Design of high reliability organizations in health care

Following the IOM reports, ^{1, 2} healthcare organizations have sought ways to improve their safety performance. Many seek to emulate high reliability organizations (HROs) from industries such as nuclear power and air traffic control that are considered to operate in hazardous settings with reliability and safety. ^{3, 4} The purpose of this paper is to examine the design of HROs and to ask how healthcare organizations can design safer and more effective operations.

CHALLENGES OF SAFETY AND RELIABILITY

Organizations such as hospitals, nuclear power plants, and air traffic control agencies seek to ensure high levels of safety for customers, employees, and the public. Safety is one of many organizational goals that can be pursued with high reliability. In contrast to other goals such as low clinic waiting times, fast and accurate laboratory results, or shareholder return on investment, safety is a particularly challenging goal for several reasons:

Organizations have primary service and production goals that compete or may be perceived as competing with safety. ^{5- 8}

Primary service and production activities usually have immediate bottom line effects measured with quantitative precision whereas safety is a "dynamic non-event" ⁹ produced by people making continual and often invisible small adjustments that may be difficult to define and measure.

As safety increases, the decreasing frequency of problems may lead to complacency and diversion of safety focus and resources. ^{4, 7, 10}

The combined challenges of managing frequent but routine interruptions of daily work along with occasional novel problems requires skills and techniques that may conflict with each other. ¹¹

The champions of safety are often external organizations (regulators, citizens' groups, media, public) or unfamiliar safety specialists who may be seen as interfering with the legitimate service and production work of the organization. ¹²

ORGANIZATIONAL DESIGN

Organizational design typically refers to the decomposition of the organization into subparts and the processes that integrate the subparts to support the strategy and achieve organizational goals. ¹³ The formal organizational design includes separating what the organization will do itself rather than buy from others, dividing sub-tasks and assigning roles, choosing or developing technology, and establishing and enforcing policies and procedures. A hospital, for example, may be public or private, be part of a larger healthcare system, include an emergency department, build...