What high-reliability organizations get right

As Industry 4.0 continues to advance with breathtaking speed, unleashing new capabilities at equally breathtaking speed, it’s all too easy for business leaders to succumb to relying solely on technology to drive operational improvement. Automation, advanced analytics, digital performance management, cloud computing, machine learning—all offer powerful and game-changing ways for organizations to achieve new heights in operational performance.

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But the costs and effort these technologies and platforms entail can often exceed their payoff. The expectations surrounding them, it turns out, are often inflated. Take, for example, advanced analytics-driven predictive maintenance. As a means of boosting reliability, it is not the panacea many think it is. Without engineers who are trained in data analysis and in developing solutions based on those analytics, companies cannot possibly expect to realize the full potential of the technologies . Often, there are simpler, more cost-effective ways to accomplish the same goal.

Moreover, technology alone does not make for excellence in reliability. In industries that live by the laws of science, leaders often underestimate the role of management processes and skills in reliability-engineering success.

Research we conducted in a cross-section of predominantly heavy-asset industries reveals what distinguishes high-reliability organizations (HROs) from the rest. These companies focus as much on the enablers—the rigorous processes, role clarity, and accountability systems—as they do on the Industry 4.0 technologies.

Yet as essential as these enablers are, they’re still not enough. HROs also focus on talent: they put a premium on certain skills that other companies don’t, and they invest more in professional development. Finally, HROs structure their organizations according to how centralized the function and its accountability are. To be sure, advanced technologies can deliver dramatic improvements, but ultimately, it’s the human element that spells success.

The three core business practices that drive reliability

We selected eight best-in-class reliability organizations from a cross-section of industries, based on internal reliability metrics (such as percentage of downtime and overall reliability) and external performance benchmarks and industry awards for operational excellence. We then interviewed in depth a dozen current and former leaders of these organizations to identify the organizations’ key characteristics and practices.

As varied as our study sample was—it spanned the mining, energy, power generation and distribution, pharmaceuticals, airline, and military sectors—all the organizations adhere to three fundamental business practices (Exhibit 1).

HROs implement robust reliability processes.

All eight organizations follow strong reliability processes across their operations, from the ground level up. In this respect, they stand out from the average reliability organization, whose processes are either lacking specifics or inconsistently followed.

For example, HROs clearly define the assets critical to their operations, ensuring that the list is not merely well-understood but also considered in decision making. They are skillful in disseminating the definitions and standards throughout their companies. They create equipment-reliability strategies and execute them by strictly following preventative-maintenance schedules, closely monitoring equipment health, and identifying issues and proactively or promptly resolving them.

HROs also engage in root-cause problem solving to determine underlying issues and implement holistic, practical solutions. Their reliability engineers draw on a variety of data sources, tools, capabilities and subject-matter expertise.

Another common practice among HROs is that they all have robust systems in place for managing, preserving, disseminating, and updating their reliability knowledge base—including both reliability analysis and reliability design standards. For instance, these companies effectively share learnings from every reliability event, and update their equipment-design standards and work processes accordingly to ensure the event is not repeated. Finally, HROs hold other functions accountable to execute the reliability processes they’ve put in place.

One manager from an energy company noted that his organization eschews advanced reliability techniques or “fancy predictive maintenance models,” relying instead on traditional root-cause problem solving and defect-elimination approaches to get results. Another interviewee, a former submarine officer, put it plainly: the reason there’s rarely a failure of critical equipment “is twofold: the design is robust, and things just get done when they need to get done. Period.” HROs employ systematic methods to carry out root-cause problem solving on the front lines.

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They define roles clearly and institutionalize knowledge..

Roles and responsibilities are clearly defined and well understood by operational leaders as well as all those with whom they work: the plant managers, maintenance leaders, operators, technicians, supply-chain managers, and so forth. Each member of the organization has a clear understanding of the role they play in driving reliability, so the guidelines for dealing with and engaging personnel are thus unambiguous. A leading pharmaceutical company in our research, for example, rotates personnel— including reliability engineers—to give them a firsthand understanding of the critical roles in the organization and how they interact.

They set accountability at the executive level and delegate it down.

