The 5 characteristics of high reliability organizations

Quality improvement and the STAR method of decision making


As part of its year-long Road to High Reliability learning series, the Center for Patient Safety is offering a webinar, “Gotta’ Make it Better,” on April 21, at 1 p.m. CST. Dr. Douglas Kupas will use examples from real EMS agency situations to demonstrate how principles from patient safety, culture of safety, just culture, simulation, team skills and other attributes of high reliability can be directly applied to EMS. Visit the CPS’s “The Road to High Reliability” for additional information and to register.

Nearly three weeks had gone by since the incident. Dwayne had spent plenty of restless nights trying to shake the images from his head. Pediatric calls are always tough, but a 4-year-old traumatic death is the worst. Now he feared it was happening again. At first, his paramedic partner Mikaela had been empathetic. But, he had the feeling others were trying to tell him that bad calls come with the territory, and he should simply get on with it.

As they arrived on the crash scene, both paramedics were glad to see familiar faces among the police and fire department crews already there. There was a sigh of relief when they received the initial report from the fire department. Two patients: a 32-year-old mom who was the belted driver with airbag deployment and a 3-year-old male secured in back with a car seat. Both were alert and oriented. The child was crying and acting appropriately in the situation. The driver of the other car had no obvious injuries and no complaints.

With the large group on hand, the extrication and packaging of the two patients went quickly. En route to the hospital, Dwayne shared his attention between mom and her son; but admittedly, he was hyper-focused on the child. He did not want to see another bad pediatric outcome on this shift. He was frustrated because it took him several minutes to locate the pediatric bag with an appropriately sized blood pressure cuff and other equipment. His efforts were further hindered as the lighting seemed strangely dim in the patient compartment; he shrugged and attributed it to being a cloudy day. Despite those annoyances, the trip was largely uneventful. It was not until they had almost arrived at the hospital that mom mentioned for the first time that she had lower back pain, and it was getting worse. Previously, she had spurned Dwayne’s attempts to get a good history and secondary exam due to her concern for her son.

A high-reliability organization is described as one where significant failure or catastrophic events are rare, despite operating in hazardous environments.
A high-reliability organization is described as one where significant failure or catastrophic events are rare, despite operating in hazardous environments. (Photo/Wikimedia Commons)

In the emergency department, mom was getting worse. It was not long before her blood pressure plummeted, and she struggled to remain conscious. The ED staff scurried to stabilize her, and the emergency physician ordered a CT scan and surgical consult. After things settled down, curious about the mechanism of injury in a teachable moment, the physician called the paramedics aside to discuss the case. The ED physician shared with Dwayne and Mikaela that the 3-year-old was going to be fine. But their adult patient had significant internal injuries. She had ecchymosis (bruising) across her lower abdomen and shoulder, commonly known as seat belt signs. The CT scan showed a large tear to the small intestine and she was destined for surgery and a tough recovery. While everyone eventually did OK, both Dwayne and Mikaela had a sickening feeling that things could have gone much better on this call.

This story is not real. But cases just like it happen every day. This is what the team might have learned as they reviewed the day’s events:

  • Dwayne was distracted, understandably so. Not because he was a poor paramedic; on the contrary, he was an accomplished and compassionate one. But he worked in a system that did not have resilience strategies that might have acknowledged the previous trauma weighing on his mind and provide opportunities for support and mitigation.
  • Should there have been a second person riding in the back of the rig? Some organizations require such when there is more than one patient. If additional ambulance resources are an issue, perhaps one of the EMT firefighters could have ridden along.
  • True, the bruising of a seat belt sign can be a late sign but a telltale one – if it is picked up on. That is difficult to do in a noisy, chaotic and dim environment. Later, we learned one of the firefighters, an EMT who helped with extrication, had heard mom complaining of abdominal and back pain early on. He had seen seat belt injuries once before but did not want to say anything because he worried he would sound foolish if he was wrong. After all, he knew Dwayne and Mikaela to be experienced, competent paramedics. Certainly, they would catch it, right?
  • The old threadbare pediatric bags had been recently upgraded. Following delivery, it was discovered they were a bit larger than the old ones and did not fit in the same compartment, so they were relocated. There was no hands-on in-service offered to explain this change. All staff members received an email from Clinical Services, but the bag change was buried in the third paragraph of a lengthy message and was one of a dozen emails received that day – not very effective communication.
  • Nearly everyone assumed people knew about the broken ceiling light in the patient compartment of that rig. It had been that way for more than a week, but had not been reported to maintenance. Each supervisor left the task to the next, and consequently, it never was repaired.

Despite good intentions, this fictitious ambulance service and crew has much work to do on the road to becoming a highly reliable organization (HRO).

