>> Organizational researchers usually define reliability as “the unusual ability to continuously produce collective results of a certain minimum quality” (Hannan/Freeman 1984, p. 153). In practice, the collective result can take different forms (Ramanujam 2018; Auschra et al. 2022): Typically it is about achieving safety - both in classic HROs such as nuclear power plants and in the health sector. Other possible goals that can be reliably achieved in this sector include quality, patient orientation or constant performance in general (possibly even with a view to economic goals).
The literature consistently assumes that a certain organizational culture and design, which is reflected in the respective practices of an HRO, promotes the achievement of high reliability. To this end, Weick and colleagues (1999) proposed five basic design principles at the end of the 1990s based on a literature review of existing individual case studies of HROs. These principles became widespread, including in practice, through the publication of the book “Managing the Unexpected: Assuring High Performance in an Age of Complexity” (Weick/Sutcliffe 2001). They are briefly explained below (see also Fig. 1).
1. Focus on mistakes: Mistakes are simultaneously seen as a starting point for greater damage and an opportunity to learn to avoid it. HROs therefore strive to deal with errors constructively in order to eliminate the causes of errors in the long term.
2. Aversion to simplification: Cognitive simplifications such as certain assumptions or worldviews can lead to simplification by ignoring information that could be used to prevent harm. HROs therefore try to make such simplifications, e.g. B. to avoid redundancies such as the four-eye principle, training and cognitively diverse teams with a trusting atmosphere of collaboration.
3. Sensitivity to operational processes: HROs strive for “situational awareness” among their members, who always keep an eye on the big picture of an action and are ready to react immediately if problems arise. This is intended to prevent small errors in operational processes from escalating into a major catastrophe. This situational awareness requires free cognitive resources and a continuous exchange of information between organizational members.
4. Striving for Resilience: HROs need the ability to anticipate unexpected events, successfully manage them as they occur, and recover quickly from them. Examples of this include improvisation and knowledge networks that can react ad hoc in unexpected situations.
5. Respect for expertise: In HROs, technical expertise is more important than hierarchical structure. Decisions in challenging situations are made quickly by the best qualified members of the organization.

According to the representatives of this approach, the continuous pursuit of the five principles in culture and routines leads to increased mindfulness of the organization. This state describes the ability to detect and manage unexpected events early, which leads to the desired reliability. Achieving reliability is therefore not a one-time result, but rather a complex, dynamic process (Weick 1987; Sutcliffe et al. 2017). Thus, high reliability theory assumes that highly complex organizations can almost always avoid the occurrence of serious errors through clever management. It thus stands in contrast to the “Normal Accident Theory” (Perrow 1984), which was developed in the same period, according to which serious events inevitably occur in such organizations over time due to complexity and close coupling (Tamuz/Harrison 2006).
The original HRO research looked at organizations that operate a complex technology (e.g. nuclear power) with enormous potential for harm to the broader public. At the same time, these organizations were run by the public sector, which may have helped meet the high resource requirements for achieving such reliability. Nevertheless, the question soon arose as to the extent to which high reliability could also be achieved in other contexts such as health care.