HROs believe accountability resides at the top. To ensure that, they set executive compensation according to reliability-specific metrics and outcomes. These organizations establish clear corporate reliability standards and communicate them well: for example, they’re included in capability models and reliability metrics, which are tracked publicly on scoreboards. In addition, HROs discuss outcomes at all levels of the organization, from the frontline control room to the boardroom. At a major power generation company, executive sponsorship is considered a key success factor. “Senior executives really bought into frontline support for reliability and communicated its importance for our business clearly and frequently.”

HROs put people first

HROs recognize that it takes more than technical expertise to make a great reliability engineer. Our research revealed that to attract and retain the best and the brightest, HROs follow three specific talent-management practices: they pay higher salaries, emphasize communication and coordination skills relevant to the reliability engineer’s role as cross-functional problem solver, and provide well-defined career options and paths.

HROs offer higher pay than their peers.

We analyzed two years’ worth of job postings from the companies in our sample, comparing their pay levels with those of their competitors. Salaries at the HROs—average, as well as the low and high end of pay scales—were 15 percent higher than those of their peers (Exhibit 2). HROs also reward high performance; several we interviewed have developed specific key performance indicators (KPIs) for performance-based compensation and bonuses.

The fact that HROs pay better is hardly surprising: in any industry, offering a higher salary is an obvious way to attract top talent. But it is by no means the only way. Nor does it guarantee talent retention or reliability success.

HROs prize communication and problem-solving skills.

They appreciate that technical expertise alone is not enough for a first-rate reliability engineer. Knowing how to solve problems and how to communicate— up, down, and across the organization, in ways that earn trust and support—are critical skills. In fact, HROs rank communication among the three most critical skills in job candidates, followed by problem solving—a skill most companies omitted from their top eight (Exhibit 3).

HROs recognize the importance of being able to communicate equally well with the frontline and management; their engineers are adept at translating technical issues into laymen’s terms that their non-technically trained peers can understand. Effective problem solvers are solid conceptual thinkers who can understand a problem or condition by identifying patterns and connections that reveal which underlying issues to address. They’re also leaders: HROs give more weight to leadership skills than the more than 70 other organizations in our comparison set. Creativity and rigor in problem solving are always valuable, particularly at a time when organizational complexity is growing and the costs of failure (financial, social, and environmental) are ever-increasing. Each day that a plant is sidelined can translate into millions of dollars lost; a malfunction that releases toxins in the environment can cause untold damage and even loss of life. Similarly, today’s higher-stakes operating environment heightens the importance of communication skills: specifically, the ability to engage different teams in constructive dialogue, raise concerns and potential issues proactively, and foster consensus on the appropriate action to take.

HROs create attractive paths for career advancement.

Reliability engineers typically follow one of three main career tracks, each with different rates of retention (Exhibit 4).

  • Field-based engineer to operations manager: Entry-level personnel with technical degrees make up this track. While each organization is different, we see common patterns. Generally, there is little opportunity for advancement in the initial years. Near the five-year mark, field engineers have two options if they want to stay with the company: they can either become a supervisor, or switch career tracks. There is no ultimate role in reliability engineering for reliability-focused personnel. Not surprisingly, this track experiences the lowest retention levels: fewer than one in four remain in it to become field operations leaders.
  • Junior to senior field-based subject-matter expert (SME): These individuals typically have five years of industry experience or an advanced degree (or both), and usually spend the first few years as a functional area expert. At that point, their choices are either to become a senior SME, change tracks—or leave the company. Engineers in this track have greater longevity than the first track; 50 percent remain in the track, most likely because companies effectively prescreen for this role, and senior onsite SME is considered an ultimate role.
  • Site-based engineer to corporate SME: From the get-go, these engineers (either entry-level or experienced technical personnel) know that corporate-level opportunities await them at a specific career milestone. They will be able to choose among different tracks, including corporate-level functional expert. Not surprisingly, employees on this track have the highest retention levels, as they have more opportunity to progress to higher-level roles and influence decision making across multiple sites. However, companies must manage expectations and performance effectively to ensure that the corporate SME stays connected with site operations and continues to deliver value across the network.

HROs demonstrate that they value quality talent by investing accordingly in their reliability bench. They establish well-defined career tracks to give their engineers ample opportunities for professional and personal development. The HROs we studied employ a variety of talent-management and -retention practices. All strive to offer numerous career-path options, even within the technical or managerial ranks.

