The document discusses the importance of high reliability organizations (HROs) in healthcare. HROs are organizations that manage to have few or no accidents despite operating in complex, hazardous environments. The principle of HROs is paramount for ensuring patient safety. HROs cultivate resilience by prioritizing safety over performance pressures. To become an HRO, healthcare organizations must implement the characteristics of preoccupation with failure, reluctance to simplify, sensitivity to operations, deference to expertise, and commitment to resilience. This involves risk analysis, risk control through standardization, and continuous learning. Adopting an HRO approach can help healthcare organizations better manage unexpected events and achieve reliable, resilient systems.

1. Strategy
30 Health Biz Insight August & September 2018
By: Dr AK Khandelwal
H
ealthcare organisations
are very complex and
in spite standardisation
of most processes, failure and
catastrophes do occur. Sudden
death in an imaging room, fall
of patients, suicide of patients,
wrong site, wrong patient
surgery, wrong investigations,
failure of treatment, failure of
equipment are some examples
of unexpected events. So, it is
important to recognise that
standardisation is necessary
but not sufficient for achieving
resilient and reliable healthcare
systems.
Managing the expected is
the paramount for a healthcare
organisation.
Industries like airline,
gas and oil, nuclear power
are working in high hazard
domains without serious events
and catastrophic failure by
implementing principle of high
reliability organisation. This
principle of high reliability
organisation is a paramount
necessity to ensure safe
healthcare ecosystem and
healthcare organisations should
adopt lessons about safety
management practices in safety-
critical industries. Examples
include the introduction of
incident reporting systems
and the WHO Surgical Safety
Check List.
What is High Reliability
organisation?
Literature mentions that high
reliability organisations are
those that
manage to have few or no
significant accidents even
though they operate complex
technology in highly hazardous
environments, such as aircraft
carriers and nuclear power
plants.
It is based on the principle
of persistent mindfulness in
the organisation of deficiency
or failure of services resulting
in damage or death. Literature
mentions that high reliability
organisations cultivate
resilience by relentlessly
priotising safety over the
performance pressure. High
reliability organisations
consider safety as a dynamic
culture changing with the
new emerging threats in
the healthcare ecosystem.
Managing the Unexpected
The principle of high reliability organisation is a paramount
necessity to ensure a safe healthcare ecosystem

2. Strategy
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Health Biz Insight August & September 2018
An administrator in a
high reliability healthcare
organisation should anticipate
emerging safety threat, detect
early and act early to mitigate
catastrophic damage.
Characteristics of a High
Reliability organisation
Preoccupation with failure:
All stakeholders should be
aware of and think about
the potential for failure.
They should not forget
that unexpected failure and
deficiency emerge regularly in
the ever-changing healthcare
ecosystem. All stakeholders,
healthcare providers,
healthcare recipient, payors
and healthcare organisations
should actively think about
what could go wrong and are
alert to small signs of potential
problems.
It should be emphasised
among all levels of healthcare
providers that the absence
of errors or accidents leads
not to complacency but to a
heightened sense of vigilance
for the next possible failure.
The organisation culture
should encourage to learn from
near misses.
Reluctance to simplify:
High reliable healthcare
organisations consider that
all processes are complex
and dynamic and prone to
error and failure. Healthcare
organisations should create a
system that provides resource
to investigate and pursue
potential problems proactively
and more widely.
Sensitivity to operations:
All stakeholders in a
high reliability healthcare
organisation should maintain a
high vigilance on all operations.
They should understand what
they are doing/where they
are doing/who is doing/what
wrong can occur.
Deference to expertise:
Hierarchy in a high reliable
healthcare organisation should
be flat. Organisations should
give importance to the front-
line staff who are directly
involved in the process in
decision making specially in
crisis situation.
Commitment to resilience:
Literature mentions that
resilience is the intrinsic ability
of a high reliable organisation
to adjust its functioning
according to the dynamic
healthcare ecosystem and
continue to function even
after a major mishap or in the
presence of continuous stress.
High reliable organisations
invest in resilience engineering
to cope with and recover
from unpredicted, unforeseen,
unexpected demands and
situations.
Implementation of high
reliability culture
Healthcare organisations
can implement the above-
mentioned behaviours toward
their journey for becoming a
highly reliable organisation.
Needless to mention that this
journey may be faster in some
areas and slower and difficult
in other areas of a healthcare
organisation.
The success of
implementation depends
Literature mentions
that high reliability
organisations are
those that manage
to have few or no
significant accidents
even though they
operate complex
technology
Implementation of high
reliability culture

3. Strategy
32 Health Biz Insight August & September 2018
upon three main abilities of
healthcare organisation: risk
analysis and control, adapting
capacity to changes, and
learning continuously.
Risk analysis
Experts suggest that there is
large variation in the reliability
of different care processes, and
that overall, care process have
a significant failure rate that
can be improved upon.
Healthcare organisations
should identify high
risk process like CPR,
IV cannulation, oxygen
administration, operations,
invasive procedures,
identifications, blood
transfusions, sedations,
anesthesia etc. and anticipate
the probability of failure and
severity of outcome of failure
by most effective quality tool
like failure mode and effect
analysis (FMEA).
Risk control
In order to improve the
reliability of processes,
organisations usually attempt
to exert greater managerial
control over how care is
delivered. This can be achieved
by simplification
and standardisation of
processes by using a
management tool like process
mapping, lean method, care
bundle etc.
Investing in such activities
is a prerequisite for enhancing
the reliability of care processes
to higher levels, and it is a
key component of mindful
organising.
Learning continuously
A healthcare organisation
should develop culture of
learning organisation to
provide safe and reliable
healthcare. Safe and reliable
care is facilitated by individual
learning, team learning and
organisation learning.
Conclusion
Managing the unexpected in
a healthcare organisation is a
challenging and arduous task.
Experience of other
industries like aviation, nuclear
power etc. have proved that
it is possible to achieve this.
A healthcare organisation
can start its journey towards
becoming an HRO with
vision, leadership and safety
culture. HBI
About the author
Dr. Ashok Kumar
Khandelwal is the VP
& Medical Director,
Anandaloke Hospital &
Neurosciences Centre,
West Bengal. He is a
trained Assessor from the
National Accreditation
Board for Hospital and
Health Care Provider
(NABH). He carries
around two decades of
experience in the hospital
industry and 20 years of
experience as a hospital
administrator.
The 8 Es of Implementation