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This study demonstrates how becoming a high-reliability institution in health care is a priority, given the high-risk environment in which an error can result in harm. Literature conceptually supports the need for highly reliable health care facilities but does not show a comprehensive approach to operationalizing the concept into the daily workforce to support patients. The Veterans Health Administration closes the gap by documenting a case study that not only demonstrates specific actions and functions that create a high-reliability organization (HRO) for safety and improvement but also created a learning organization by spreading the knowledge to other facilities.

The authors instituted a methodology consisting of assessments, training and educational simulations to measure, establish and operationalize activities that identified and prevented harmful events. Visual communication boards were created to facilitate team huddles and discuss improvement ideas. Improvements were then measured and analyzed for purposeful outcomes and return on investment (ROI).

HRO can be operationalized successfully in health care systems. Measurable outcomes verified that psychological safety was achieved through the identification and participation of 3,184 process improvement projects over a five-year period, which yielded a US$2.8m ROI. Documented processes and activities were used for educational teachings, which were disseminated to other Veteran Affairs Medical Center’s through the Truman HRO Academy.

This case study is limited to one hospital in the Veterans Health Administration (VHA) network. As the VHA continues to deploy the methods outlined to other hospitals, the authors will perform incremental data collection and ongoing analysis for further validation of the HRO methods and operations. Hospitalists can adapt the methods in the case study for practical application in a health care setting outside of VHA. Although the model is rooted in health care, the methods may be adapted for use in other industries.

This case study overcomes the limitations within literature regarding operationalizing HRO by providing actual activities and demonstrations that can be implemented by other health care facilities.

Given the pace of industry change and the rapid diffusion of high reliability organization (HRO) approaches, lags and divergences have arisen between research and practice in healthcare. The purpose of this paper is to explore several of these theory-practice gaps and propose implications for research and practice.

Classic and cutting-edge HRO literature is applied to analyze two industry trends: delivery system integration, and the confluence of patient-as-consumer and patient-centered care.

Highly reliable integrated delivery systems will likely function very differently from classic HRO organizations. Both practitioners and researchers should address conditions such as how a system is bounded, how reliable the system should be and how interdependencies are handled. Additionally, systems should evaluate the added uncertainty and variability introduced by enhanced agency on the part of patients/families in decision making and in processes of care.

Dramatic changes in the sociotechnical environment are influencing the coupling and interactivity of system elements in healthcare. Researchers must address the maintenance of reliability across organizations and the migration of decision-making power toward patients and families.

As healthcare systems integrate, managers attempting to apply HRO principles must recognize how these systems present new and different reliability-related challenges and opportunities.

This paper provides a starting point for the advancement of research and practice in high-reliability healthcare by providing an in-depth exploration of the implications of two major industry trends.

This chapter describes the efforts of a team of health care workers to make a sub-acute health care facility (SCF) serving profoundly damaged children into a high reliability organization (HRO). To obtain this goal, the health care team implemented change in four behavioral areas: (1) risk awareness and acknowledgment; (2) defining care; (3) how to think and make decisions; and (4) information flow. The team focused on five reliability enhancement issues that emerged from previous research on banking institutions: (1) process auditing; (2) the reward system; (3) quality degradation; (4) risk awareness and acknowledgment; and (5) command and control. These HRO processes emerged from the change effort. Three additional HRO processes also emerged: high trust, and building a high reliability culture based on values and on beliefs. This case demonstrates that HRO processes can reduce costs, improve safety, and aid in developing new markets. Other experiences in implementing high reliability processes show that each organization must tailor make processes to its own situation (e.g. BP, U.S. Chemical Safety and Hazards Board, Federal Aviation Administration, U.S. Navy Aviation Program, and Kaiser Permanente Health Care System). Just as in the flexibility called for in organizing for high reliability operations, flexibility is called for in deciding which HRO processes work in specific situations.

Long-term care (LTC) organizations have struggled to protect their vulnerable clients from the ravages of the COVID-19 pandemic. Although various suggestions on containing outbreaks in LTC facilities have gained prominence, ensuring the safety of residents is not just a crisis issue. In that context, the authors must reasses the traditional management practices that were not sufficient for handling unexpected and demanding conditions. The purpose of this paper is to suggest rethinking the underlying attributes of LTC organizations and drawing insight from the parallels they have to high-reliability organizations (HROs).