Moreover, HROs are committed to training their people on an ongoing basis, whether through internal classroom sessions for professional certification, paid time off to attend industry-sponsored events, on-the-job training, or informal mentoring.

At a major energy company, field-based reliability employees are “truly engineers, closely linked to the equipment,” as a former manager noted. The company considers them high-potential employees and “gives them the option to pursue other technical, commercial, or managerial roles.”

The former head of reliability at another major energy company commented on the multiple career options of field reliability engineers, including moving into operations or risk management. “More importantly,” the leader added, “their career is well-managed from the start, with performance reviews every six months. We tend to keep our good engineers.”

The digital difference in measuring production performance

The digital difference in measuring production performance

Hros recognize that form follows function.

For all their similarities, HROs vary widely in structure, according to the specific characteristics and challenges of their industry, their overall organization structure and culture, and the nature of their products. Essentially, there are four basic archetypes that vary along two dimensions: the strength of the central reliability function, and how centralized accountability is: that is, who tracks asset reliability and who is ultimately responsible for outcomes (Exhibit 5).

A center of excellence.

With this archetype, the corporate center establishes rigorous reliability protocols, but each local site is responsible for demonstrating its adherence to processes and procedure. This archetype works well for organizations whose assets are uniform and where there is little variability or change in the production process.

At a major airline, each fleet has a dedicated team of reliability engineers who work remotely to monitor equipment and oversee basic maintenance (when heavy maintenance is needed, they travel to sites). The center’s reliability analysts study big data and their analysis informs decisions about preventive maintenance. Reliability engineers engage subject-matter experts from the central corporate-reliability function (along with other technical resources) to help make recommendations. The senior manager of the company’s large maintenance organization reports directly to the COO.


In this model, a central team designs, implements, and enforces the reliability programs and standards throughout locations. This approach works well for industries or companies that are very process-oriented and where there are distinct differences between production or operating facilities. In such companies, strong oversight is needed; there is a high risk of catastrophic failure, and repeat failures are unacceptable. A top-down approach ensures all facilities and businesses comply with corporate reliability standards.

At a third energy company, a functional group sets global reliability strategy, and a small central SWAT team implements procedures throughout the sites. (SWAT, because they are quick, tactical, and execute with precision.) Integrity and reliability teams are responsible for site-level reliability. Each of the company’s business units has a reliability engineer who oversees maintenance and implementation for each discipline (for example, equipment rotation or electrical operations). The functional group works with the local reliability engineer, operators, technicians, operations managers, and vice presidents, all of whom are versed in the reliability standards that apply to their roles.

Bottom-up reliability.

Here, local entities define reliability standards and practices and are responsible for reliability outcomes. Technicians conduct tests and file reports to central reliability teams with the help of process engineers. In some cases, reliability work is outsourced. Such an approach is well-suited to decentralized businesses where no two sites are alike, either in their culture, operating environment, or both.

A major resource company illustrates the benefit of this model, with its dozens of facilities and assets that include all manner of heavy equipment, refineries, and processing operations. Although reliability programs and accountability are decentralized, the company defines metrics for use across different sites—and considers it a priority to make them transparent to the entire organization.

Corporate oversight.

With this archetype, local operations define the reliability program, but the corporate center tracks (and has ultimate responsibility for) outcomes. The central office often develops KPIs for use enterprise wide. This model is effective for businesses whose products vary considerably and which require relatively tailored processes across facilities (such as pharmaceutical companies). The hybrid structure makes sense, given the strong local leadership that can be relied upon to carry out reliability without direct responsibility for outcomes. Crucial prerequisites include either having strong, local reliability processes and capabilities, or having other robust processes and strict metrics that reinforce reliability excellence, such as through quality control.

At a leading pharmaceutical company with dozens of facilities, corporate maintains consistency in reliability practices by establishing clearly defined KPIs, which local sites report on via dashboards. The central team also shares best practices (and failures) companywide. It holds weekly meetings with local facilities to review key topics and issues, and provides resources for major initiatives, such as implementing new technologies.

But it’s field engineers who lead such initiatives. Local reliability personnel also focus on root-cause investigations (RCIs) and failure-mode and effect analysis (FMEAs). Led by a maintenance manager and general manager, the local engineers, maintenance group, project teams, and planning and scheduling teams work in concert with the central reliability function.

