The Healthcare Hub

A Guide to High-Reliability Organizations (HRO) in Healthcare

Thursday, May 11, 2023

Learn how high-reliability organizations (HROs) operate in the healthcare industry and supply chain, including benefits, challenges to operations and strategic implementation for promoting patient safety in care delivery.

You will also discover specific examples of high reliability organizations and their work, implementation strategies from healthcare experts, and resources that hospitals and health systems can leverage in 2023 and beyond to progress toward high reliability.



Table of contents

  1. Understanding HROs in healthcare
  2. 5 principles of high reliability organizations
  3. Benefits and healthcare HRO success stories
  4. Challenges: are there HROs in healthcare?
  5. Strategies for implementing HRO principles
  6. Learning resources for healthcare HROs



Understanding High-Reliability Organizations

The U.S. Department of Health and Human Services (HHS) Agency for Healthcare Research and Quality (AHRQ) defines high reliability organizations (HROs) as those organizations that "operate in complex, high-hazard domains for extended periods without serious accidents or catastrophic failures."

Some of the first high risk industries to embrace HRO concepts were nuclear power operations and commercial aviation, where even the smallest of errors can lead to tragic results and past failures had led to catastrophic consequences: airplane crashes, nuclear reactor meltdowns, and other such disasters.

💡 Read more about priorities for high-reliability healthcare supply chains.

A history of HROs in healthcare

Based on success in other industries in avoiding catastrophes, healthcare organizations began exploring how they could leverage the principles of high reliability organizations to improve patient care quality and safety.

Since the Institute of Medicine's (IOM) publication of "To Err is Human" in 1999, which "concluded that 100,000 patients die from medical errors annually in the United States" healthcare organizations have secured leadership commitment in engaging frontline providers (nurses, clinicians) and other stakeholders to improve patient safety, reduce medical errors, provide more reliable healthcare, enhance patient satisfaction, and work toward continuous improvement in operational excellence.

That same year, Karl E. Weick, Kathleen M. Sutcliffe and David Obstfeld published their paper, "Organizing for high reliability: Processes of collective mindfulness," which "gave the high reliability organization domain renewed energy to go in different directions. Around that time, those kinds of ideas started becoming more visible to people in health care," said Dr. Sutcliffe.

Over two decades later, in a 2021 BMJ Quality & Safety journal editorial on high reliability organizations, "High reliability organising in healthcare: still a long way left to go, Dr. Sutcliffe stated, "Interventions to improve healthcare quality and safety grounded on HRO theory have become commonplace" in the past two decades... Yet, little is known about how these interventions have fared, with a particular dearth in understanding the mechanisms of change that might explain more or less successful adoption."



5 principles of HROs

At their core, high reliability organizations (HROs) embody these five principles:

  1. Sensitivity to operations. Preserving constant awareness by leaders and staff of the state of the systems and processes that affect patient care. This awareness is key to noting risks and preventing them.

  2. Reluctance to simplify. Simple processes are good, but simplistic explanations for why things work or fail are risky. Avoiding overly simple explanations of failure (unqualified staff, inadequate training, communication failure, etc.) is essential in order to understand the true reasons patients are placed at risk.

  3. Preoccupation with failure. When near-misses occur, these are viewed as evidence of systems that should be improved to reduce potential harm to patients. Rather than viewing near-misses as proof that the system has effective safeguards, they are viewed as symptomatic of areas in need of more attention.

  4. Deference to expertise. If leaders and supervisors are not willing to listen and respond to the insights of staff who know how processes really work and the risks patients really face, you will not have a culture in which high reliability is possible.

  5. Resilience. Leaders and staff need to be trained and prepared to know how to respond when system failures do occur.

HRO benefits and success stories in healthcare

Commitment to and progress toward becoming a high reliability healthcare organization can offer many benefits to healthcare delivery:

  • greater staff engagement

  • collective mindfulness

  • solutions to complex problems

  • improved patient safety

  • quality improvement

  • more reliable care

  • a safer work environment for clinicians (including psychological safety)

  • ability to better manage unexpected events, etc.

Providence's "Care Reliably" model

Two years into the program, Providence achieved a "5% improvement in the safety climate domain of the Safety Attitudes Questionnaire and a 52% decrease in serious safety events."

Providence, a U.S. health system comprised of 51 hospitals, 1,000 clinics and a comprehensive range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington, has documented significant success with its high reliability program, "Care Reliably."

Much of their work focuses on culture creation and cultural data - understanding how a highly reliable approach is dependent upon individual's commitment to improve reliability. Examples of their high reliability tools, developed using principles inside and outside healthcare, include:

Stop, Think, Act, Review (STAR)

Brief, Execute and Debrief

Situation, Background, Assessment, Recommendation (SBAR)


The U.S. Veteran's Health Administration

The U.S. VHA began has long been on a journey to become a high reliability healthcare organization, and has documented evidence based success in various areas of patient safety.