The authors analyzed qualitative data collected from a Canadian LTC facility to shed light on the current state of reliability practices and culture of the LTC industry and to identify the strengths and weaknesses of the traditional management approaches.

To help the LTC industry develop the necessary crisis management capacity to tackle unexpected future challenges, there is an urgent need for adopting a more systemic top-down approach that cultivates mindfulness, learning and resilience.

This study contributes by applying the HRO theoretical lens in the LTC context. The study provides the LTC leaders with insights into creating a unified effort at the industry level to give rise to a high-reliability-oriented industry.

The purpose of this paper is to expand understandings of interorganizational collaboration among high reliability organizations (HROs). It proposes that HROs face unique needs for relationship building, pre-planning, and retrospective sensemaking that do not fit within prior models of collaboration. For HROs, definitions of collaboration vary contextually based on needs that arise during emergency situations. HROs have a need for both hierarchical structure and collaborative processes and use collaboration as a sensemaking frame that allows practitioners to attend to both needs.

The paper uses a case study from an ongoing ethnographic study of an emergency response collaboration. The paper uses open-ended interviews about collaboration with all key members of the incident response hierarchy, and participant observation of collaboration before, during and after a key emergency incident.

The paper proposes a new framework for HRO collaboration: that collaboration is a sensemaking frame for HROs used to make sense of individual actions, that HRO collaboration is more complex during pre-planning and focused on individual decision making during incidents, and that members can communicatively make sense of the need for hierarchy and collaborative action by defining these needs contextually.

The paper uses an in-depth case study of an incident to explore this collaborative framework; therefore, researchers are encouraged to test this framework in additional high reliability collaborative contexts.

The paper includes implications for best communicative practices to recognize the need to be both hierarchical and flexible in high reliability organizing.

This paper fulfills a need to expand collaboration literature beyond idealized and egalitarian definitions, in order to understand how practitioners use communication to understand their actions as collaborative, especially in organizations that also require hierarchy and individual actions. This case study suggests that collaboration as a sensemaking frame creates collaborative advantages for HROs, but can also limit sensemaking about incident management.

The focus of this study was to analyze crisis management in a context of high-reliability organizations (HRO) evidenced in two cases of Brazilian air disasters. Aspects of human and technological natures were examined, addressing the complex sociotechnical system.

This in-depth case study addressed the two most serious air disasters on Brazilian territory. The first case involved a midair collision between Gol Flight 1907 and the Legacy jet. In the second case, TAM flight 3054 had difficulty braking when landing at the airport and crashed into a building. Data were collected from official disaster documents.

The results revealed that the management and operational activities aimed to maintain the necessary conditions that prioritize a high level of reliability. High reliability mainly involves concern over failure, reluctance to accept simplified interpretations, sensitivity to operations, commitment to resilience and detailed structure specifications.

The implications are based on alerting highly reliable organizations, emphasizing the focus on managing more reliably, resiliently and conscientiously. Changes will be required in the operations of organizations seeking to learn to manage unexpected events and respond quickly to continually improve the responsiveness of their services.

In the perspective of an intrinsic case study for crisis management in a context of HRO and disaster risk management, the originality of this study lies in its examination of the paradoxical nature of control within the systems of dangerous operations in complex organizations, as well as their contradictions in a high-reliability system.

This study aims to describe how the Army and the Army Medical Department matured as a learning organization (LO) during the period after the 2014 Military Health System Review through the incorporation of changes aimed at improving patient safety, data transparency and becoming a high-reliability organization (HRO). This study explores the relationship between HRO and LO concepts by adding to the body of knowledge in both disciplines.

Four large-scale system changes are presented and evaluated against the principles of the LO. Metric data were collected longitudinally and presented as submitted to several nationally-recognized organizations in healthcare quality and safety. Post initiative observations are paired with a corresponding LO principle to assess US Army Medical Command’s (MEDCOM’s) maturation as a LO. System changes/improvements and the advancement of LO principles are discussed.

System improvements, analyzed critically alongside paired LO principles, show strong correlation between high-reliability and LO principles. Despite inherent institutional barriers, this study demonstrates that, when leveraged effectively, the leadership hierarchy and command culture can accelerate transformation into an LO.