A driving principle and enterprise priority

Reliability engineering emphasizes statistical analysis, but experience and history show that quantitative methods alone are insufficient for success. In many of the most dramatic operational failures in modern times, miscommunication or poor decision making exacerbated a fundamental engineering failure—in some cases resulting in catastrophic loss of life that could have been averted. Such events stand as sobering reminders of the importance of rigorous management, transparency, and accountability in reliability engineering.

Today, supply-chain complexity, heightened business interdependencies, competitive and financial pressures, and intensified public and regulatory scrutiny all mean that reliability organizations, regardless of industry, have their work cut out for them. Leaders cannot expect Industry 4.0 technologies alone to be a cure-all. Rigorous reliability processes, role clarity, and clear accountability structures that align with the broader organization—all are essential components of reliability success. So is talent management and development. But high-reliability organizations go one step further: they make reliability an explicit priority, not just an afterthought. As one reliability manager put it: “Everyone at our company takes reliability seriously, not just the reliability engineers. They know that reliability is a top priority, and one of our main criteria for success.”

Matt Gentzel is a partner in McKinsey’s Pittsburgh office, where Bill McDonnell is a business analyst; Ethan Hessney is an engagement manager in the New York office; and Joël Thibert is an associate partner in the Santiago office.

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High Reliability Organizations: Principles, Strategies & Examples

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Ever wonder why a 150-ton flying machine became the world's safest transportation? It’s an incredible achievement—and it’s possible because of the concept of high-reliability organizations (HROs) .

HROs are remarkable for achieving consistent excellence in the face of complex and high-risk environments. From healthcare to aerospace, the concept of HROs has found its foothold in industries where precision and safety stand in the way of catastrophes.

However, the principles and strategies that underlie HROs have a broader application. In this article, we’ll extract insights from HRO practices and dive into a concrete example where Cascade helped an organization implement HRO-related strategies. You’ll see how HRO principles can help you improve processes, achieve excellence, and reach organizational goals.

We’ll cover: 

  • What Is A High-Reliability Organization?

5 Key Principles Of HROs

5 common hro implementation strategies, case study: how cascade solves challenges for an hro, become a high-reliability organization with cascade 🚀.

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What Is A High-Reliability Organization? 

A high-reliability organization (HRO) is an entity that operates in complex and high-risk environments while consistently delivering impeccable results and avoiding accidents that would cause harm.

HRO theory prioritizes safety, resilience, and error reduction as core values. It creates a culture of accountability and allows the organization to navigate difficult situations with precision and situational awareness.

HROs strive to create a system where problems can be solved by everyone. In doing so, they empower people with centralized observability of the organization and procedures they should employ in case of a problem.

HRO principles provide benchmarks across various industries—most notably aviation, healthcare, nuclear power, emergency services, and the military.

Let's explore these principles of high reliability and how they translate into broader business contexts.

5 key principles of high reliability organizations hros diagram

#1 Preoccupation with failure

In an HRO, there's a constant focus on identifying potential failures or even near misses before they escalate into critical incidents. This principle encourages a proactive approach to risk management and problem-solving by all employees within the organization. It’s not about achieving improvements one project at a time, but rather making zero harm a natural byproduct of how organizations operate and do business.

💡Example: In healthcare, this could mean adopting stringent safety protocols workers must abide by to prevent medical errors or burnout. In manufacturing, daily huddles involving production and quality control teams can foster proactive teamwork that identifies potential defects early, ensuring high-quality output.

#2 Reluctance to simplify

HROs understand that oversimplifying complex situations can lead to misunderstandings and errors. They value in-depth analysis and appreciate the intricate nature of their operations. They embrace that complex problems might need complex solutions.

💡Example: Pharmaceutical companies dealing with medications often have complex global supply chains. They cannot afford to simplify logistics and distribution. They employ advanced tracking systems, quality control measures, and stringent storage conditions to ensure the safe and timely delivery of life-saving drugs. This approach minimizes the risk of medication shortages or compromised product quality.

#3 Sensitivity to operations

Being highly attuned to day-to-day operations is critical for HROs. Leaders work closely with frontline workers who often have invaluable insights into operational challenges and opportunities. This means that even minor deviations from the norm are acknowledged and addressed promptly to achieve zero harm. 

