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Management Brief No. 157

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Management eBriefs
Issue 157July 2019

The report is a product of the VA/HSR Evidence Synthesis Program.

Evidence Brief: Implementation of High Reliability Organization Principles

High Reliability Organizations (HROs) are those that "experience fewer than anticipated accidents or events of harm despite operating in highly complex, high-risk environments." At the core of an HRO is a culture of "collective mindfulness," in which all workers look for, and report small problems or unsafe conditions before they pose a substantial risk to the organization. Nuclear power and aviation are classic examples of industries that have applied HRO principles to achieve minimal errors, despite highly hazardous and unpredictable conditions. In February 2019, VA began rolling out the first steps of a nation-wide HRO initiative to improve patient safety, including the establishment of HRO workgroups, performance readiness assessments, and conducting training events and programs.

As death due to medical errors is estimated to be the third leading cause of death in the country, a growing number of healthcare systems are interested in adopting HRO principles.

The use of HRO is designed to change the thinking about patient safety through the following five principles:

  • Sensitivity to operations (i.e., heightened awareness of the state of relevant systems and processes);
  • Reluctance to simplify (i.e., acceptance that work is complex, with the potential to fail in new and unexpected ways);
  • Preoccupation with failure (i.e., viewing near misses as opportunities to improve rather than proof of failure;
  • Deference to expertise (i.e., value insights from staff with the most pertinent safety knowledge over those with greater seniority); and
  • Practicing resilience (i.e., prioritize emergency training for many unlikely, but possible, system failures).

This evidence brief sought to systematically evaluate the literature on 1) frameworks for the implementation of an HRO, 2) metrics for evaluating a health system’s progress towards becoming an HRO, and 3) effects of HRO implementation on process and patient safety outcomes. Investigators with VA’s Evidence Synthesis Coordinating Center in Portland, OR reviewed the literature including: Medline®, PsycInfo, CINAHL, and the Cochrane Central Register of Controlled Trials from January 2010 through January 2019. They identified 20 articles published on HRO frameworks, metrics, and evidence of effects.

Summary of Findings

  • Investigators identified five common HRO implementation strategies across eight frameworks: 1) Developing leadership; 2) Supporting a culture of safety; 3) Building and using data systems to measure progress; 4) Providing training and learning opportunities for providers and staff; and 5) Implementing quality improvement interventions to address specific patient safety issues.
    • Based on these strategies, the Joint Commission’s High Reliability Health Care Maturity Model (HRHCM) and the Institute of Healthcare Improvement’s Framework for Safe, Reliable, and Effective Care were the most comprehensive. They included all five strategies, contained sufficient detail to guide implementation, and were the most rigorously developed and widely applicable.
  • The Joint Commission’s HRHCM/Oro2.0. is the most rigorously developed and validated tool available for evaluating healthcare organizations’ progress on becoming an HRO; however, it has some conceptual gaps that might be addressed by incorporating metrics from other evaluation tools.
  • Multicomponent HRO interventions delivered for at least two years are associated with improved process outcomes (i.e., staff reporting of safety culture) and patient safety outcomes (i.e., serious safety events). However, the overall strength of evidence is low, as each HRO intervention was only supported by a single fair-quality study.

Developing Leadership, Data Systems, Implementing Interventions, Training and Learning, and Culture of Safetly

The overall strength of evidence is low, as each HRO intervention was only evaluated in a single fair-quality study. Further, as none of the studies compared an HRO intervention to a concurrent control group it is not possible to determine whether these effects are due to HRO implementation or a concurrent intervention or secular trend. Studies also lacked information on whether intervention components were delivered with fidelity over time, and whether the interventions were associated with unintended effects on provider workload or efficiency.

This is the first evidence review to systematically evaluate primary research on the effects of HRO implementation in healthcare settings. Further, although much has been written about the concepts of HRO and individual healthcare systems’ experience with HRO implementation, few have looked across different systems to describe similarities and differences in frameworks and metrics, and what lessons might be learned based on the successes and challenges encountered using different approaches. Gaining a better sense of how HRO has been successfully delivered is critical to informing the work of VA and other health systems as each embarks on its HRO journey.

Future Research
The biggest gaps in knowledge on HRO implementation are:

  • Whether the improvements in process and safety outcomes are truly caused by HRO interventions or are due to concurrent interventions or secular trends;
  • If HRO does lead to improved outcomes, and which components of HRO interventions are causing the positive effects;
  • Whether certain implementation frameworks lead to better outcomes; and
  • What are the contextual factors (i.e., barriers and facilitators) affecting successful HRO implementation.

Future HRO implementation research should use quasi-experimental designs, such as natural experiments that deliver HRO interventions at a group of sites with other sites serving as a wait-list control to evaluate the effects of specific intervention components – and to assess the mechanism of change driving outcomes.

Veazie S, Peterson K, Bourne D. Evidence Brief: Implementation of High Reliability Organization Principles. Washington, DC: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #09-199; 2019.

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ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.


This report is a product of VA/HSR&D's Evidence Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers – and to disseminate these reports throughout VA.

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