Hospital as a High Reliability Organization (HRO), a possible solution to tame the wicked problem of Preventable Errors
[Position Paper]
Jason Uppal.P.Eng. 
Oct 2019



If the High-Reliability Organization (HRO) is a candidate solution to tame the wicked problem of preventable errors, then questions remain. First,   how will we know when we have achieved the HRO milestone?  Secondly,   how can we create necessary capabilities to help build HRO across different care delivery systems where healthcare is a managed for Public Good and not for profit.  

The goal of this Discussion Paper is to advocate candidate measures, methodology to collect the necessary data, not require additional  resources to deliver  care and compute the measures in real-time. This working paper showcases work done by our team and highlights both obstacles and lessons learned to date.  As part of our scope, It is our expectation that  the proposed measures should   enable the organization to develop and hardwire the capabilities  to help create HRO in repeatable manner.   



“Never Events” or Preventable Errors are the kind of serious harm mistakes that should never happen in the field of medical treatment [1]. The idea of Never Events do not imply blame; “Never” is a call-to-action, not a demand or an attempt to shame mistakes [2]. The financial cost of Never Events varies, however there is broad consensus that it is  around 20 billion US dollars per year in Canada and in the US combined. Additionally the cost of  unnecessary human suffering inflicted by never events is incalculable [2,3]. In general, there is no evidence to conclude that cost both financial and human outside of North America is less.


Studies have suggested that a Hospital as High-Reliability Organization (HRO) could be a step in the right direction [4]. This study specifically identified characteristic of a HRO, but fell short, without offering specific performance measures that could be used to guide the HRO effort at the health system level.   


The goal of this discussion paper is:

  1. propose a set of performance measures for a HRO Dashboard  

  2. advocate a method  to compute these measures  using data collected as part of effective  and efficient care delivery;

  3. and  demonstrate how to use these measures in a clinical setting to help tame the wicked problem of preventable errors.  

  4. Finally, define the architecture of necessary capabilities to implement them repeatedly across different systems


Scope: In patient care within a Hospital.




HRO Performance Measures  

By adopting Systems Engineering approach to performance measures, we advocate two sets of measures - Capability Measures and Outcome Measures.


Capability Measures: Process Repeatability and Resilience : Measures that describe the relative (relative to itself, not a benchmark agent other Units, Services or  Hospital Systems) Maturity of Processes that are used to deliver care. These processes are grouped into three  broad categories;

  1. “Frontline Care Delivery” – Processes to deliver care at the bedside with care context aware best practices

  2. “Cross Functional Care Team” – Processes  to coordinate care  across the hospital service lines and patient care units  

  3. “Engaged Provider” - Processes  that create and enhance staff engagement  with the Organization  and each other.


Outcome Measures: Quality of Care  : Objectively measure   Quality of Care  that is determined by “Real vs Complex” Work [5].  The premise of this measure is different from  IHI Triple Aim [6].       

Assertion: Healthcare is delivered by regulated and certified professionals, hence the HRO Measures described here within imply that Quality of Care CANNOT  be assessed by an outside 3rd party and/or Patient. The professional care providers are the best evaluators of the quality of care [7].


Principles:  The following principles guide the development and implementation of the proposed  HRO measures: 

  1. DO use these measures to guide the HRO effort

  2. DO NOT  use the HRO measures  to externally or internally  benchmark  your organization or facility  against other services, units, hospitals and systems.  

  3. DO NOT use these measures to penalize staff. Correct use of these measures is to coach staff to build a learning organization.

  4. The HRO measures MUST   be computable with data that is generated through  natural flow of patient care delivery.  

  5. HRO processes must not increase cost of care at the bed side.


HRO Measures Computation

This section provides a detail discussion on how to compute the  HRO measures within  a care delivery system.


Capability Measures

  1. Frontline Care Delivery :  Staff knowledge of best practices, ability to deliver care according  to best practices, and   quality of care delivered to patients who are most susceptible to harmful conditions. Care processes include but are not limited to VAP, CAUTI, Pressure Ulcer, CLABSI, etc.  For each care process  computation shows:

  • % of staff with 100% knowledge of best practices and/or guidelines

  • % of staff with expertise and competence to deliver care 100% of the time according to the best practices. Assessed by real-time peer to peer observations.

