Practical Considerations of High Reliability in Medical Quality & Safety

Practical Considerations of High Reliability in Medical Quality & Safety

Is Your Quality System Stuck in the Mud?

Practical Considerations of High Reliability in Medical Quality

Moving from Good to Great

July 26, 2016

Wes Chapman & Pieter Weijand

Stuck in the Mud

Static performance – stuck in the mud

From good to great – a fundamental system review

We’ve spoken to a number of very frustrated hospital executives of late – people who’ve been told that they need to move up the quality spectrum to the elusive land of High Reliability. The complaints are familiar, and all too common – “we’ve been doing this for 10 years, trained everybody in the organization, spent millions on new systems, but for the last 3 years we are stuck in the mud. Our quality goes up in some areas, down in others, but on balance nothing seems to change.”

These same executives go on to question the benefits of High Reliability based on the relatively dismal track record of prior quality improvement management fads – all of which are expensive, time consuming and of little discernable value – long or short term. They dread launching yet another quality program at the Board level, only to have to explain its failure down the road. But they need to do something, and it has to move the needle. In the coming world of MACRA/MIPS, providers of healthcare services will suffer financially if they don’t break the code on moving from good to great in quality.

For those new to this terminology, High Reliability Organizations (HROs) are a loosely defined group of very high performing organizations, typically functioning as distinct sub-systems in larger organizations. These can include launch crews on aircraft carrier flight decks, commercial airline flight crews and operators in nuclear power facilities and energy/chemical industries. Over the last 20-30 years, each of these HRO types has distinguished itself by enviable, and continuously improving safety levels. The Joint Commission, together with a select group of pilot medical groups, including the US Army, has begun the process of adapting HRO methods to medical care in the US, hoping to finally achieve durable improvement in patient care and safety.

For healthcare executives, first, a few words of caution. HROs are a dubious panacea for all of your quality and safety needs. These methods have only worked in small teams, where risk and the cost of failure are highest. These very high performing systems will do nothing to improve overall operating or financial performance, and should not be instituted to achieve those goals. These are tip-of-the-spear methods, very effective, but limited in scope. Consider the contrasts highlighted below, for the classic HROs mentioned above:

HRO Example Areas of Success Areas not Included Areas of Noteworthy Failure
US Navy: Carrier flight decks Effective and very safe flight operations Aircraft Procurement All variants of the F35
US Utilities: Nuclear power generation Safety of power plant operations Billing and customer service Monthly billing, service resumption after storm based disruption.
US Commercial Airlines: Flight crew operation Flight operations and safety Customer service, scheduling, baggage Skyrocketing service fees and declining quality of service.
Oil & Gas, Chemical industries Control of explosions, fires and environmental damage Former operations Piper Alpha, Alexander L. Kielland, Seacrest Drillship


HRO design and operation is still a juvenile concept, with little in the way of published guidance that can serve as a basis for design and implementation. HRO advocates do themselves no favors by describing HROs as depending on the achieving collective mindfulness, as described by Weick and Sutcliffe in their book, Managing the Unexpected: Resilient Performance in an Age of Uncertainty. This is some kind of unquantifiable nirvana that sounds like channeling a yoga class. That’s a pretty tough concept for a hard-nosed hospital executive to sell to a skeptical Board, or a bunch of tired and over-worked nurses and physicians.



High Reliability – Moving from the Metaphysical to the Practical

Flight Deck

Flight deck crews – the classic HRO

Crews on flight decks are the classic example of functional HROs, and it is worth taking a moment to consider how they actually get that way. These are 20 year old kids in their first jobs, entrusted with vital functions involving thousands of lives and billions of dollars – and they do it perfectly every time. Now we are talking about something that makes sense – how do they do it?

It is a very simple process and it involves three practical steps:

  • Training. Each person is trained and drilled to the point of exhaustion, and the training is constantly evaluated for effectiveness and improvement. Then they train and drill some more. People who don’t pass are thrown out – there is no room for compromise here, and no room for improvisation. They train in a variety of methods, and with various failure scenarios, but they keep on training. These guys aren’t given trust, they earn it every day.
  • Teamwork. They know their teammates, the points of high failure potential, and they have a shared mission. From the men on the flight deck, to the Admiral looking down from the bridge, they have a single shared goal and purpose. Like in the Toyota Production System, the issue isn’t that each person can stop the entire show if they see something wrong – but rather that they must.

Commercial Airline crashes

  • Focus on the Job at Hand. These guys aren’t worried about where the planes are going, or what they do when they get there – they are only focused on the job at hand – and doing it exactly right every time. They only study the job at hand, and how to make it more safe and effective, and they do it all the time. Most importantly they focus on the outcome – getting the aircraft launched safely. Their training is on their part of the job, but they understand the entire process, and take collective credit or blame for each success or failure respectively.


