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High reliability organizing: The pathway to organizational resilience

Coauthored by Carole Stockmeier, SVP, Safety and Reliability Solutions.

Leaders from CMS and CDC recently identified an urgent need for a resilient healthcare system that must be achieved by “redesigning our current processes and developing new approaches that will permit the delivery of safe and equitable care across the healthcare continuum during both normal and extraordinary times.”1 The authors rightly recognize that resilience is the outcome, not the starting point of improvement efforts. Many organizations have been focusing on individual resilience, with attention on professional burnout. Far less attention, however, has been given to achieving organizational resilience, described as “the flexibility to pivot as new and unexpected challenges arise, and to absorb unexpected shocks that cannot be avoided even with proper planning.”2 The COVID pandemic has highlighted the importance of organizational resilience like nothing before, with a recent assessment identifying eight categories of gaps in preparation and response with causal factors rooted in behaviors, structures, processes, protocol, and environment.3 In this article, we make the case that high reliability organizing is the starting point to achieving resilience and closing gaps effectively.

Like individuals, organizations have a finite amount of energy. Figure 1a models a healthcare organization’s total energy as energy expended (the black line) plus energy in reserve. In normal operations, energy expended is relatively stable. During a short-term crisis, energy expended increases, often tapping into energy reserves. As the crisis abates, energy expended moderates. In contrast, during a prolonged crisis, such as the COVID pandemic (Figure 1b), energy expended remains high, and energy in reserve nears depletion. Data substantiates a COVID-coincidental nationwide performance decline in safety and quality, likely due to the energy expended on the crisis with less attention placed on routine quality and safety activities.

Graph: energy balance under short-term stressGraph: energy balance under long-term stress

Yet there are positive variations (Figure 1c). For some organizations, energy expended during normal operations is less than that of others—they operate more effectively. Closely related, the increase in energy expended during crisis is less steep—they are able to take on more with less and expend less energy in reserve. The extra energy these organizations have can then be placed on other, noncrisis related activities, reflected by stable or even improved performance during the pandemic. For example, Sentara Healthcare experienced a reduction in hospital-acquired infections and an increase in overall workforce engagement (personal communication).

Graph: high reliability organizing

What enables some organizations to manage more effectively and maintain—or improve—during a crisis? “HRO” is a well-known acronym for high reliability organization.4 More powerfully, consider HRO as an action—high reliability organizing.5 High reliability organizing is a deliberate undertaking of leaders to shape processes and behaviors to prevent adverse events and optimize outcomes. Organizations in high-consequence industries—like nuclear power and aviation—understand that outcomes result from the actions and interactions of organization members. They recognize the importance of clear behavior expectations for individuals and leaders and understand that behaviors are influenced by organizational processes. Leaders align and integrate behavior expectations with organizational values, structures, processes, and environments to make it easy to do the right thing and hard to do the wrong thing.

We interviewed executives at health systems, like Sentara, that had embarked on a focused safety and reliability culture transformation prior to the pandemic to understand the impact that HRO had on how their organization managed during the pandemic.

Without knowing what lay ahead, the safety and HRO efforts of these organizations formed the foundation for resilience during the COVID pandemic. Insights from these interviews can be organized into three themes: (1) safety as the core value; (2) leadership structures and expectations for shared situational awareness, problem identification, and problem solving; and (3) behavior expectations for individual and team actions and interactions to mitigate human errors and mistakes.

Organizations that revere safety as their core value demonstrate a commitment to zero harm in word and in deed. This commitment is led by the board and the CEO; it is reflected in how leaders think, speak, and act; and, importantly, it is evidenced in the moment-to-moment decision making of the front-line workforce. All executives interviewed cited the important role their commitment to safety played during the COVID pandemic. Zero harm was not a new articulation that required alignment effort, but a familiar true north that pointed the way, reassured, and served as a check on prioritization and decision making.

“Our work in reliability culture puts safety in the forefront of everything we do,” shares Nick Testa MD, Chief Medical Officer at Dignity Health Southern California. “When COVID started, there was fear and concern among our people about their personal safety. Our work in creating a culture of safety didn’t stop that fear, but it did do two things. First, our people knew very well our commitment not only to patient safety, but to their safety as well. Second, it allowed us to move quickly through the fear factor and into being productive and operational.”