  • % of the patients who received care 100% of the time according to the agreed upon  best practices and guidelines.


  1. Cross Functional Care Team: Select processes that are executed across the organization, away from the bedside, such as  interprofessional communication, handoff, transfer of care, clinical documentation etc.

  • %  of total inter-professional communications addressed within the agreed upon service level (time and quality)

  • % of handoff information elements managed within agreed upon concurrency

  • % of information elements that meet the required information quality (statistical) 


  1. Engaged Provider -  Method to  assess degree of provider engagement and Care Context Awareness .    

  • Values alignment between the Organization and the Individual Care Providers  

  • # of new knowledge events published in adoption ready format and adopted from other organizations

  • Engagement points acquired through activities that demonstrate care context awareness  


Outcome Measures

Quality of Care (QoC):  Method to objectively measure Quality of Care  is determined by “Real vs Complex” work.  Healthcare is  delivered by professionals who have received years of rigours education,  training and government regulated professional certifications. The need for formal professional certification of medical staff arose from the fact that average customer, i.e. patient, is unable to assess the quality of care [6].  Therefore, in this paper we advocate the following definition of “Quality of Care” to assess the NET NEW VALUE of HRO capability.    

  • Quality of Care : = Real Tasks/Total Care Plan Tasks

  • Total Care Plan Tasks : All tasks on a patients care plan  

  • Complex Task: Tasks that are  performed because lack of timely and accurate information as well as any other  task not being completed on time or completed with imperfect information, resulting additional work.

  • Real Task =  Total Tasks – Complex Tasks : real  value add tasks  ad determined by guidelines and care context


QoC Tasks Computation Options

  • Option 1: count number of tasks – considering all tasks have same influence  on quality of care  and required resources

  • Option 2: total resources required to execute each  task that includes labour cost, opportunity cost, cost of materials, medications  etc. (total cost of quality as defined by American Society of Quality Control )


In this discussion paper, we advocate the Quality of Care  is not what patient thinks is the quality, rather what a certified professional care provider thinks is the quality. If 100% care tasks on the care plan were type Real, it is reasonable to conclude that professional care providers did all the tasks that were advocated  by the guidelines as well provider improvised tasks due to  their training and awareness of care context. 


Our Experience


 Our team  has been working with number of hospitals in Canada and the United States. We currently have the ability to compute these measures based on data collected through the natural care delivery process, engage frontline care staff and leverage the expertise of resident physicians, nurses, and ancillary professionals to audit the care plan for complex work. The performance is reported via real –time dashboard available to all staff.

Results to date  - voluntary adoption  of underlying systems by nearly 1300 care providers who access the system 3 to 5 times per shift.  



There is considerable  amount of consensus among care providers that HRO could be a possible candidate  solution to tame the wicked problem of preventable errors during hospital care.  The challenge still  remains how can we measure the state of HRO,  its impact on reduction of “never events” as well support the professional care providers . After six years of  work effort, we believe  we are on the right track. Now is the time to engage other care delivery organizations to replicate and help advance  the knowledge to build and sustain HRO.


Call to Action  

We invite  thought leaders and care providers from other organizations to share their experience in building a High-Reliability Organization culture   and specifically requesting  input on the following:  

  1. What other measures could be valuable  to assess the HRO milestone and resulting outcomes?

  2. What organization challenges do you envision in embarking on HRO journey?

  3. Jason Uppal is a practicing engineer and can be reached at

Print Version 


1 Never Events – NHS England,

2: Never Events for Hospital Care in Canada Safer Care for Patients September 2015,

3: Never Events, PSNet AHRQ

4: High-Reliability Health Care: Getting There from Here

5: Melan Eugene, H, Process Management Methods for Improving Product and Services, McGraw-Hill Inc.  

6: IHI Triple Aim,

7: Profession vs Discipline a HBR Discussion ,

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