High reliability organization


A high reliability organization is an organization that has succeeded in avoiding catastrophes in an environment where normal accidents can be expected due to risk factors and complexity.
Important case studies in HRO research include both studies of disasters and HROs like the air traffic control system, naval aircraft carriers, and nuclear power operations.

History

HRO theory flowed out of Normal Accident Theory, which led a group of researchers at the University of California, Berkeley to study how organizations working with complex and hazardous systems operated error free. They researched three organizations: United States nuclear aircraft carriers, the Federal Aviation Administration's Air Traffic Control system, and nuclear power operations.
The result of this initial work was the defining characteristics of HROs hold in common:
  1. Hypercomplexity – extreme variety of components, systems, and levels.
  2. Tight coupling – reciprocal interdependence across many units and levels.
  3. Extreme hierarchical differentiation – multiple levels, each with its own elaborate control and regulating mechanisms.
  4. Large numbers of decision makers in complex communication networks – characterized by redundancy in control and information systems.
  5. Degree of accountability that does not exist in most organizations – substandard performance or deviations from standard procedures meet with severe adverse consequences.
  6. High frequency of immediate feedback about decisions.
  7. Compressed time factors – cycles of major activities are measured in seconds.
  8. More than one critical outcome that must happen simultaneously – simultaneity signifies both the complexity of operations as well as the inability to withdraw or modify operations decisions.
It is important to note that many organizations display some of these characteristics, but HROs display them all simultaneously.
Normal Accident and HRO theorists agreed that interactive complexity and tight coupling can, theoretically, lead to a system accident. However, they hold different opinions on whether those system accidents are inevitable or are manageable. Serious accidents in high risk, hazardous operations can be prevented through a combination of organizational design, culture, management, and human choice. Theorists of both schools place a lot of emphasis on human interaction with the system as either cause or prevention of a systems accident. High reliability organization theory and HROs are often contrasted against Charles Perrow's Normal Accident Theory . NAT represents Perrow's attempt to translate his understanding of the disaster at Three Mile Island nuclear facility into a more general formulation of accidents and disasters. Perrow's 1984 book also included chapters on petrochemical plants, aviation accidents, naval accidents, "earth-based system" accidents, and "exotic" accidents. At Three Mile Island the technology was tightly coupled due to time-dependent processes, invariant sequences, and limited slack. The events that spread through this technology were invisible concatenations that were impossible to anticipate and cascaded in an interactively complex manner. Perrow hypothesized that regardless of the effectiveness of management and operations, accidents in systems that are characterized by tight coupling and interactive complexity will be normal or inevitable as they often cannot be foreseen or prevented. This pessimistic view, described by some theorists as unashamedly technologically deterministic, contrasts with the more optimistic view of HRO proponents, who argued that high-risk, high-hazard organizations can function safely despite the hazards of complex systems. Despite their differences, NAT and high reliability organization theory share a focus on the social and organizational underpinnings of system safety and accident causation/prevention.As research continued, a body of knowledge emerged based on the studying a variety of organizations. For example, fire incident command system, Loma Linda Hospital's Pediatric Intensive Care Unit, and the California Independent System Operator were all studied as examples of HROs.
Although they may seem diverse, these organizations have a number of similarities. First, they operate in unforgiving social and political environments. Second, their technologies are risky and present the potential for error. Third, the severity and scale of possible consequences from errors or mistakes precludes learning through experimentation. Finally, these organizations all use complex processes to manage complex technologies and complex work to avoid failure. HROs share many properties with other high-performing organizations including highly trained-personnel, continuous training, effective reward systems, frequent process audits and continuous improvement efforts. Yet other properties such as an organization-wide sense of vulnerability, a widely distributed sense of responsibility and accountability for reliability, widespread concern about misperception, misconception and misunderstanding that is generalized across a wide set of tasks, operations, and assumptions, pessimism about possible failures, redundancy and a variety of checks and counter checks as a precaution against potential mistakes are more distinctive.
Defining high reliability and specifying what constitutes a high reliability organization has presented some challenges. Roberts initially proposed that high reliability organizations are a subset of hazardous organizations that have enjoyed a record of high safety over long periods of time. Specifically she argued that: “One can identify this subset by answering the question, “how many times could this organization have failed resulting in catastrophic consequences that it did not?” If the answer is on the order of tens of thousands of times the organization is “high reliability””. More recent definitions have built on this starting point but emphasized the dynamic nature of producing reliability. Some researchers view HROs as reliability-seeking rather than reliability-achieving. Reliability-seeking organizations are not distinguished by their absolute errors or accident rate, but rather by their “effective management of innately risky technologies through organizational control of both hazard and probability”. Consequently, the phrase "high reliability" has come to mean that high risk and high effectiveness can co-exist, for organizations that must perform well under very trying conditions, and that it takes intensive effort to do so.
While the early research focused on high risk industries, many others expressed interest in high reliability organizations and sought to emulate their success. A key turning point was Karl Weick, Kathleen M. Sutcliffe, and David Obstfeld's reconceptualization of the literature on high reliability. These researchers systematically reviewed the case study literature on HROs and illustrated how the infrastructure of high reliability was grounded in processes of collective mindfulness which are indicated by a preoccupation with failure, reluctance to simplify interpretations, sensitivity to operations, commitment to resilience, and deference to expertise. In other words, HROs are distinctive because of their efforts to organize in ways that increase the quality of attention across the organization, thereby enhancing people's alertness and awareness to details so that they can detect subtle ways in which contexts vary and call for contingent responding. This construct was elaborated and refined as mindful organizing in Weick and Sutcliffe’s 2001 and 2007 editions of their book Managing the Unexpected. Mindful organizing forms a basis for individuals to interact continuously as they develop, refine and update a shared understanding of the situation they face and their capabilities to act on that understanding. Mindful organizing proactively triggers actions that forestall and contain errors and crises and requires leaders and their employees to pay close attention to shaping the social and relational infrastructure of the organization. They establish a set of interrelated organizing processes and practices, which jointly contribute to the system’s overall culture of safety.

Characteristics

Researchers have found that successful organizations in high-risk industries continually reinvent themselves. For example, when an incident command team realizes what they thought was a garage fire has now changed into a hazardous material incident, they completely restructure their response organization.
There are five characteristics of HROs that have been identified as responsible for the "mindfulness" that keeps them working well when facing unexpected situations.
Although the original research and early application of HRO theory into practice occurred in high risk industries, research today covers a wide variety of applications and settings. Health care has been the largest practitioner area for the past several years. The applications of Crew Resource Management is another area of focus for leaders in HROs requiring competent behavior systems measurement and intervention. Wildfires create complex and very dynamic mega-crisis situations across the globe every year. U.S. wildland firefighters, often organized using the Incident Command System into flexible inter-agency incident management teams, are not only called upon to "bring order to chaos" in today's huge mega-fires, they also are requested on "all-hazard events" like hurricanes, floods and earthquakes. The U.S. Wildland Fire Lessons Learned Center has been providing education and training to the wildland fire community on high reliability since 2002. HRO behaviors can be recognized and further developed into high-functioning skills of anticipation and resilience. Learning organizations that strive for high performance in things they can plan for, can become HROs that are able to better manage unexpected events that by definition cannot be planned for.