💡Example: In aviation, even small irregularities are taken seriously to prevent potential accidents. Business leaders in other industries can adopt this mindset by valuing employees’s insights closest to the execution on the ground. Manufacturers could improve production processes by encouraging feedback from workers responsible for product assembly. 

#4 Commitment to resilience

HROs prioritize building systems that can withstand unexpected disruptions and safety issues. They anticipate and prepare for troublesome events. This prepares organizations to navigate economic downturns, market shifts, or technological disruptions.

💡Example: In healthcare, this might involve disaster response plans for situations like pandemics. In a broader business context, leaders can cultivate resilience by diversifying supply chains to mitigate risks of disruptions or have multiple revenue streams to reduce dependency on a single product or service.

#5 Deference to expertise

HROs recognize that expertise resides at all levels of the organization and value it over authority. They empower workers with specialized knowledge or relevant experience to voice concerns and contribute insights. This practice enhances decision-making and overall operations. 

💡Example: Manufacturing companies often form cross-functional teams where experts from different departments collaborate to identify and implement quality improvement measures. Such teams acknowledge that expertise exists throughout the organization and should be used for efficient problem-solving.

Implementing the principles of HROs requires concrete strategies that transform theory into actions and drive an organizational culture of excellence and reliability.

5 common hro implementation strategies diagram

Let's delve into 5 common HRO implementation strategies and their potential applications:

#1 Leadership development

A cornerstone of HRO success is effective leadership that champions the principles at every level. Organizations should train and develop individuals with the skills to navigate complexity, drive strategic alignment , and ensure accountability . This strategy transcends industries, reminding us that leadership is a universal catalyst for organizational success.

💡Example: In healthcare organizations, zero harm is a natural byproduct of how they take care of patients every day. Following this, medical directors and department leaders learn how to implement change management to facilitate HRO principles for all workers and team members. That’s how they enhance the ability of the whole institution to manage complex medical cases, ensure evidence-based practices, improve care delivery, and effectively communicate about even the smallest things that seem off at any level. By developing leadership skills that trickle down and empower everyone, healthcare organizations improve patient care and patient safety as well as reduce the risk of patient harm.

#2 Culture of safety

Creating a culture of safety means instilling a mindset where employees can raise concerns without fear of reprisal. A culture of safety is vital for ensuring a secure, productive environment across diverse industries.

💡Example: In the manufacturing sector, encouraging workers to report potential safety hazards without hesitation fosters an environment where everyone's input is valued, and employees' safety and well-being are actively prioritized.

#3 Data systems

By harnessing data for predictive insights, risk assessment, and process optimization, HROs chart a course toward reliability, resilience, and sustainable growth. 

💡Example: In transportation, utilizing real-time tracking and monitoring of vehicles ensures efficient routes, maintenance schedules, and compliance with safety regulations. Data-driven insights enable companies to optimize operations, reduce fuel consumption, and enhance overall transportation reliability.

#4 Training and learning

Continuous training ensures that employees are well-versed in HRO principles and their applications. By equipping employees with the knowledge and skills to respond adeptly to unforeseen challenges, organizations cultivate a culture of adaptability and resilience.

💡Example: In the hospitality sector, hotel staff undergo regular training on handling unexpected situations with grace and professionalism, mirroring the preparedness exhibited by HROs in critical scenarios.

#5 Implementing interventions

Implementing interventions involves proactively addressing potential failures before they escalate. By fine-tuning processes, identifying weak points, and executing interventions with precision, organizations across industries ensure continuous improvement, operational excellence, and ultimately, reliability.

💡Example: In the IT sector, taking proactive cybersecurity measures includes conducting regular simulated phishing exercises to educate employees about potential email threats. Additionally or deploying intrusion detection systems.

By implementing these strategies , organizations can bridge the gap between theory and practice, effectively embedding the principles of HROs into their operations.

The core tenets of HROs emphasize trackability, systems, visibility, and accountability, but many organizations are facing challenges in these areas. For such organizations, Cascade can serve as a platform that enhances alignment and observability as well as provides a centralized space for ongoing strategy execution and process improvement.

In this case study, we’ll show you how Cascade helps solve the challenges of high-reliability healthcare for a large regional health system. 

The organization in question employs more than 29,000 employees and has 4,600 affiliated healthcare providers offering primary and specialty care at 11 hospitals, in more than 150 locations.

