High Reliability

There's another new theory on better quality management. This one is called High Reliability Organization (HRO) theory, and it draws on the lessons learned from high-risk industries like aircraft carriers, nuclear power plants and nuclear submarines. It defines the characteristics of high reliability industries - as well as what HRO is not.

• What is High Reliability?
• The challenges that call for High Reliability
• Characteristics of High Reliability
• What High Reliability is NOT
• References

August 2008

In this era of laboratory uncertainty, it can be depressing to engage in the current debates on quality. The focus of much contemporary discussion seems to be how much we can reduce, rename, abandon, ignore and/or eliminate quality control. For advocates of better quality, this can feel like a rearguard struggle in a long retreat.

But there are other approaches to quality. While ISO, Risk Management, Equivocal QC, Lean and Six Sigma dominate the quality conversation today (at least as of 2008), they aren’t the only quality management systems out there. There is at least one quality management approach that doesn’t get discussed very often. It’s not a hot management fad or a consulting industry favorite or a regulatory scheme. It’s called High Reliability Organization (HRO) theory, and the management principles have been built on behaviors witnessed in the high-stakes environments of nuclear reactors, military flight operations, and forest firefighting.

What is High Reliability?

The classic description of a high reliability organization can be found in a classic study on the difficulty of running flight operations on an aircraft carrier:

“Imagine that it’s a busy day, and you shrink San Francisco airport to only one short runway and one ramp and one gate. Make planes take off and land at the same time, at half the present time interval, rock the runway from side to side, and require that everyone who leaves in the morning returns the same day. Make sure the equipment is so close to the envelope that it’s fragile. Then turn off the radar to avoid detection, impose strict controls on the radios, fuel the aircraft in place with their engines running, put an enemy in the air, and scatter live bombs and rockets around. Now wet the whole thing down with sea water and oil, and man it with twenty-year-olds, half of whom have never seen an airplane close-up. Oh, and by the way, try not to kill anyone.”[1]

An aircraft carrier is an organization that successfully handles an incredibly dynamic, complex environment and it is a perfect illustration of High Reliability Organization (HRO). An entire field has grown out of observing HROs, with scholars and engineers who have investigated High Reliability and expressed several key concepts and characteristics of these organizations.

While healthcare laboratories lack the drama of flight operations on a carrier deck, they do have to handle ever-changing, high-stakes activities. Indeed, in healthcare laboratories today, there are far more lives at stake. Without doubt, healthcare professionals can

Recently, the Agency for Healthcare Research on Quality (AHRQ) released a report on High Reliability in healthcare, including examples of High Reliability theory applied in hospitals and healthcare organizations.

The Challenges that Call for High Reliability

On the face of it, there wouldn’t seem a lot of similarities between fighting wildfires and monitoring a nuclear reactor, but the literature on High Reliability has found a number of common threads in these organizations. High Reliability usually occurs because the circumstances of the environment (or market) force the organization to develop a robust management system in response.

Hypercomplexity. “Complex environments that are dependent on multi-team systems that must coordinate for safety.”

Tight Coupling. Processes and sub-processes within the system are connected with little buffering for error; a single mistake in one part of the process quickly spreads to the rest of the system, often with unanticipated consequences.

Extreme hierarchical differentiation. The hypercomplexity of the system demands that individuals working within the system develop into specialists. “Roles are clearly differentiated and defined. Intensive coordination efforts are needed to keep members of the teams working in a cohesive manner.”

Multiple decision-makers in a complex communication network. The system requires many different individuals to work together and make important, interconnected decisions. Key to the success of all these decisions is the ability of the different decision-makers to communicate effectively with each other.

High degree of accountability. When errors occur in an HRO, they have severe consequences to the system. Whether justified of not, the organization is held responsible to clearly avoid these errors. When errors occur, there are also severe consequences for the organization, too.

Need for frequent, immediate feedback. Given the hypercomplexity of the system, decision-makers need to be able to quickly adjust to changing conditions. This requires the ability to get information frequently and urgently. Not only do they need this information, they need to be able to understand, react and act on that information.

Working under compressed time constraints. Decisions in the system need to be made now, not later. Time works against the decision-makers, depriving them of any extra time to marshal information and resources. Because things have to be done quickly, with partial information and less-than-ideal resources, decision-makers need to be skilled at improvisation.[2]

If this list doesn’t describe the healthcare organization where you work, please let us know - we'll send in our resume. It goes without saying that healthcare faces all of the challenges that other HROs face. But instead of managing the plane traffic of a major airport, a network of commuter trains, the launch of fighter jets off an aircraft carrier, or a nuclear reactor, healthcare organizations manage an unpredictable population of patients.

Characteristics of High Reliability

Despite the differences in the many industries mentioned in HRO theory, several common themes emerge. Investigators have identified are five essential characteristics of an HRO. We’ll mention them briefly here, and tackle each one in depth in a future lesson.