To guide its work, the VHA established a high-reliability hospital (HRH) model for HRO adoption, and conducted a pilot in collaboration with the Truman VA Medical Center. The model's high reliability hospital components included:

  • Annual patient safety (PS) assessment
  • Annual PS culture survey
  • Annual root cause analysis training
  • Daily leadership walk-arounds
  • Monthly PS forum
  • Annual processes standardization review
  • Just Culture training
  • Unit-based Clinical Team Training
  • Unit-based continuous improvement projects
  • Annual Clinical Team Training simulation education

The VHA published the results of this "3-year intervention period" (January 1, 2016-December 31, 2018) in the January 2022 Journal of Patient Safety:

Truman internally improved PS culture and PS event reporting rates resulting in outcomes better than all VHA facilities (All VHA; P < 0.001 and P < 0.001, respectively).

Low-harm PS event reporting increased (P < 0.001); however, serious safety event rate remained unchanged versus All VHA.

Significant improvement in Truman standardized mortality rate and complication rate versus All VHA occurred immediately and were sustained through intervention (slopes, P < 0.001 and P < 0.020; respectively).


High reliability electronic health record (EHR) system implementation

The University Health Network, Toronto, Ontario, Canada applied all five principles of high reliability organizations during an electronic health record (EHR) implementation that replaced a primarily paper-based record system. Commenting on their work, they stated:

"Implementing a new EHR system across a multi-site academic health science centre was a large clinical transformation requiring coordinated attention to quality and safety in the planning and go-live periods. The introduction of the new EHR disrupted the pre-existing work system, and new processes were introduced which had the potential to impact patient and organizational outcomes (e.g. avoidable patient harm). Applying HRO principles enhanced the organization’s ability to provide high quality care, as well as understand the complexity of the system during a large scale clinical transformation."



Challenges: does healthcare have HROs?

"Simply adopting an HRO structure is not enough to transform a hospital or health care system into a true HRO. This effort typically requires a multidisciplinary approach as well as cultural change."

Deloitte, Transforming into a high reliability organization in health care (2017)

There is a lot of debate in healthcare when it comes to the HROs. The Joint Commission even goes as far as to state that, "while many health care organizations have embraced high reliability and made zero harm their goal, we haven’t yet found any health care organization that has achieved this."

Dr. Sutcliffe points to the healthcare sector's resistance to implementing principles from other industries as one of the roadblocks to becoming a high reliability organization. In her view, the healthcare industry's focus on training individuals in high reliability concepts, rather than an "emphasis on broader systemic or cultural challenges to safe, reliable performance," has also stifled progress.



HRO implementation strategies

Weaving high reliability concepts throughout healthcare organizations requires buy-in and support from decision makers for more reliable healthcare, acknowledgement of medical errors and their impact on patient care, commitment to applying HRO principles to health care delivery to improve patient safety, dedication to continuous learning across all stakeholders (nurses, clinicians - it's everyone's responsibility), evidence based operations and processes, and ultimately a preoccupation with failure and a strong desire and drive to overcome it through resilience.


3 pillars of high-reliability training (the Joint Commission)

Leadership committed to the goal of zero harm.

An organizational safety culture where all staff can speak up about things that would negatively impact the organization.

An empowered work force that employs Robust Process Improvement® (RPI®) tools to address the improvement opportunities they find and drive significant, lasting change.


9 steps to becoming a HRO (Deloitte)

In Deloitte's eBook, Transforming into a high reliability organization in health care, Deloitte offers the following recommendations:

Commit to a goal: Evaluate organizational priorities and develop vision statements and guiding principles to establish a quality-focused culture built upon the foundations and pillars of high reliability, and ensure key stakeholders understand the importance and rationale for embracing these principles.

Embrace the leadership challenge: Ensure leadership understands and embodies the principles and tenets of high reliability, taking a “top-down and bottoms up” approach to quality and patient safety. Demonstrate strong leadership and an approach to quality and patient safety that is pervasive at all levels of the organization.

Develop and support champions: Begin to engage stakeholders early and often through creation of quality champion change agents that help other stakeholders embrace these approaches and concepts.

Establish governance: Design a governance and oversight structure and system to manage and own quality improvement within the organization.

Train for excellence: Educate key stakeholders and develop a quality-focused curriculum, emphasizing the importance of ongoing and continuous learning at all levels. Adopt robust process-improvement tools and procedures to achieve sustainable high reliability.

Develop and use information: Gather, aggregate, and analyze available data and train others to understand, interpret, and identify actionable insights that help guide the organization and contribute to continuous quality improvement.

Promote a culture of improvement: Reinforce “systemness” through effective communication and messaging to encourage information-sharing and global problem-solving. Promote a culture of openness through team check-ins or executive walk-arounds, and empower staff to challenge questionable orinappropriate behaviors.29

Learn early and often: Consider the complexities of each situation to properly understand what happened and/or will happen in the future.30 In addition, procure accurate and complete information about a given situation and use it to guide decision making.

