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High reliability organizations (HROs)

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Academic and professional disciplines, such as organisation and management theory, psychology, sociology and engineering, have, for years, grappled with the multidisciplinary issues of safety and accident prevention. However, these ideas are just beginning to enrich research on safety in medicine. This article examines a domain of research on system safety – the High Reliability Organization (HRO) paradigm. HROs operate in hazardous conditions, but have fewer than their fair share of adverse events. HROs are committed to safety at the highest level and adopt a special approach to its pursuit. The attributes and operating dynamics of the best HROs provide a template on which to better understand how safe and reliable performance can be achieved under trying conditions, and this may be useful to researchers and caregivers who seek to improve safety and reliability in health care.

Section snippets

The high reliability paradigm

The ‘high reliability organization’ paradigm was developed by a group of researchers at the University of California, Berkeley,4, *5, *6 to capture observed commonalities of operations among aircraft carriers, air traffic control (and, more generally, commercial aviation) and nuclear power. These three settings constitute the default reference when describing the processes found in the most effective HROs. Although they may seem diverse, these organisations have a number of similarities. First,

The relevance of HROs to anaesthesia

The HRO paradigm provides insight into adaptive organisational forms for complex environments. In fact, it is surprising how well the qualities of well-functioning HROs (e.g., carriers) can be generalised and applied to medical care, and, in particular, to anaesthesia. The Institute of Medicine2 identified the close parallels between health-care systems and the systems that contribute to effectiveness in carriers:

People are quick to point out that health care is very different from a

Competing approaches to achieving reliability

Research shows that HROs pursue two competing approaches to achieve reliable performance15: the prevention (anticipation) approach and the resilience (containment) approach. We consider each of the two approaches in the following paragraphs.

Attributes of HROs

Researchers have identified a number of unique properties of HROs.*5, *6, 8 Although these specific attributes vary between scholars, there are a number of commonalities. Several properties, such as outstanding technology and task and work design, highly trained-personnel, continuous training, effective reward systems, frequent process audits and continuous improvement efforts,30 are ubiquitous and found in many high-performing organisations. Nevertheless, other properties such as an

Respectful interaction

People in all organisations often face situations where their private views come into conflict with a majority view. These situations frequently threaten social life.33 Furthermore, they make it harder for people to speak up about safety threats. These dynamics may be much more acute in health-care settings where patients’ conditions evolve and change over time, where there are frequent transitions or handoffs between providers, where team compositions change and where care is provided by

A culture of high reliability

Research on HROs often intersects that of safety culture, a concept that is often cited as a key contributor to organisational accidents and crises. Safety culture is a facet of organisational culture, with the latter often defined as an emergent ordered system of meaning and symbols that shapes how an organisation’s members interpret their experience and act on an ongoing basis. In health-care organisations, culture encompasses what is valued, beliefs about how things work and behavioural

Conclusion

This article examines the mechanisms of system safety and accident prevention from the perspective of the high reliability organisation paradigm. The high reliability theory is not a prescription or roadmap for success. Rather, it is one lens through which researchers, caregivers and administrators can better understand how safe and reliable performance, under trying conditions, can be pursued. HROs are distinguished by their processes and ways of organising. Specifically, the best of the best

Conflict of interest

None declared.

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