HRO & Health Care

 HRO & Health Care


 By David “Scott” Hencshel

What are the components of an HRO in health care?

When we speak of High Reliability Organizations we think of organizations that are successful in highly complex environments that are prone to the kind of human and systemic errors that can lead to catastrophic failure. Although the nuclear power and aviation industries immediately come to mind, hospitals and health systems operate in the very same realm. In 2007, social psychologist Karl Weick, PhD, and Kathleen Sutcliffe, PhD, penned Managing the Unexpected and identified a general orientation or “mindfulness” that exists in HROs generated from five specific considerations or principles. They are:

Preoccupation with failure. HROs do not ignore any failure, no matter how insignificant it may seem, for the simple reason that even a small deviation from the norm can cascade into tragedy.

Reluctance to simplify. HROs know that accepting simple diagnoses means not looking any deeper or further. They know the risk of simplification and are reluctant to accept it.

Sensitivity to operations. HROs know that the earliest indicators of a problem often appear as a small changes in the organization’s operations, and work to ensure that frontline employees —those most intimately involved in operations — report any deviations from expected performance.

 Commitment to resilience. HROs are adept at recognizing errors and containing them quickly, preventing the harm that occurs when small errors compound into what could be a major catastrophe.

 Deference to expertise. HROs have the culture and mechanisms in place ensure that the individual with the greatest expertise relevant to the situation at hand making decisions, regardless of seniority or rank within the organizational hierarchy.

 How are health care organizations integrating changes?

Making changes in any organization can be a daunting task, but HRO concepts are slowly proliferating through the industry. Government organizations like the Agency for Health Research and Quality (AHRQ) and The Joint Commission (TJC) have been leading advocates. A guide published by AHRQ reflects the experiences and insights of leaders committed to transforming their healthcare systems into high reliability organizations. In developing the guide, Becoming a High Reliability Organization: Operational Advice for Hospital Leaders, executives met for more than a year to discuss their successes and challenges in implementing HRO concepts. The Joint Commission also offers numerous resources through its Oro 2.0 program, available to Joint Commission accredited facilities. Admittedly, adoption has been slow, but it is rapidly gaining speed as research and results are beginning to mature and reflect vastly improved financial performance when patient safety improves.

Where are organizations learning best practices?

Individual apprentices, experts and diverse inter-professional teams drive patient safety within highly complex health care systems and organizations. It stands to reason that these organizations must also become “learning organizations” and develop a collective educational process to record and share the best practices professionals develop through their work both within their specific organization and the global medical profession. Perhaps the paramount example is The Armstrong Institute for Patient Safety and Quality, which resides within Johns Hopkins Medicine. The Armstrong Institute represents Johns Hopkins’ dedication to safety and quality, actively coordinates improvement efforts across the Johns Hopkins corporate health system, directly supports scholarly activity and provides internal consultative services.

What is the best way for organizations to start making the transition to a high reliability team?

The first thing to know about transitioning to an HRO is that it’s a marathon, not a sprint. Ironically, most HROs don’t define themselves as HROs. They simply perform with such a level of cultural mindfulness and commitment to safety and safeguards that they can’t imagine operating in any other way. An HRO is an organization whose leadership is highly involved, but defers to those with the practical experience to identify and solve problems. It’s an organization whose employees are empowered to bring matters to the attention of leadership and “stop the line” without fear of reprisal. This type of organization is not created overnight but, once the leadership is onboard and committed, the arduous and rewarding process can begin.

Why now?

Because despite extensive efforts to across the industry to improve the quality of health care, preventable hospital errors are now the third leading cause of death in the United States. In fact, research estimates that over 400,000 Americans are dying annually from preventable hospital errors. Think of burying the population of Omaha or Miami every year because of preventable errors. Though “medical error” is not currently included on death certificates or in the rankings of cause of death, many patients still suffer preventable harm every day and to date, no hospital or health system has achieved consistent excellence. This fact underscores the immediate need for hospitals to get it right and better protect their patients and their families from preventable harm.

What are the biggest challenges health care organizations face as they strive to become HROs?

The most significant challenges to the HRO journey come from within the organization. In a forthcoming work in the Journal of Healthcare Management, a group of researchers discuss what salient elements must be in place for high reliability concepts to flourish. Specifically, they find high reliability organizations must (1) have clear, effective and supportive leadership, (2) develop of culture of improvement and mindfulness, (3) attract and retain highly engaged employees, (4) develop and maintain long term, mutually supportive relationships with patients and (5) continually improve their processes (Beauvais et al., 2016).

 David “Scott” Hencshel is a Business Transformation Leader, facilitator and teacher with over 28 years of federal government experience in healthcare leadership, business transformation, strategic planning, process improvement, change management, and education. He is the President of Imminent Domain, LLC in San Antonio, TX; serves as the Chief of Staff and Director of Special Staff for the US Army Medical Department Center and School; and is adjunct faculty at Trinity University where he teaches “Performance Improvement in Healthcare Organizations” into the Masters in Healthcare Administration program. Scott is a certified Lean Six Sigma Master Black Belt, certified Balanced Scorecard Professional and a GE Healthcare trained Change Agent. Scott will be introducing his Lean Six Sigma program into the Baylor Executive MBA- Executive Development workshop series in Fall 2016. Healthcare professionals interested in discovering more about high-reliability organizations, or Lean Six Sigma programs, can contact Baylor’s Executive MBA program in Austin at


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