High Reliability Organizations

High Reliability Organizations

One area of focus for the Center for Health and Nursing Research is the study of High Reliability Organizations in healthcare. High Reliability Organizations (HROs) are being studied and applied in increasing numbers in healthcare, and HRO theory has been incorporated into regulatory and accreditation protocols. So, what are HROs, and why should we study them?

The study of High Reliability Organizations, while relatively new to healthcare, has been ongoing in a number of other industries for the last few decades. Carolyn Libuser completed dissertation work on the banking industry. This research was picked up by Karlene Roberts from University of Berkeley, who delineated specific identifiers of HROs (Sutcliffe, 2011). Additional support came from University of Michigan, the Naval Postgraduate School, and a number of other schools (Padgett, 2014; van Stralen, 2008). What the researchers were trying to understand was why high-risk organizations had fewer than expected accidents (Sutcliffe, 2011). As study continued, Roberts when on to define High Reliability Organizations as an organization that conducts operations with minimal error, over an extended time, and consistently makes good decisions that result in both high quality and high reliability (1990). Additional researchers contributed a description of what these operations entail. High Reliability Organization principles include: 

  • Developing and maintaining standard processes
  • Implementing checks and redundancy to mitigate potential failure
  • Authority migration
  • Developing teams that openly communicate about failure to prevent recurrance of unsafe incidents (Hartmann, Meterko, Zhao, Palmer, & Berlowitz, 2013).

Early studies of organizations meeting both Roberts' definition, and the outlined principles above included the U.S. military, wildland firefighting, public safety, commercial aviation, and nuclear power. It has been gaining momentum in healthcare as well (Chassin & Loeb, 2013). This is where the CHNR comes in.

There are a number of research opportunities available within the bounds of High Reliability Organization Theory. Because early researchers identified that there is much to be learned from other industries, HRO theory developed as an interdisciplinary field of study. There are opportunities to dig into the research in other fields and determine the lessons healthcare and nursing organizations may apply in practice. There are other opportunities for sharing lessons learned in healthcare with other industries. The integration of multiple fields of study will be valuable in future HRO research.

In addition to theoretical contributions to HRO theory is the opportunity to improve safety within healthcare organizations. Case studies on organizational change can be benefitial as more healthcare organizations seek to move toward high reliability.  One organization documented the prevention of 1,500 deaths related to preventable error (Pryor, Hendrich, Henkel, Beckmann, & Tersigni, 2011). Another documented the rapid growth of a pediatric ICU (van Stralen, 2008). A third studied how the nurses and respiratory care practitioners at a pediatric subacute facility experienced and contributed to the organizational shift toward high reliability (Padgett, Gossett, Mayer, Chien, & Turner, 2017). Additional research is needed to help other organizations contribute to improved patient care.

These are just a few ways CHNR fellows and affiliates may contribute to the continuing study of High Reliability Organizations. What other ways might be useful? Feel free to utilize the CHNR forums for HRO discussions, to reach out for collaboration, or to run your ideas by like-minded researchers. Stay tuned to this blog as well for additional ideas from the field.


Chassin, M. R., & Loeb, J. M. (2013). High-reliability health care: Getting there from here. Milbank Quarterly, 91, 459–490. doi:10.1111/1468-0009.12023

Hartmann, C. W., Meterko, M., Zhao, S., Palmer, J. A., & Berlowitz, D. (2013). Validation of a novel safety climate instrument in VHA nursing homes. Medical Care Research and Review, 70, 400-417. doi:10.1177/1077558712474349

Padgett, J. D. (2014). Patient safety culture and high reliability organizations. Retrieved from ProQuest Dissertations & Theses Global (1557705479)

Padgett, J., Gossett, K., Mayer, R., Chien, W., & Turner, F. (2017). Improving Patient Safety through High Reliability Organizations. The Qualitative Report 22(2), 410-425. Retrieved from https://nsuworks.nova.edu/tqr/vol22/iss2/4

Pryor, D., Hendrich, A., Henkel, R., Beckmann, J., & Tersigni, A. (2011). The quality “journey” at ascension health: How we’ve prevented at least 1,500 avoidable deaths a year-and aim to do even better. Health Affairs, 30, 604. doi:10.1377/hlthaff.2010.1276

Roberts, K. H. (1990). Some characteristics of one type of high reliability organization. Organization Science, 1, 160–176. doi:10.1287/orsc.1.2.160

Sutcliffe, K. M. (2011). High reliability organizations (HROs). Best Practice & Research Clinical Anaesthesiology, 25, 133–144. doi:10.1016/j.bpa.2011.03.001

van Stralen, D. (2008). High-reliability organizations: Changing the culture of care in two medical units. Design Issues, 24(1), 78–90. doi:10.1162/desi.2008.24.1.78

About the Author

Jared D. Padgett



Journal of Leadership Studies-Symposium Piece-Relational Leadership: Perspectives of Key Constructs on Diversity, Inclusion, and Social Equity in Higher Education

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