December 6, 2021

Journey to Zero Harm: Building a High Reliability Organization

Leadership Development | Team Development

Reading Time: 4 minutes

Across our industry, data continues to reflect a troubling pattern: Patients and healthcare workers are harmed in hospitals each day. According to OSHA, hospitals are one of the most hazardous places to work, nearly doubling the rate of work-related injuries and illnesses compared to private industry. The cost, both in terms of human suffering and clinical waste, is staggering. In response, hospitals across the country are exploring steps to become “high reliability organizations” — a journey to zero harm — learning from other industries that have made this journey. 

To date, the results of these well-intended efforts have been mixed. Good intentions have fallen short of material progress in many instances. In our work with healthcare leaders across the country, it has become clear that the journey to zero harm demands equal parts cultural and scientific transformation. Neglecting either dimension will impede progress as both are essential to success.

The Scientific Rigor of High Reliability Organizations

Organizations that consistently excel in safety, quality and efficiency goals employ five core principles:

Preoccupation with failure
High reliability organizations have an obsessive focus on real and potential sources of failure, constantly seeking opportunities to mitigate those risks. Teams don’t let themselves get complacent or rest on their laurels. Rather, there is a collective understanding that no news just means that system weaknesses have not yet been revealed.

Reluctance to simplify
High reliability organizations cultivate sophisticated skills and tools to understand and monitor key drivers of process performance. In doing so, these organizations accept that they live within a complex environment and take the time to understand the systems that contribute to performance.

Sensitivity to operations
High reliability organizations recognize that potential threats can be detected early and may appear as small changes to their operations. With that in mind, they employ real-time tools to continuously evaluate process performance under variable conditions to allow timely adjustments as needed to sustain reliability and avoid error. 

Commitment to resiliency
Resilience refers to an organization’s ability to recognize errors quickly, contain them and recover, preventing catastrophes. To that end, high reliability organizations build robust systems to navigate unforeseen events and anomalies while maintaining process performance under degraded conditions. Leaders continuously learn from errors and design redundant systems to prevent failure.

Deference to expertise
High reliability organizations reject hierarchical approaches to wielding power and influence (e.g., title, credentials, years of experience, etc.) in favor of deferring to those closest to the process with the deepest expertise. They democratize the pursuit of zero harm in order to assure the drive for improvement is guided solely by the best information.  

The Cultural Pillars of High Reliability

While the scientific and technical principles underlying High Reliability Organizations are essential, those principles are not enough if a strong cultural foundation for the drive to zero harm has not been established. The following practices are central to a high reliability culture:

A passionate belief that zero harm is possible
This belief is modeled by senior leaders and exemplified in words, symbols, allocation of time and resources. Rather than seeing the world with rose-colored glasses, leaders adopt a posture of realistic optimism: the ability to confront barriers to zero harm with an unwavering belief that those barriers can be overcome.

Strong clinician leadership
Zero harm and high reliability lie at the intersection of the clinicians’ clinical judgement and the organizational processes and systems which support their practice. Given that, any movement to pursue high reliability cannot be imposed on clinicians but must be undertaken in partnership with them. The key is to engage trusted, credible physician leaders who embody high reliability characteristics in their practice and have a demonstrated commitment to continuous improvement. As partners in leading the movement, their influence is key in overcoming the predictable resistance of their peers.

Commitment to a culture of improvement — not compliance, shaming or blaming.
In this environment, data is used to provoke inquiry and exploration of root causes, not assign blame. Leaders embrace an improvement mindset and processes to better understand and navigate complexity. There’s a presumptive belief that all share a commitment to the goal of zero harm.

An environment of psychological safety
Psychologically safe teams operate with the presumption that failure resides in the process, not in human error or carelessness. To make that possible, high reliability organizations strive to build foundational trust among team members and develop the skills to manage differences in ideas vigorously, thoughtfully, and safely. There’s skillful facilitating of the team process, cultivating the rigorous exploration of differences without threatening another’s status or competency. The flow of information is candid and transparent, without hesitation or fear of provoking defensiveness. All are committed to building stronger systems that are designed for people.

A commitment to mutual respect and collaboration
Teams and leaders practice deep listening to understand, explore and reconcile the requirements of essential, interdependent functions. They also defer to expertise over title, credential, or experience. Creativity is encouraged to uncover solutions beyond conventional thinking, translating into concrete benefits to staff and patients.

Putting It All Together

The transformation needed to achieve zero harm can only be done by those who understand and have the means to identify and address the conditions which lead to harm. It is not enough to approach challenges from an objective, scientific perspective. Change of this nature predictably provokes resistance as stakeholders fear that change will erode their autonomy or fail to address their legitimate needs.

Resistance is a normal, predictable, and manageable part of any disruptive change. Careful consideration to combine the cultural transformation with implementation of the capabilities associated with the science of process improvement will increase the probability of success and accelerate progress toward zero harm.   

Anne Marie Benedicto is Vice President of the Joint Commission Center for Transforming Healthcare. She is an expert in Robust Process Improvement® and high reliability methods applied to health care clinical and business processes.


Robert (Bob) Porter has extensive experience in working with senior executives in complex organizational settings, with a track record for engaging diverse stakeholders in the redesign of systems and processes to achieve breakthrough improvements in performance.



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About the author

Robert "Bob" Porter, JD, MBA, PCC

Robert "Bob" Porter, JD, MBA, PCC is an accomplished organizational leader with over 30 years’ experience in health system leadership. Bob has extensive experience in working with senior leadership executives in complex organizational settings, with a proven track record for engaging diverse stakeholders in the redesign of organizational systems and processes to achieve breakthrough improvement in performance.

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