundancy, scheduling, connection to habits||Limits on individual choice, limited autonomy, failure risk lies with leadership, transparency|
|Examples||Evidence based prescribing||Multi-element process bundles,||Team based environments|
|Defeating Factors||Fatigue, environment, task design, mental state, competing demands||Alarm overload, excess IT systems, inability to deliver best practice (shortages)||Six sigma events, complacency, drift|
|Expected Range of Performance||10-2-10-3||10-3-10-4||10-4-10-5|
HROs are a structure that has been in development for decades. Our analysis and implementation of them is just catching up with the reality of how they really work. At the end of the day, HROs depend on dedicated and relentless leadership, that puts quality and safety as the central focus of strategic success. Perhaps the best example of this is the lifetime work of Admiral Hiram Rickover, who pioneered the application of nuclear power in the US Navy – a uniquely successful of example of HRO principles:
“Over the years, many people have asked me how I run the Naval Reactors Program, so that they might find some benefit for their own work. I am always chagrined at the tendency of people to expect that I have a simple, easy gimmick that makes my program function. Any successful program functions as an integrated whole of many factors. Trying to select one aspect as the key one will not work. Each element depends on all the others.”
Admiral Hyman G. Rickover, father of the US Nuclear Navy.