Proactively address risk: Address any error of system breakdown as a high priority despite the magnitude of the issue, and act quickly based on observed data points.32 Remain resilient and nimble despite errors and demonstrate the ability to avoid failure over time.


Advice on implementing HRO principles

Health care is a high risk industry where medical errors threaten patient lives; therefore, reliable healthcare should be a priority on the path toward zero harm. While HRO theory and its five core principles seem straightforward on the surface, enacting this level of enterprise wide sensitivity to operations, recognition of systems issues, collective mindfulness, situational awareness and commitment to operational excellence is no easy task.

Consider alone the level of psychological safety that must be cultivated to make nurses, clinicians and others feel comfortable to voice their concerns with their health system or hospital's safety culture. Not all healthcare organizations embody a dynamic environment for change, where providing feedback is encouraged, cultural data is valued, and reliance is driven from the bottom up.

As The Joint Commission points out, high reliability is a goal that very few (if any) self proclaimed high reliability organizations have achieved.

Looking back over the past three years, health care organizations that weathered unexpected situations better than others - most notably, the the COVID-19 pandemic - often embody HRO attributes. Here are HRO six strategies surfaced during a HIMSS roundtable discussion that other health care organizations can leverage as they work toward high reliability:

  • Developing Effective Leadership
  • Prioritizing Training and Learning
  • Building Robust Data Systems
  • Implementing Successful Interventions
  • Creating a Culture of Improved Patient Flow
  • Data sharing
  • Establishment of strategic and effective processes
  • Evaluation of current metrics
  • Identification of opportunities for improvement
  • Driving HRO-led Care Improvement Across the Continuum



Educational resources for healthcare HROs

There are a variety of resources available to healthcare organizations looking to embrace a high reliability approach in 2023, or continue on their established HRO journey. Here are a few to consider:

Thomas Jefferson University High Reliability Healthcare Academy: The series of seven online sessions, beginning October 6, 2023, "will showcase the myriad ways High Reliability looks in practice across the United States, with an emphasis on how unique populations and other contextual variables (e.g., organizational culture, COVID, type of organization) impact fidelity to the High Reliability framework." Thomas Jefferson University is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC).

Society of Hospital Medicine (SHM) High Reliability In Healthcare: From Zero-Harm To High-Value Care: Described as "a comprehensive array of educational and networking opportunities designed specifically for the hospital medicine professional," the online course is open until April 2026, with a target audience of hospitalists, physician leaders and practice administrators; hospital, health plan and medical group executives.

American College of Healthcare Executives (ACHE) High-Reliability Healthcare: Improving Patient Safety and Outcomes with Six Sigma: "Written in a practical, how-to style and now extensively revised, this book provides healthcare executives with a tool kit for understanding variability, managing change, and ultimately reducing errors and improving patient outcomes."


Disclaimer: The third-party contributor of this piece is solely responsible for its content and accuracy, and the views expressed do not necessarily reflect the opinion of GHX.




  1. High-Reliability Organizations (HRO) in Healthcare. Patient Safety Network, Agency for Healthcare Research and Quality.
  2. High Reliability Organizing for Healthcare: A Research and Development Roadmap. Veterans Health Administration.
  3. A Framework for Safe, Reliable, and Effective Care. Agency for Healthcare Research and Quality.
  4. To Err is Human, To Tolerate Inhumane. APSF Newsletter, Anesthesia Patient Safety Foundation.
  5. Weick, Karl E., et al. Organizing for High Reliability: Processes of Collective Mindfulness. Administrative Science Quarterly, vol. 44, no. 4, 1999, pp. 765-769. PsycNET.
  6. Conversation with Kathleen Sutcliffe, MN, PhD. Patient Safety Network, Agency for Healthcare Research and Quality.
  7. Sutcliffe, Kathleen M. High Reliability Organising in Healthcare: Still a Long Way Left to Go. BMJ Quality & Safety, vol. 31, no. 12, 2022, pp. 845-848.
  8. High Reliability Training. Joint Commission Resources.
  9. Transforming into a High Reliability Organization in Health Care. Deloitte, 2017.
  10. High Reliability and Infection Prevention. The Joint Commission.
  11. High Reliability Healthcare: From Zero-Harm To High-Value Care. Society of Hospital Medicine.
  12. High-Reliability Healthcare: Improving Patient Safety and Outcomes with Six Sigma. American College of Healthcare Executives.
  13. Teletracking White Paper: Insights from the HIMSS Roundtable on High Reliability in Healthcare. HIMSS.
  14. High Reliability Healthcare Academy. Thomas Jefferson University.
  15. High-Reliability In Healthcare: A Research Compendium. Society of Hospital Medicine Learning Portal.
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Kara L. Nadeau

Healthcare Industry Contributor

Kara L. Nadeau has more than 20 years of experience as a writer for the healthcare industry, working for clients in fields including medical device/supply manufacturers and distributors; software, solution and service providers; hospitals and health systems; and industry associations.

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