Hospitals and health systems are always striving to improve quality and become more reliable providers of healthcare, but some are setting even higher goals by striving to become high reliability organizations (HROs). With the HRO concept, these hospitals are aiming not to just improve and reduce errors, but to completely eliminate them.

That may sound like a recipe for failure, but hospitals are showing that it can be done as they achieve HRO status. Cincinnati Children’s Hospital in Ohio and Memorial Hermann Health System in Houston are both HROs that have eliminated many risks entirely and are on the way to zero with others.

Memorial Hermann’s mission to zero was prompted in part by two blood transfusion errors in 2006 that left one patient dead and another in critical condition. A new protocol was established that requires more thorough identification and cross-checking at each stage of the process, but reducing transfusion errors would not be enough. The goal was to eliminate them altogether, and from 2007 to today, more than 1.1 million transfusions were performed in Memorial Hermann facilities without a single transfusion adverse event. That first effort at reaching zero evolved into Memorial Hermann’s crusade to become an HRO.

Memorial Hermann was among the earliest healthcare providers to strive for HRO status, but the industry is adopting the concept more readily now, says Chief Medical Officer M. Michael Shabot, MD, FACS, FCCM, FACMI, at Memorial Hermann.

“Applying the high reliability concept had a slow start, but it is picking up some momentum,” Shabot says. “The usual hindrance is a cultural belief that accidents and errors can’t be prevented, especially in healthcare, due to the non-perfectibility of man. While it is true that man is non-perfectible, high reliability organizations don’t count on perfect employees and perfect users to achieve high reliability.”

Cincinnati Children’s Hospital has been striving for high reliability for 10 years and Stephen E. Muething, MD, vice president for safety and an attending physician, has come to realize that there is no end point for an HRO. The philosophy at Cincinnati Children’s is that the good comes from always striving for more. “High reliability is not something you achieve,” he says. “We believe the important thing is to relentlessly be on the journey to try to achieve high reliability. The more we improve, the more we feel that we have to improve.”


The HRO concept was first developed through studies of the air traffic control system, naval aircraft carriers, nuclear power operations, and other systems that must operate with zero defects where minimizing errors is just not enough. HROs have many feature in common, including risky and complex technologies that present the potential for error and complex processes. They also have highly trained personnel, ongoing training, process audits, and continuous improvement efforts. One of the main traits of an HRO is that they can’t afford to learn through trial and error; the scale of the potential harm is too great.

In HROs, senior leaders are conducting frequent walk-rounds to reinforce safety behaviors and find and fix critical safety issues, Muething notes. Senior leaders also meet in daily operational briefs where they look back to learn from failures and look forward to predict and lessen risk or harm. At Cincinnati Children’s, frontline leaders such as unit charge nurses round with staff every day, giving 5:1 positive to negative feedback, conduct daily huddles, and model the expected safety behaviors. HRO leaders also manage by anticipation and prediction rather than reaction, Muething notes. They focus on predicting events in the next 24 hours and making real-time adjustments.

Support from the highest levels of administration and the C-suite are crucial to achieving high reliability, Muething says. Transparency is a critical element in high reliability, he says, and that cannot happen without support from top leaders. “You can’t be on this high reliability journey if you aren’t willing to talk about what went wrong every single day,” he says. “If you have a culture of fear and uncertainty, you can’t do this.”

Impressive results for HROs

Shabot emphasizes that HRO is about making a cultural change in the organization, which takes time. It is about establishing the belief that measurable adverse events can be prevented for long periods of time, he says. Once that concept is accepted, the hospital can focus on developing systems to reach that goal. Three hospitals in the Memorial Hermann system have gone for more than five years without a retained foreign object, Shabot says, which he says is a testament to how an HRO achieves what previously would have been called an unrealistic goal.

“Is it because we found a whole crop of perfect surgeons and nurses? No, we have the same surgeons and nurses, but five years ago they developed new processes for what to do when a sponge count is off and the actions taken before the patient is closed,” he says. One of the process improvements was the implementation of radio frequency identification (RFID) scanning of sponges in addition to the radiopaque marker.

“The healthcare organizations that are moving toward high reliability are seeing very dramatic results,” Shabot says. Memorial Hermann worked with the Joint Commission Center for Transforming Healthcare to target hand hygiene and saw the average across all 12 hospitals in the system go from a baseline of 44% hand hygiene compliance to 92%. As a result, the rate of central line-associated bloodstream infections and ventilator-associated pneumonia decreased to essentially zero across the system, Shabot says.

Memorial Hermann also began a program called “Board to the Bedside,” intended to engage all 21,500 health system employees in high reliability. To achieve that goal, the health system centralized its quality departments, trained all employees off-site in the principles of high reliability, and emphasized the use of evidence-based protocols. It also documented performance on quality measures with data dashboards.

Striving for high reliability also has led Cincinnati Children’s to broaden its view on what constitutes patient harm, Muething says. What might previously have been regarded as a complication or just an inevitable part of the medical process can now be classified as patient harm.

“It might be slowness in making a diagnosis or managing a situation, or a complication that was considered just a risk that came with the treatment,” Muething says. “Now we look at that and say, ‘No, that is unacceptable harm.’ We keep raising our standards about what we consider preventable. Instead of debating whether a harm was preventable or not, now we’re moving toward thinking that all harm is preventable and we just don’t know how to prevent some if it yet.”

Muething notes that at Cincinnati Children’s, little distinction is made between patient safety and employee safety. Metrics for both are intertwined, so any discussion of patient safety metrics will be accompanied by similar data on employee lost work time injuries and similar measures.

Shabot notes that while safety is the primary goal of high reliability, reaching zero risks in a particular area also has the added benefit of improving the work experience for many people in the system.

“No one gets in trouble. Our physicians and nurses don’t get in trouble because a patient was harmed, and nobody goes to peer review,” he says. “We don’t have lawsuits. Everybody wins, and we’re proving that hospitals can do it. It’s not just airlines and nuclear power plants.”

Memorial Hermann recognizes hospitals with a Certified Zero Award for eliminating risks. One hospital received a Certified Zero Award for having no central line-associated bloodstream infections for 12 months, for instance, and five hospitals eliminated ventilator-associated pneumonia. Others have received the award for eliminating retained foreign objects, serious pressure ulcers, hospital-associated injuries, deaths among surgical inpatients with serious treatable complications, birth traumas, accidental punctures and lacerations, deep vein thrombosis, and many other risks. Two hospitals have now gone longer than a year without a catheter-associated urinary tract infection, “something we thought was impossible as recently as two years ago,” Shabot says.

Memorial Hermann recently assisted the Hospital Association of South Carolina with implementing the HRO concept for its member hospitals, and the association included the Certified Zero Award.

“They have now given out 188 Certified Zero Awards to hospitals in South Carolina,” Shabot says. “That is remarkable because before they did this they had no hospitals going a year without these kinds of adverse events. It’s not because they made people perfect, but because they put in processes and systems that catch errors before they ever get close to patients. That’s how well it works.”

Muething endorses a word of advice he was given years ago when first considering high reliability: Start before you’re ready.

“Because you’re never going to be ready,” he says. “It’s a journey you just have to get started on. There is so much to learn from other organizations that have taken this step, and I have been so impressed by how much people from other industries are willing to share their insights if you just ask.”