One powerful HRO leadership structure is Daily Check-In, a focused leadership meeting about safety events and risks. In structured order, the team looks back on significant issues from the last 24 hours; looks ahead by anticipating issues in the next 24 hours; and follows up on significant issues previously identified.5 Common across organizations interviewed, leadership teams leveraged Daily Check-In as a means of communicating rapidly changing information and maintaining awareness of COVID-related issues. If Daily Check-In had already been embedded into their processes pre-pandemic, less energy was expended on establishing communication structures once the pandemic began. “Our history and ongoing work in high reliability enabled our healthcare system to stay focused on our core safety commitments while managing rapid changes,” says Genemarie McGee, RN, Chief Nursing Officer of Sentara Healthcare. “Daily huddles were embedded in our culture. We utilized the process to expand communication with specialized COVID huddles. This ensured communication reached front-line employees and providers, keeping them informed and engaged in the quickly changing landscape.”

The HRO efforts of these organizations also included defining and embedding behavior expectations as individual and teamwork habits. These behaviors include paying attention to detail, communicating clearly, having a questioning attitude, and peer checking and coaching.5 The clear articulation of such behaviors and the elevation of these behaviors as personal and professional habits reduces human errors and mistakes that lead to failures in safety, as well as all areas of performance. Those interviewed identified these embedded behaviors and habits as foundational to their energy performance during COVID.

According to Sandy Cox, Director of Safety at Novant Health: “Our high reliability foundation prepared our team to be battle-ready for any crisis. We had developed safety and high reliability muscle memory and habit formation. Skills that have been put into practice day in and day out, year over year, situated our organization to be prepared when crisis hit rather than preparing for the crisis at its start.”

Through these principles and practices, HRO underpins high performance and enables organizations to manage their total energy more efficiently and effectively. Essential HRO components include safety as the core value, leadership structures and expectations for shared situational awareness, problem identification, problem-solving, and behavior expectations. HRO is the starting point for resilience by both preventing failures during routine operations as well as containing the impact and managing during times of crisis.

  • Sandy Cox – Director of Safety at Novant Health 
  • Genemarie McGee, RN – Chief Nursing Officer, Sentara Healthcare 
  • Nick Testa, MD – Chief Medical Officer, Dignity Health – Southern California Division
  1. Fleisher L, Schreiber M, et al. "Health Care Safety during the Pandemic and Beyond – Building a System That Ensures Resilience." NEJM, 17 February 2022.  

  2. Barash, I and Kahn, J. "Fostering hospital resilience – lessons from COVID-19." Journal of the American Medical Association, August 24/31, 2021; Volume 326, Number 8: 693-694. 

  3. Jarrett, M et al. "Pandemic preparedness: COVID-19 lessons learned in New York’s Hospitals." The Joint Commission Journal on Quality and Patient Safety, 2022. 

  4. Weick, K. E. and Sutcliffe, K. M. "Managing the unexpected: resilient performance in the age of uncertainty, 2nd ed." Jossey-Bass, 2007. 

  5. Clapper C, Merlino J, Stockmeier C, eds. "Zero harm – how to achieve patient and workforce safety in healthcare." McGraw Hill, 2019: 51-71.  

About the author

As Chief Safety and Transformation Officer, Dr. Gandhi, MPH, CPPS is responsible for improving patient and workforce safety, and developing innovative healthcare transformation strategies. She leads the Zero Harm movement and helps healthcare organizations recognize inequity as a type of harm for both patients and the workforce. Dr. Gandhi also leads the Press Ganey Equity Partnership, a collaborative initiative dedicated to addressing healthcare disparities and the impact of racial inequities on patients and caregivers. Before joining Press Ganey, Dr. Gandhi served as Chief Clinical and Safety Officer at the Institute for Healthcare Improvement (IHI), where she led IHI programs focused on improving patient and workforce safety.

Profile Photo of Dr. Tejal Gandhi, MPH, CPPS