December 27, 2019

Healthcare HROs Unlocked: Part 3

As a continuation of our Healthcare HROs Unlocked series we will begin to deep dive into specific aspects of High Reliability Organizations, specifically the Principle of Anticipation. In our November article, Healthcare HROs Unlocked: Part 2, Gillingham, Corbridge, Warner Shaub, and Hoffman identified three principles of anticipation: 1. Preoccupation with Failure and Its Cause, 2. Reluctance to Simplify Interpretations, and 3. Sensitivity to Operations (2016).  Each of these principles contribute to an organization’s High Reliability.

Preoccupation with Failure and Its Cause: (RISK MITIGATION)

For most organizations, the objective or goal of being error free is an elusive vision, fraught with disappointment and complex challenges that end up being a dream not a reality. Often the failure comes from the poor implementation of an organization’s strategy for risk mitigation. It is true that the possibility of achieving 100% error free operations within any organization or enterprise is near impossible, even more so in such highly dynamic and complex organizations as hospitals and healthcare, where there are literally thousands of possible variations of disease, infections, or any other variable one could imagine. However, getting as close to a zero mishap, accident, or risk rate is certainly achievable by following principles that have been well established and tested over a significant period of time by the military, specifically, the military aviation enterprise.


There are many avenues to producing error free performance in a healthcare organization.  Standardization is the proverbial low hanging fruit in healthcare or any organization, and not surprisingly a hallmark of any successful HRO. During my time in the Navy, I became very involved with the processes Naval Aviation used to mitigate, anticipate, and manage risk. The concept or Operational Risk Management (ORM) has become so ingrained in all aspects of Naval Aviation that any member of a squadron can recite the four principles verbatim: 1) Accept risk when the benefits outweigh the costs, 2) Accept no unnecessary risk, 3) Anticipate and manage risk by planning 4) Make risk decisions at the right level. The theory behind ORM is very simple; manage, anticipate, accept, and decide, however; the implementation of the principles of ORM can take years to master, requiring constant reinforcement, re-evaluation, and open communication to ensure that the principles of ORM are met and appropriate risk decisions are made at the right level. As an example, a decision of whether or not to do a life saving surgery may be easy for some individuals to make, however; when one begins to thoroughly evaluate all the factors or variables that would influence the level of risk, such as, life expectancy, health of the patient, amount of sleep the surgical team has had, the level of experience of the surgeon, anesthesiologist, or nurses, one can begin to see how risk levels could easily change.


Much like in military operations where risk is managed by a clear chain of command, checklists, inspections, practice, education and teamwork, much can be said about mitigating risk in certain aspects of medicine, such as an emergency or operating room. The largest difference may be the level at which those members of the “team” in the operating and emergency rooms work together and train together. One way to address this is to standardize the training of Operational Risk Management to all members of an organization, so that everyone understands the underlying concepts and principles of ORM. In Naval Aviation, the use of ORM sheets to address the most common issues associated with a flight are used resulting in a score. That score is then compared with varying degrees of risk level that have been benchmarked over time.  The senior member of a team then can make appropriate risk decisions if the scores fall within a level of acceptable risk. If the score is above that individual’s authority to make the risk decisions, the next most senior person would be brought into the risk decision matrix for a determination on how to proceed. Ultimately, if the amount of risk is too great compared to the benefit, the team would not proceed until some aspect of the risk can be better managed or reduced. It is not hard for one to begin to see where the correlations between military operations and healthcare, with respect to risk, begin to appear.


Reluctance to Simplify Interpretations: (CHANGES TO THE NORM)


Change occurs, it is inevitable. Whether a surgery, a routine check-up, blood draw, or just about anything you can think of, things happen; variations to the norm occur. An organization’s ability to rapidly recognize, interpret and respond to changes in normal operations or procedures is a necessary component of high reliability. This aspect involves the entire “team” being involved and actively participating in the process. One phrase that has surfaced in the last years is, “see something, say something”. This is the most important aspect with regards to preventing the most common source of error, human error. Again, the concept and theory are sound, but the implementation can often be fraught with difficulty due to factors such as seniority, positional authority, experience, education, and qualification levels. Aviation uses a tool which empowers all members of the crew to speak up, when in their judgement, critical information needs to be considered, or one does not feel comfortable with the given situation. CRM (CREW RESOURCE MANAGEMNT) is a defined set of principles that any member of the team can use to address any other member of the team or the given situation. Many hospitals and healthcare systems use some of the common principles of CRM currently, such as, surgeons signing surgical locations, having patient confirm surgical procedures in their own words, and having nurses confirm opioid prescriptions or allergy issues with doctors and patients. Naval Medicine has committed to the concept by using TeamSTEPS, which empowers members to speak up if they believe an error is about to occur or something may be overlooked (Gillingham et al., 2016).  COORS Leadership Capital is assisting healthcare organizations through the teaching of HRM (Hospital Resource Management) which focuses on the seven principles of:

