In many healthcare organizations, the hot topic is how to become a High Reliability Organization (HRO). HRO’s are what everyone wants but to achieve that status is not easy to achieve. Let’s review the characteristics of an HRO as defined by Chassin and Loeb in their groundbreaking paper¹.

First, the organization has to exhibit a sensitivity to operations. This means that the organization shows flexibility to the changing needs in terms of resources and how it operates. Imagine a major accident in your town, would your hospitals be able to respond with the appropriate level of care as required by the number of people hurt? We think of teams pitching in to provide care where it is needed and not stopping until everyone has been taken care of. That is a challenge in many hospitals today simply due to shortages in equipment, supplies, doctors and nurses.

Secondly, there is a reluctance to simplify any situation. It is a focus on doing the “right” thing not the “fast” thing. How do we make sure that all possible aspects have been investigated? The challenge here is to not overlook anything. We all love the doctor shows where the hero finds the real problem instead of the easy to find problem. That requires some courage to not jump to conclusions but to follow the process.

Third, the organization has a preoccupation with failure. Teams are challenged to identify how their work processes can fail so that they can create robust processes that will work no matter what happens. The team practices the new process until it become hardwired to them. This then becomes the new standard of performance.

Fourth, the organization has as deference to expertise. In healthcare, this is assumed to be a deference to the doctors but in HRO’s, it goes beyond this. Here it is the acknowledgement and utilization of whoever in the organization has the specialized knowledge needed to resolve the issue. This is a very difficult point since the expertise may not reside in the provider group but some other team.

The fifth characteristic is the ability to practice resilience. How well does the organization recover from errors? Does the organization react like a pro basketball player who has missed the last free throw and now has a chance to win the game by sinking one? Can the organization “shake it off” and move forward?

In looking at these characteristics, one thing comes to mind when trying to decide if an organization wants to move down this path. Leadership! Making the changes necessary to become an HRO requires a vision and strategic plan that focuses on changing the culture. Culture change is one of the most difficult things to manage as a leader and this is the basic belief behind moving the organization to an HRO status. This is where many organizations fail.

Why does this failure occur? There are a number of reasons but primarily because the leadership team does not stay the course. Culture change does not happen overnight. It takes time, as in years, to accomplish. That is why the vision and strategic plan are so critical. In healthcare, many organizations are different in that they do not understand how a strategic plan is used. In traditional business it is the roadmap that is followed by the CEO and the leadership team since they will be held accountable for the results by the board of directors. It does not matter if the leadership team changes people since the strategic plan defines the goals and objectives over the long term. If the CEO retires, the board holds the new CEO to the same plan. It is the path the organization will use to create the new culture. In healthcare, leadership teams change with a greater frequency than traditional business. But the board does not enforce use of the strategic plan so healthcare organizations tend to flounder in their long term accomplishments.

We have to recognize that changing culture is a five to seven year process. So to do this right, the leadership team and the board of directors need to buy into it right from the start. It is imperative that these groups have an accountability to each other to set the direction and keep on it until it is achieved. It is similar to an organization committing to work toward attain the Baldrige award. It does not happen overnight. It is a commitment to excellence that is reinforced every day by everyone in the organization. The minute the commitment is not reinforced, then there is slippage and it will keep slipping until the leadership stops it.

How does leadership stop the slippage? First they have to communicate what the strategic plan and vision is to everyone in the organization. This communication is then reinforced at every meeting large and small by engaging the middle managers to actions that support the effort. One of the best practices is to have each department define what they are going to do to support the strategic plan. They will set SMART goals to help them and the leadership team to track their progress. Likewise, teams in the department will set goals that will support the department goals.

When goals are met, then there is a celebration and again, here is where senior leaders need to step up and participate. It is critical that the leaders are there. It will be noticed if they are not and the underlying message that will go around is that they are not really behind the strategic plan. They need to be part of every celebration. In addition, they need to constantly reinforce how important this is to the long range plans for the organization.

In one organization that I worked with this point was demonstrated very clearly. One leader was very authoritarian in their approach to things, consequently, they did not see the need for reinforcement. This person felt that just saying that this needed to be done was all that was needed. Needless to say, this person also did not participate in any celebrations because they were too busy. Soon the groups avoided attending anything that this leader was doing since they felt that it was counter to what the organization was trying to do. Within three months, that leader was no longer with the company. Other leaders had recognized that the atmosphere created by this one person was so negative to where the organization wanted to go that they needed to go. It did not matter what the quality of their work was, it was the toxic environment that they created that threatened to destroy the culture change that was taking place. The rest of the leadership team realized that action had to be taken and did so. This organization is now recognized by many in healthcare as one of the leaders in High Reliability.