This study explores changes implemented in MEDCOM, as it evolved as a stronger LO. It demonstrates how healthcare organizations and other high-risk industries that embrace high-reliability concepts will become better LOs and expands current knowledge on how LO concepts in healthcare can affect better system accountability and improved patient safety. Organizations can learn from MEDCOM’s journey changes that can hasten progress toward adoption of LO principles, especially in hierarchical organizations.

The purpose of this paper is to describe and analyze nurses’ perceptions and evaluations of healthcare developmental work after the introduction of Lean and Six Sigma and, how nurses aspire to maintain a high reliability organization (HRO).

Nurses’ roles and the way they respond to new efficiency and quality working methods are crucial. Underlying themes were analyzed from in-depth, semi-structured interviews with (n=17) nurses at two Swedish hospitals.

The nurses perceived that Lean worked better than Six Sigma, because of its bottom-up approach, and its similarities with nurses’ well-known work qualities. Nurses coordinate patients care, collaborate in teams and take leadership roles. To maintain high reliability and to become quality developers, nurses need stable resources. However, professional’s logic collides with management’s logic. Expert knowledge (top-down approach) without nurses’ local knowledge (bottom-up approach) can lead to problems. Healthcare quality methods are standardized but must be used with flexibility. However, HROs ensue not only from method quality but also from work attitudes, commitment and continuous work-improvement.

Management can support personnel in developmental work with: continuous education, training, teamwork, knowledge sharing and cooperation. Authoritarian method structures that limit the healthcare professionals’ autonomy should be softened or abandoned.

The study uses theoretical concepts from HROs, which were developed for unexpected events, to explain the consequences of implementing Lean and Six Sigma in healthcare.

The purpose of this paper is to examine the relationship between patient safety culture and hospital performance using objective performance measures and secondary data on patient safety culture.

Patient safety culture is measured using data from the Agency for Healthcare Research and Quality’s Hospital Survey on Patient Safety Culture. Hospital performance is measured using objective patient safety and operational performance metrics collected by the Centers for Medicare and Medicaid Services (CMS). Control variables were obtained from the CMS Provider of Service database. The merged data included 154 US hospitals, with an average of 848 respondents per hospital providing culture data. Hierarchical linear regression analysis is used to test the proposed relationships.

The findings indicate that patient safety culture is positively associated with patient safety, process quality and patient satisfaction.

Hospital managers should focus on building a stronger patient safety culture due to its positive relationship with hospital performance.

This is the first study to test these relationships using several objective performance measures and a comprehensive patient safety culture data set that includes a substantial number of respondents per hospital. The study contributes to the literature by explicitly mapping high-reliability organization (HRO) theory to patient safety culture, thereby illustrating how HRO theory can be applied to safety culture in the hospital operations context.

High-reliability performance and high-hazard are intertwined in High-Reliability Organizations (HROs) operations; these organizations are highly safe, highly hazardous and highly significant for the modern society, not only for the valuable resources they have, but also the indispensable services they provide. This research intend to understand how HROs could produce high quality performance despite their challenging and demanding contexts. The research followed an emic approach to develop an organizational framework that reflects the contribution of the seeming traits of the organizations to the operations safety based on the workers point of views about the safety of workstations.

This research adopted mixed methods of in-depth interviews and literature review to identify the structural characteristics of high-reliability organizations (HROs) embedded in the organizations studies and developed a theoretical based structural framework for HROs. Furthermore, a systemic literature review was adopted to find the evidence from the organizations literature for the identified characteristics from the interviews from the first stage. The setting for this study is six Chinese power stations, four stations in Hubei province central China and two stations in the southern China Guangdong province.

The organizational framework is a key determinant to achieve high-reliability performance; however, solely it cannot explain how HROs manage the risks of hazard events and operate safely in high-hazard environments. High-reliability performance is attributed to the interaction between two sets of determinants of safety and hazard. The findings of this research indicate that HROs systems would be described as reliable or hazardous depending on the tightly coupled setting, complexity, bureaucracy involvement and dynamicity within the systems from one hand, and safety orientation, failure intolerance, systemwide processing, the institutional setting and the employment of redundant systems on other hand.

The authors developed an organizational framework of organizing the safety work in HROs. The applied method of interviewing and literature review was not adopted in any other researches.