High-reliability EMS organizations

High-reliability organization – Wow! It sounds great, and we all wish to achieve that status. But what does it really mean for EMS? HROs have been around for decades, beginning with nuclear power plants and aviation. HROs can be found in EMS as far back as the 1970s. In 1980, Daved vanStralen, author and current president of the Institute for High Reliability Organizing, was known as an “ambulance man” working for a private ambulance service and the Los Angeles City Fire Department. He enrolled in medical school, became a pediatrician and used his knowledge of working under uncertainty and threat throughout his career. For him, the development of a pediatric intensive care unit addressed at least some of the HRO challenges. Later, organizational theorist Karl Weick included vanStralen’s experience in his writings.

A high-reliability organization is described as one where significant failure or catastrophic events are rare, despite operating in hazardous environments. EMS providers find themselves constantly operating in hazardous environments. In structure and dynamics, EMS differs little from a space shuttle, nuclear power plant, commercial jet or operating room. Our systems have become increasingly complex to the level that accidents are not only predictable, but they can be expected. A catastrophic event in EMS can lead to a potentially preventable death or disability. Our significant failures cause increased injury, longer hospital admissions and patient or provider injuries resulting from our treatments. High reliability organizations do not accept that accidents will happen. They use a specified set of tools to avoid them.

The concept of HRO has helped engineers, system managers and operators at all levels across industries better understand risk and improve their systems. The result is a significant decrease in system failures through the application of the HRO principles. The experience of U.S. commercial aviation further shows that improved reliability reduces daily financial costs, not from fewer air crashes but from more efficient and productive daily actions. The good news is that this can be the outcome for EMS providers as well if they integrate the five HRO principles into their work culture and processes. This is pro-active work; we must improve before we risk harm to our patients and providers.

The 5 HRO principles

Social psychologist Karl Weick, PhD; and Kathleen Sutcliffe, PhD, describe five principles of HROs in their book "Managing the Unexpected." The first three principles help prevent errors from occurring; the last two principles help to mitigate errors.

Have you ever heard the term “the normalization of deviance?” The phrase itself sounds wicked. But it simply means turning a blind eye to the little thing so often that they sneak up on you and eventually become the normal things. “Who needs a spotter when I back up the rig anyway?” “Who cares if I don’t wear my name tag on my uniform.” “Why must I repeat the medication type and dosage out loud before administration – it’s no big deal?” Sloppy and lazy behaviors are insidious and can lead to really big (and bad) consequences.

What you can do: Remain alert to small, inconsequential errors as a symptom that something is wrong. Implement and encourage event reporting, start a near miss program with recognition for those who report and hold regular huddles to discuss patient safety.

  • HRO Principle 2: Reluctance to simplify. HROs are reluctant to accept simplifications but rather have an attitude of digging further into the situation to be sure you achieve the best solution. EMS is an environment of ambiguity, complexity and imperfect information. To perform in this environment, it becomes necessary to simplify. But HROs recognize the risk of simplification, hence the term “reluctant.” You simplify because you choose to, not because it’s easier or your only method of analysis.

This HRO principle refers to the simplification of analysis: don’t accept the easy answer. You have to dig deep to understand processes and what could happen. It’s why we do root cause analysis instead of just accepting everyone’s first idea about why an event occurred. At the same time, reducing unnecessary complexity in our procedures and workflow usually supports reliability. Simplification doesn’t mean the same thing as taking shortcuts. Be reluctant but thoughtful about what you simplify. Enhance things with an eye toward those that keep patients and providers safe.

What you can do: Pay close attention to what’s happening on the front line. Schedule times to ride on the ambulance to experience first-hand what is going on. Consistently round with providers to obtain their input on how to improve your processes.

  • HRO Principle 3: Sensitivity to operations. Everyone in the organization needs to know what is going on, from the front line to the leaders. Taking frontline operations for granted, not supporting them and not accepting the complex interactions necessary to work in dynamic, hazardous environments contributes to avoidable failures. The front line performs the real work in an HRO. They are focused on each changing situation. This requires the free flow of information, which is most easily lost when crews fear speaking up or only giving limited information. Implementation of Just Culture supports this HRO principle.

For example, suppose a medical director or manager decides to add a new widget of any kind, such as a mechanical CPR device, new airway or medication. In that case, the entire team needs to be part of the conversation.

  • What is its purpose and will it improve patient outcomes?
  • How will we train staff on this new procedure?
  • Do first responders need to know where to find this thing on the rig?
  • Does it even physically fit in the ambulance compartment?

Be sure to consider everyone who may be impacted by these decisions and ask yourself, “who needs to know about this?”

What you can do: Leaders should encourage diversity in experience, perspective and opinion across their staff. Develop a robust QI process with consistent implementation of a standardized improvement model used consistently across the organization. Encourage free communication of concerns and suggestions from the front line. Communicate and celebrate the improvements.

