High-Reliability Principles Must Be Tied to Value-Based Outcomes

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WellStar Health System and the Medical University of South Carolina (MUSC), highlighted in this issue’s feature articles, are two organizations seeking to drive high reliability by educating leaders and incorporating high-reliability principles into their quality improvement (QI) efforts. The organizations have taken slightly different approaches to executing on high reliability, yet both are encouraged by the apparent success of high-reliability principles in other industries.


The high-reliability framework is often applied to healthcare despite the limitations of comparing healthcare organizations to nuclear reactors, commercial airlines, and aircraft carriers. Notably, these industries were classified as “highly reliable” after the fact, meaning their employees and leadership already had existing routines and qualities that researchers would describe, after direct observation, as a shared distinguishing feature. Thus, in contrast to Lean, Six Sigma, and other QI movements that have been applied in healthcare, industries such as nuclear power and aviation came with tools and quantitative processes already embedded. The high-reliability framework is qualitative, while the actual hard, quantitative tools and processes differ by industry. This fact makes adopting high-reliability principles difficult because the tools must be created and scaled for each industry. Healthcare is still in the early stages of building these tools to support the high-reliability framework, and the articles by Saunders and Brennan (at WellStar) and Cawley and Scheurer (at MUSC) describe early attempts to provide insights into launching high-reliability principles and tools in healthcare.


High reliability is a theoretical construct that is difficult to implement without a concrete framework for execution. The five characteristics that frame a high-reliability organization (HRO), as outlined by Cawley and Scheurer (citing Weick and Sutcliffe 2001), are (1) preoccupation with failure, (2) reluctance to simplify interpretations, (3) sensitivity to operations, (4) commitment to resilience, and (5) deference to expertise. Although these elements point in the right direction, they remain theoretical if not tethered to an organization’s operating cycle.

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