  • Situational Awareness
  • Assertiveness
  • Decision Making
  • Communication
  • Leadership
  • Adaptability/ Flexibility
  • Mission Analysis

Each of these principles will be expanded upon and will be addressed in future articles. The key take-away for this element of an HRO is the ability and willingness to not dismiss changes and look at every “outside the norm” aspect of a situation as a possible catalyst to a harmful situation. Sometimes the culmination of several “outside the norm” instances come together to create an accident or error that could have been prevented along the way if any one of the “outside the norm” instances was addressed.


Sensitivity to Operations: (NEVER SETTLE) 

High Reliability Organizations thrive due to an understanding and need for constant feedback and re-evaluation of practices and procedures. Standardization is the foundation of a rock solid HRO, however, complacency and comfortability within an organization can lead to catastrophe when not addressed or challenged. The use of procedural debriefs after, not only complex procedures, but even the most mundane procedures, can result in an incredible cache of useful data that can derive a more efficient and effective process for an organization. Often times organizations put on their best for evaluations to ensure a passing grade, however, the point of “sensitivity to operations” is to create an atmosphere and organization that is constantly striving to be perfect, where putting on your best self for an evaluation, is your everyday way of operating, not something you do only when one is being evaluated. Furthermore, this can be of limited use in the healthcare industry because individuals may feel limited in what they feel they can honestly say due to legal ramifications or concerns with what a superior may say or do. There may be limited “safe space” for an individual to speak freely about what occurred during a surgery, procedures or day to day operations without fear of appraisal. There are several ways that this can be addressed, but one of the more simpler ways is to have “anonymous” boxes throughout an organization that someone can leave a note regarding a situation that is, has, or may occur if things don’t change. This is just one of many ways to address this complex aspect where fear of appraisal may limit individuals from fully participating in debriefing.


The above only begin to scratch the surface of the Principles of Anticipation, which are three essential principles of any High Reliability Organization. Implementation of the principles require an organization that is open to change and improvement by taking a hard and difficult look into good and bad practices by the organization and its employees. In Part 4 of Healthcare HROs: Unlocked we will begin looking into the Principles of Containment, specifically Commitment to Resilience and Deference to Expertise.


Principles of High Reliability Organizations

Principles of Anticipation: Principles of Containment:
1.     Preoccupation with Failure and It’s Causes 1.     Commitment to Resilience
2.     Reluctance to Simply Interpretations

2.     Deference to Expertise

3.     Sensitivity to Operations

(Gillingham, Corbridge, Warner, Shaub, Hoffman, 2016)


  1. Karl Weick and Karen Sutcliffe, Managing the Unexpected: Assuring High Performance in an Age of Complexity (San Francisco: Jossey-Bass, 2001).
  2. RDML Bruce Gillingham, (MD), MC, USN; LT Joshua Corbridge, MSC, USN; CAPT Howard Warner III, USN; CAPT (ret) Curtis Shaub, USN; LCDR (ret) Richard Hoffman, (Ed. D), USN; High Reliability Health Care: Lessons From the Fleet (May 2016)

About the Author:

LCDR Stephen J. Hartz, MS, MBA, CBA is currently serving within the Directorate for Integrated Warfare.  He is a qualified Combat Helicopter Pilot and Surface Warfare Officer.  He has spent much of his military career learning and teaching risk mitigation and resource management at every level in the military and healthcare.  Steve’s last active duty flying assignment was as the Officer-in-Charge of the Whidbey Island Search and Rescue Unit, the Department of Defense’s number one Search and Rescue Unit in the world, conducting over 70 real world complex rescues a year, including dozens of trauma one medical rescues within the Cascade and Olympic mountain ranges, which constantly required the use of ORM and CRM practices, and was world recognized High Reliability Organization.

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