Table 1

 Values exhibited by high reliability organizations (HROs) and high reliability teams (HRTs)

ValueOrganization levelTeam level
EMS, Emergency Medical Services.
Sensitivity to operationsOngoing concern with the unexpectedClosed loop communication: Team’s ability to exchange information accurately and clearly and to acknowledge receipt of information (e.g. during shift change, outgoing nurse informs incoming nurse of patients’ status. Incoming nurse summarizes that information and outgoing nurse confirms its accuracy).
Attentiveness to those on the front lineInformation exchange: Team members’ ability to speak clearly, concisely, and in an unambiguous manner with other team members (e.g. an EMS technician provides vital signs of incoming patient to emergency room team). Information exchange skills should be transportable, meaning improvement in their ability to communicate increases across tasks.
Acknowledgement that the cause of an accident is often not the result of a single active error but rather errors lying latent in the systemShared situation awareness: Team’s ability to develop shared mental models of the environment (internal and external) to apply correct task strategies and anticipate future situations (e.g. a surgical team discusses “if-then” scenarios prior to the procedure).
Sources: Weick and Sutcliffe,9 Roberts and Bea15Sources: Cannon-Bowers et al,17 Endsley18
Commitment to resilienceAbility to identify, control, and recover from errorsBack-up behavior: The capability of team members to give, seek and receive task instructive feedback. Assisting team members to perform their tasks. Back-up behavior can be achieved by providing a team mate with verbal feedback or coaching, helping a team mate behaviorally in carrying out actions, and/or assuming and completing a task for a team mate (e.g. a doctor offers assistance to another doctor during an emergency to reduce workload).
Errors and failures kept smallPerformance monitoring: Team’s ability to monitor team members’ performance and provide constructive feedback (e.g. a nurse monitors a doctor’s performance during a procedure to ensure steps are not omitted).
Practice worst case scenariosShared mental models: Team’s ability to share compatible knowledge pertaining to individuals’ roles in the team, the roles of fellow team members, their characteristics, and the collective requirements needed for effective team interaction (e.g. a surgical team has a shared and overlapping understanding of the procedure to be performed).
Develop general strategies to expect and react to the unexpectedSources: Cannon-Bowers et al,17 Dickinson and McIntyre51
Source: Weick and Sutcliffe9
Deference to expertiseEncourages communication of expertise from all levelsAssertiveness: The willingness of team members to communicate ideas and observations in a manner that is persuasive to other team members. Allows team members to provide feedback, state and maintain opinions, address perceived ambiguity, initiate actions, and offer potential solutions (e.g. a nurse questions a doctor’s medication order because of a patient’s known allergies).
Decisions made on the front lineCollective orientation: Some team members have been found to be more collectively oriented than others, meaning they exhibit more interdependent behaviors in task groups (e.g. all ER team members worked together to solve the challenging problem).
Cultivate diversityExpertise: Knowing how to do something well and is gained through experience (e.g. the ER team required the expertise of all members to identify the cause of a patient’s unusual symptoms).
Source: Weick and Sutcliffe9Sources: Roberts and Bea,15 Helmreich and Merritt,19 Blickensderfer,27 Smith-Jentsch et al,52 Smith et al53
Reluctance to simplifyUnwillingness to simplify a situationAdaptability/flexibility: Team’s ability to gather information from the task environment and adjust their strategies by reallocating their resources and using compensatory behaviors such as back-up behavior (e.g. a stable patient goes into cardiac arrest and the team must respond quickly).
Create more complete pictures of situationsPlanning: Planning both prior to and during a mission helps teams improve performance by setting goals, sharing relevant information, clarifying member’s roles, prioritizing tasks, discussing expectations, and environmental characteristics and constraints (e.g. prior to the arrival of a critical patient to the emergency room, the attending resident discusses roles, responsibilities, and expectations for when the patient arrives).
Encourage spanning of boundaries, negotiating, scepticism, and differences in opinionsSources: Cannon-Bowers et al,17 Stout et al54
Source: Weick and Sutcliffe9
Preoccupation with failureEncourage error reportingError management: Based on understanding the nature and extent of error, changing conditions found to induce error, and determining and training behaviors that decrease errors (e.g. an emergency room team recognizes that an inappropriate drug has been administered and quickly takes actions to mitigate the consequences).
Accept human error as inevitableFeedback: Team’s ability to provide constructive feedback, seek feedback on own performance, and accept feedback from others (e.g. following surgery, the lead surgeon provides a debriefing of the surgery including positive aspects and areas in need of improvement).
Obsession with success liabilities (e.g. overconfidence)Team self-correction: Team’s ability to monitor and categorize their own behavior to determine its effectiveness, which generates instructive feedback so that team members can review performance episodes and correct deficiencies (e.g. surgical team meets following a procedure to discuss positive and negative aspects of procedure and ways to improve performance in the future).
Source: Weick and Sutcliffe9Sources: Cannon-Bowers et al,17 Helmreich55