Transforming into a high reliability organization

The journey to consistent health care quality

US health care is in the midst of a major transformation, evolving from a financial model that pays for volume to one that pays for value and outcomes. With the introduction of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), traditional fee-for-service payments for physicians and other provider professionals are being replaced with risk-bearing business models and financial incentives that reward health care providers for improved patient outcomes and reduced costs.

Quality improvement, a core tenet in this transition to value-based care (VBC), has been a longstanding focus in US health care. Many VBC incentives and penalties rely on quality measures. Thus, delivering quality health care consistently and reliably will be key to succeeding in a value-based environment.

Despite financial, clinical, and technology drivers—and dedicated efforts at many levels—the health care industry generally struggles to achieve widespread, consistent quality improvement. One answer to providing consistent, widespread quality in health care already exists in other industries: Become a high reliability organization (HRO).

HROs are entities which are exceptionally consistent at:

• Accomplishing their goals
• Avoiding potentially catastrophic errors in an environment where normal accidents can be expected due to risk factors and complexity
• Delivering consistently safe and high-quality service

Over the past 20 years, increasing numbers of health care provider organizations have started the journey toward becoming an HRO that delivers quality care effectively, efficiently, and predictably. For many, though, the destination remains far ahead. Although it may take considerable time and effort to get there, this paper lays out a path for health care organizations that wish to embark on the journey.

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The path to becoming a high reliability organization

​Traditional HROs include airlines, nuclear power plants, chemical processing, military operations, and firefighting crews. Among defining characteristics, HROs rarely have errors; they have been highly successful in honing their abilities to act reliably and handle adversity. In addition, HROs prize the identification of “near misses” as an opportunity to extract lessons, analyze what occurred, and adjust protocols or procedures to reduce future risk.

Structurally, HROs typically are based on six foundational elements:

1. Sensitivity to operations. HROs work quickly to identify anomalies, problems in their system, and potential errors to reduce the number of actual errors.
2. Reluctance to simplify. HROs avoid overly simple explanations of failure. This does not mean that HROs do not work to simplify processes as much as possible; rather, they do not attribute failure to a singular cause.
3. Preoccupation with failure. HROs are focused on predicting and eliminating catastrophes rather than reacting to them. “Near misses” are viewed as opportunities to improve current systems.
4. Deference to expertise. HROs cultivate a culture in which team members and organizational leaders defer to the most knowledgeable—not the most senior or experienced—person relevant to the issue at hand.
5. Resilience. HROs pay close attention to their ability to quickly contain errors and improvise when difficulties occur so that systems are resilient and can function despite setbacks.
6. Collective mindfulness. “Operating ‘mindfully’ and making critical adjustments in a timely manner to manage the unexpected in a challenging, highly competitive environment”¹ creates a culture of safety and sustains highly reliable systems. Collective mindfulness also provides a mental orientation that enables continuous learning and evaluation by allowing leaders at all levels to consistently identify potential errors or unsafe conditions before they pose substantial risk.

These elements serve as foundational principles for developing a strategy focused on high reliability.

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The end of the journey is just the beginning

​The quest to deliver consistently safe and high-quality patient care—especially in the face of changing reimbursement models, clinical innovations, and technology advancements—means that the end of a provider’s journey to become a high reliability organization is really just the beginning of institutionalizing quality across all departments, employees, and processes.

Such a transformative change cannot be accomplished simply by increasing funding for ongoing health care quality measurement and reporting activities. Instead, provider organizations will likely need to fundamentally change their approach to quality by embracing a cultural paradigm shift, engaging all stakeholders at all levels, and valuing the expertise that individuals bring.

Download the full report to learn more about smart first steps toward high reliability.

¹ Weick, Karl E. and Sutcliffe, Kathleen. “Managing the Unexpected: Resilient Performance in an Age of Uncertainty.” 2001.

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