Sensitivity to operations. Highly reliable organizations maintain a constant awareness of the state of the systems and processes that affect patient care. This awareness is key to identifying risks and preventing them.

Reluctance to simplify. While simple processes may be good, simplistic explanations about why things work or fail (unqualified staff, inadequate training, communication failure, etc.) do not explain the underlying reasons why errors occur.

Deference to expertise. Reliable systems defer decisions to those individuals with the knowledge to make them, regardless of organizational hierarchy.

Preoccupation with failure. When near-misses occur, they are viewed as evidence of systems that should be improved to reduce potential harm to patients. Rather than regarding near-misses as proof that the system has effective safeguards, they are viewed instead as symptoms of processes that need to be modified.

Resilience. Highly reliable organizations are able to anticipate and quickly recover from an error. They are skilled at mitigating any consequences that stem from the original error. Resilience requires that leaders and staff be trained and prepared to respond when system failures do occur.[3]

What High Reliability is NOT

While HRO might be destined to become the new new management fad, there are several factors that will constrain its popularity:

HRO is not as quantitative as management systems like Lean and Six Sigma. You can’t “metric” an HRO as easily as those other systems can. If safety is ultimately a "non-event," it's hard to calculate a cycle time for it, for instance. Nor is it easy to calculate hard or soft dollar savings. Since HRO stresses the safety and resilience side, it errs on the side of investing in more quality rather than less.

HRO also doesn’t come with easy labels and milestones. While Six Sigma offers black belts, master black belts, and a colorful set of benchmarks, HRO is less satisfying. Indeed, it may be impossible to definitively call any organization a Highly Reliable Organization, because the judgment is ultimately subjective. Your HRO may not be my HRO – I may believe that there needs to be more Preoccupation with Failure than you do. Furthermore, achieving HRO is not a static goal, it’s a never-ending pursuit. Today's HRO can be felled by tomorrow's catastrophe. Some people might have championed NASA as a model of high reliability until the Challenger explosion.

HRO is not backed by a bureaucracy or regulatory mandate. HRO lacks the despotic fashion of the ISO movement (where market/peer pressure can force companies to adopt ISO even if they believe process performance will not be improved by certification). Nor is there any government or regulatory system that clearly enshrines the HRO principles in the rules. While CAP, JC and COLA have adopted ISO terminology in their standards and guidelines, it’s unlikely that they will infuse the HRO vocabulary into their requirements in a serious way.

HRO doesn’t offer a “cookbook” of solutions. Given the diversity of industries where HROs are present, it’s not possible to have one-size-fits-all prescriptions. In fact, part of the emphasis in HRO theory is that, ultimately, the solutions need to migrate down to those front-line workers with the expertise to truly understand and manage the problems at the time they occur. In that sense, HRO is almost an anti-management system because the theory says that during the critical moment, the managers need to let the workers do what needs to be done.

HRO is not a mutually exclusive management methodology. You can’t “do HRO” to the exclusion of Six Sigma, Lean, Baldridge, ISO or TQM. In a way, HRO stands above management systems at the higher altitude of principles and mindset. An HRO could use any of the traditional and popular management approachs to execute and implement HRO principles. Indeed, it's hard to separate the principles from HRO from the principles espoused by Patient Safety or Safety Culture. You probably can't have patient safety without a highly reliable organization, and patient safety is undoubtely the natural product of an HRO in healthcare. But what comes first, HRO or Patient Safety? I'm not sure what the answer is.

In summary, HRO as a management system isn’t a magic bullet, just as the theory itself doesn’t offer easy answers or quick fixes. But there is an appealing maturity in the approach. By avoiding the snake-oil hype that accompanies today’s management fads, where limitless promises are followed by angry disappointments, HRO can offer a more realistic, long term solution to the chronic, enduring problems of healthcare. It might not sizzle like Lean and Six Sigma, but there might be more meat in HRO.

In the coming weeks, we'll be exploring HRO in more detail. Stay tuned.

References

1. Karl E. Weick and Karlene H. Roberts, “Collective Mind in Organizations: Heedful Interrelating on Fligh Decks,” Administrative Science Quarterly 38 (1993):357, as quoted in Karl E. Weick and Kathleen M. Sutcliffe, Managing the Unexpected, Second Edition, Wiley, San Francisco, CA, 2007, p.24.
2. Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. AHRQ Publication No. 08-0022, April 2008, Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/hroadvice/. pp.7-8 of the report.
3. Carolyn M. Clancy, Putting Reliability into Practice: Lessons from Healthcare Leaders, Patient Safety and Quality Healthcare, May / June 2008 http://www.psqh.com/mayjun08/ahrq.html. Accessed July 22, 2008