The publication of the US report “To Err is Human” (Kohn et al. 2000), which denounced the high number of avoidable errors in hospitals, led to a strong take-up of the high reliability theory in the medical field from the mid-2000s (Bourrier 2011) . A large number of interventions, especially in hospitals, aimed to create a culture of high reliability or to make certain processes more reliable with a view to goals such as patient safety (Tolk et al. 2015; Auschra et al. 2022).
However, it is questionable to what extent healthcare organizations are actually HROs. There was an expansion of the HRO term, which can also include highly complex, risky work environments (instead of highly complex, closely coupled technologies) (Sutcliffe et al. 2017). On the other hand, HROs are extremely resource and cost intensive. So do e.g. B. Weick and colleagues (1999) make it clear that the sensitivity to operational processes to avoid damage is at risk when organizational members suffer from overload. Effective HROs therefore continuously uncover such staff overloads and resolve them immediately. Given the constant shortage of personnel in the healthcare system, it is questionable to what extent there can be enough resources for the creation of mindfulness. The same applies to the strong hierarchical structures found in many healthcare organizations, which can also conflict with a culture of high reliability. At the same time, there are still high numbers of preventable adverse events in healthcare that speak their own language. And the early HRO researchers already noted that HROs can be found especially in industries with strong government regulation towards a safety culture and great public pressure to avoid errors - conditions that are questioned, at least with regard to German healthcare can be.
However, it should be borne in mind that certain areas of a healthcare organization achieve greater reliability
can than others. Anesthesiology, for example, is a field that has been intensively involved in building a safety culture for decades, also drawing on the experiences of other HROs - which, among other things, has led to very low anesthesia-related mortalities. In addition, each healthcare organization must be viewed individually with regard to culture and internal processes. While individual hospitals achieve a high level of reliability in certain areas, this does not automatically apply to other hospitals - it depends on the respective organizational design (Vincent et al. 2010).

High reliability theory is a process theory that seeks to explain the continuous achievement of specific organizational goals such as patient safety or quality of care. Due to the desirability of such goals in healthcare, the theory is regularly used to design concrete interventions that relate either more or less explicitly to individual processes or to a cultural change of the entire organization (e.g. Chassin/Loeb 2013). The most common goal that can be reliably achieved is - unsurprisingly - one or more aspects of patient safety.
This is particularly useful in view of the continuous development of interventions to increase reliability in other industries (e.g. crew resource management in aviation).
Health organizations and healthcare researchers have a variety of starting points for designing interventions (e.g. Pronovost et al. 2006; Tolk et al. 2015). It is striking that most studies report on interventions in the inpatient sector. However, in recent years there have also been attempts in Germany to implement interventions such as CIRS, which reflect the principle of constructively dealing with errors, in outpatient practices.

A major challenge in transforming healthcare into high-reliability organizations is the ongoing resource requirements of such an endeavor. Therefore, appropriate political framework conditions are required that, for example, ensure the provision of the necessary and qualified personnel in all areas of the organization. The reliable achievement of goals such as patient safety is not only ethically necessary, but also desirable from an economic point of view, since the prevention of treatment errors minimizes follow-up costs.
What is clear is that the state of HRO can be understood as a desired ideal. It is therefore obvious that healthcare and other organizations (e.g. from management consulting) may tend to use the HRO term as a “marketing label” (Bourrier 2011, p. 12). However, it is always important to critically question whether a particular organization has actually achieved a high level of reliability in the desired areas in a sustainable manner and whether the label and content match.
In this context, existing measurement problems become clear: If a certain area of a healthcare organization has already achieved a certain level of reliability, the occurrence of errors and undesirable events is relatively rare or even extremely rare, which supports both qualitative and quantitative research approaches to evaluating interventions presents challenges. At the same time, the comprehensive design requirements of the high-reliability approach, as well as other interventions, raise the question of whether it can be precisely recorded how a particular measure influences a desired result in interaction with other organizational changes.
And last but not least, it remains unclear to what extent the implementation of individual HRO principles (and if so, which ones), their interaction or other individual measures are most conducive to the goal of high reliability in a specific area. Nevertheless, high reliability theory – along with other theories for generating safety cultures – offers a wide range of potential for improving care processes in healthcare organizations and systems. <<

“High reliability of healthcare organizations in achieving goals such as patient safety and quality of care would be extremely desirable. However, a high-reliability organization not only requires a special culture that enables errors to be dealt with productively in order to avoid further errors. At the same time, high reliability requires resources, which can lead to tensions with staff shortages and concerns about efficiency in healthcare. In many areas, today’s healthcare organizations are therefore not high-reliability organizations, at best they are organizations striving for reliability.”
Dr. Carolin Auschra, Free University of Berlin, Department of Economics, Management Department