  • HRO Principle 4: Commitment to resilience. Resilience is the ability to maintain or regain a stable work environment, regardless of what occurs. As a situation unfolds, the demands may exceed the abilities of individuals or the system, so it’s necessary to have a backup plan. To continue operations, the organization must be proactive and identify errors that might occur while also improvising safe workaround within constraints of their environment.

Throwing your hands in the air and walking away is not an option when providing an essential public service like EMS. Highly reliable organizations have mechanisms built in to allow for decompression after critical events, support for leaders and staff when needed, and redundancy in operational equipment and practice. Being resilient is all about understanding that mishaps will occur – that we expect something to go wrong at some point in time. It’s all about having your response thought out ahead of time. Organizations can build resilience by regularly asking themselves, “what could go wrong today?” and then drafting a plan to respond.

What you can do: Develop capabilities to detect, contain and bounce-back quickly after events occur. Practice with drills and analyze events using a root cause methodology. Develop checklists to assist providers.

  • HRO Principle 5: Deference to expertise. An HRO reduces the authority gradient that interferes with communication and facilitates the migration of authority to those with the knowledge to make the best decisions. Deferring to authorities, especially because of higher status or rank, disrupts the use of local or situational knowledge. Looking to subject matter experts, despite their rank or status, can help contain a potentially dangerous situation. In dynamic, high-risk situations, circumstances will change and may change quickly. It’s important those with intimate knowledge of the circumstances, expertise in the necessary subject matter or experience with the current situation make rapid decisions with clear communication to avoid failures.

No one can deny there is a pecking order in EMS. Far too often, providers are reluctant to defer to others who may not have the title, status or perceived experience as another. A rookie EMT with new training and fresh eyes may have the best answer in a given situation. Conversely, don’t be shy to manage-up. Ask questions of those who may outrank you or have more education, for example, reaching out to an RN or physician’s assistant. The trick is remaining open to the possibilities.

What you can do: Push decision making to the person with the most directly related knowledge and expertise. Hold regular debriefs after events and encourage the use of chain of command.

Achieving high reliability requires two things: behavior accountability and process redesign. These steps can help agencies move towards high reliability.

  • Provide tools and integrated workspace for your providers. For instance, start holding a regular patient safety stand-up meeting at a consistent time each week, never more than 15 minutes. Providers can participate by video or phone, and everyone is invited to participate. Discuss concerns, errors, events and good catches over the past week.
  • Acknowledge quick fixes that are handled and send more complex fixes to a QI committee. Keep track of all actions with the HRO principles in mind.
  • Adopt a non-punitive approach to raising and addressing issues. Events and good catches are recorded and trended to share with staff. Acknowledge and celebrate good catches.
  • Start using STAR for all providers when important decisions are about to be made. This process allows the brain to catch up with what the hands are getting ready to do. It can be used while performing high risk and/or low frequency skill-based tasks such as ordering tests or giving medications. It stands for:
    • Stop. Pause 1-2 seconds to focus attention on the task
    • Think. Consider the action you are about to take
    • Act. Concentrate and carry out the task
    • Review. Afterwards, check by asking, “is this task done right with the right result?”

CPS “Road to High Reliability” webinar series

As part of its year-long Road to High Reliability learning series, the Center for Patient Safety is offering a webinar, “Gotta’ Make it Better,” on April 21, at 1 p.m. CST. Dr. Douglas Kupas will use examples from real EMS agency situations to demonstrate how principles from patient safety, culture of safety, just culture, simulation, team skills and other attributes of high reliability can be directly applied to EMS. He will cover situations of medication safety, teamwork, device use, and high-quality CPR to improve patient outcomes while decreasing medical errors in the EMS environment.

Visit the CPS’s “The Road to High Reliability” for additional information and to register

Dr. Douglas Kupas is an EMS and emergency physician at Geisinger Health System in central Pennsylvania.
Dr. Douglas Kupas is an EMS and emergency physician at Geisinger Health System in central Pennsylvania.

About the speaker

Dr. Douglas Kupas is an EMS and emergency physician at Geisinger Health System in central Pennsylvania. He serves as the EMS medical director for Geisinger EMS and the co-director of Mobile Integrated Healthcare. He is also the director of Resuscitation Programs for Geisinger and previously held the position of associate chief academic officer for simulation and medical education. He is a professor of emergency medicine at Lewis Katz Medical School at Temple University. Dr. Kupas is a paramedic and certified prehospital EMS physician and has been a practicing EMS provider for over 40 years. He is an avid researcher and passionate advocate for EMS practitioners and patient safety. His clinical interests include trauma triage, cardiac arrest outcomes, CPR, hypothermia, end-of-life care and EMS airway management. He also has an interest in community paramedicine-mobile integrated healthcare, and has served on the CPMIH committees of NAEMSP, NASEMSO and NAEMT. Further, Dr. Kupas has served as the Commonwealth EMS medical director for Pennsylvania since 2000 and is the current medical director for NAEMT.

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