Most TJC accredited medical facilities base their operations and training on policies and procedures (P&Ps) which are developed in accordance with various regulatory requirements. All too often, these P&Ps resemble a ball of snakes, the accumulation of decades of occasional oversight; often inconsistent, redundant or contradictory; separated into manuals and all overlain by a completely disconnected quality improvement program. Staff is held accountable to these P&Ps whether they actually train to them or not, and the P&Ps typically separate processes based on departmental lines – rather than based on the needs of the patient.

This is a bad place to start training for an HRO, but is all too frequently the reality. The result is that many hospitals simply ignore the rot in their existing training program (P&Ps) and try to build a new and functional spot training system on top of it. This will never work.

Rule Number One: Get your training system right before you try to do anything else. If your P&Ps are broken, fix them. For most organizations, failed training is the metaphorical mud in which they are stuck. Every time they engineer a new process improvement, it drifts back into functional contradiction with mandated P&Ps, and gradually dies on the vine.


Many organizations pour thousands of hours, and millions of dollars prematurely into teamwork building efforts. HRO function depends on flat, non-hierarchical teams. Teamwork depends on knowledge and trust, and they depend on training of the team members. Teams will invariably revert directly back to pre-existing hierarchies unless there is effective, task focused training in advance – it happens every time. Leaders are only willing to delegate authority after ability and accountability are established – and that starts with effective training. Finally, leaders should only delegate authority in specific circumstances, related to narrowly defined tasks and situations. HROs are very limited in scope, and always relate to key issues and functions in high risk environments.

naval accidents

The most effective training for HRO applications in medical environments is crew resource management (CRM) training. This has proven to be extraordinarily powerful in commercial airline settings, which have highly variable team composition like medical care. CRM training has been instrumental in moving the US commercial airline industry from 68 deaths per billion passengers to less than 19 deaths per billion today.

Rule Number Two: Narrowly define the scope of the HRO function to easily identified and understood high risk settings. Don’t try to build an effective team, until you have built effective training. Never ask leaders to delegate authority, until the scope is defined and the training is accomplished, and proven effective. When you train teams for the HRO team, use CRM.



The single most important part of building a functional HRO is focus; focus on the problem; 1) What barriers need to fail before a critical event actually takes place, 2) What can be done to minimize the damage during the critical event, and 3) How do you mitigate the negative consequences of a critical event once it happens. What are the critical skills for the team and what are the subtle precursor signals of failure? HROs work because a lot of highly skilled and well trained people focus on a single point of failure, to make sure that it never happens. The process industries use the bow tie method to focus on the problem, optimize process understanding, continuously improve training and ensure a common team focus and understanding. I guess that some would call it collective mindfulness – others just call it top level performance.


Example of a process Bow Tie

The bow tie is particularly applicable in Healthcare for 3 reasons: 1) The actors on a healthcare stage are frequently separated from each other by time and place. It is absolutely critical that all of the team have a shared mental model of process barriers and risks. 2) The indications of failure of key are also spread over various locations, and normally engaged over different time periods. Recognizing the importance of these barriers and the implications of failure is critical to safe patient care. And 3) Building a team to prevent failure means putting in the time and effort to gain consensus on process, training, risk mitigation and resilience. Getting everybody pointed in the same direction is absolutely essential.

Rule Number Three: Focus, Focus, Focus! HROs are specialized methods, and only applicable for limited teams of well-trained people. Most importantly these people need to be focused on safety all the time, and they need tools to help them do this. The Bow Tie is a very effective tool used in many process industries to create the shared understanding necessary for highly reliable function.

HRO Mind Map

HRO Mental Model

If you want to improve, you have to change

Unfortunately, HROs have been introduced into Medical Quality as a combination of Erhard Seminar Training (EST) and snake oil – they are neither. HRO tools and methods can really help, but using them may require a substantial clean-up of P&Ps and related training and control methods. Jim Collins got it right in his book, From Good to Great; positive change in an organization is a direct result of consistent and clear focus, using new techniques and technologies sparingly, and building on the culture that made your system good. His Hedgehog Principle is worth noting, keep doing what you are good at – but push the limits of your expertise and continuously challenge your people to continue building on their success. This sounds a lot like our three rules of HROs.

Good 2 great 1

Moving from Good to Great

(Jim Collins, From Good to Great)

Getting unstuck

Teamwork is essential to getting out of the mud

Tools to get unstuck

Tools can make a good team great

HROs are really valuable when they make your existing teams stronger, providers more effective and patients healthier. Properly executed HROs will help simplify the systems that you have in place, and make them more effective. If you feel that your quality system is stuck in the mud, and you want to get out, give us a call – we can help.

Wes Chapman
Written by Wes Chapman

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