Let’s examine their 3 core challenges and how Cascade solves them.

Challenge #1: Organizational alignment 

Achieving organizational alignment is particularly challenging in HROs with complex, multi-unit structures. 

In our example, 11 hospitals operate as separate entities. Despite their affiliation, these hospitals retain their own C-suite leadership and board of directors, reflecting semi-autonomous business units within the broader health system. 

At the system level, the joint commission creates a three-year system strategy .

However, each hospital also creates its annual operating plan (AOP) , involving its respective strategy teams, healthcare leaders, and boards. This structure presents the challenge of aligning strategic objectives among these disparate units.

Even with well-defined targets, differences in tracking methods, manual status updates, and disparate information flow create inconsistencies in alignment and visibility.

The big question is: How do we make these disparate parts of a system work towards the same goals and have the same focus?

💡The Cascade solution: Connecting high-level strategy and objectives

For our customer, achieving robust organizational alignment became a pivotal focus. 

Cascade offered a solution that streamlined the alignment journey. The health system decided it was going to focus on 7 key areas. Once these 7 areas were visible in Cascade, it enabled everyone across all member organizations of the system to craft their AOP around these focus areas and strategic priorities. 

Cascade allowed hospitals to create individual plans with hospital-specific tactics, objectives, initiatives, and key measures and easily connect them with the focus areas and the high-level strategy.

While the member organizations retained their autonomy in setting AOP targets, Cascade bridged the gap between the overarching system-level strategy and the individual AOPs of individual units. It provided everyone with the objective alignment map which gave them a clear visual context of how aligned their objectives were with the organizational strategy horizontally and vertically.

alignmen map in cascade

Such streamlining of strategy planning and execution is a pathway to alignment and progress tracking, bringing unity to diverse entities operating within the same framework.

📚 Recommended read: How To Create An Effective Annual Operating Plan (+Template)

Challenge #2: Accountability and governance  

Healthcare staff are immersed in critical tasks. Balancing time-sensitive duties with strategic focus becomes tough, emphasizing the need for a solution that instills accountability. 

The challenge this organization and many other HROs face is eliminating redundant efforts, establishing a connection across multiple touchpoints, and ensuring essential updates reach the right people.

💡The Cascade solution: An easier way of establishing and distributing accountability

Cascade offers a comprehensive solution to address accountability challenges within complex healthcare systems. It makes it easier to see who’s responsible for what, assign key roles, observe progress, and visualize how different objectives connect to high-level strategy. It also makes it simpler and faster to create updates and reports .

In the case of the organization in question, everything mentioned above made it easier to create greater ownership through leadership buy-in. Now the VPs and directors use the platform and own their updates, setting an example for all employees. 

This provides two main benefits:

  • It gets crucial leadership endorsement. Commitment from the C-suite facilitates strategic execution and cascades accountability down the hierarchy, creating a culture of responsibility.
  • It disperses responsibility, distributes the workload more effectively, and creates more individual accountability. It means that a strategy manager is not responsible for collecting all the updates as it too often happens.

A specific example of Cascade's capabilities is its structured update templates . For institutions that constantly need up-to-date insights into their successes, challenges, and next steps this functionality is invaluable. The ability to structure and standardize these updates ensures that the right updates reach the right people, enhancing attention allocation and strategic execution.

update template example view

By using Cascade, our customer infused accountability across various touchpoints and optimized its plans. It’s an efficient way of ensuring that HROs can spread true ownership and responsibility across the organizations and thus become more reliable. 

Challenge #3: Centralized observability 

The health system faced the challenge of achieving an integrated view encompassing multiple hospitals, their AOPs, and system departments. This involved creating a comprehensive system that seamlessly connected data, objectives, and insights from these diverse sources, all while ensuring complete visibility.

💡The Cascade solution: Consolidating all data and insights in one place

Cascade entered the stage as the orchestrator of centralized observability , immediately bringing together different strategic elements:

  • Integrations that get all data from different sources into Cascade and streamline reporting. 
  • Tracking individual AOPs against system-level strategy, creating alignment, and tracking progress. 
  • Visibility into system departments that the health system decided to launch.

Integrations with tech tools clinicians use, such as SharePoint and Teams, were key to achieving centralized observability. These integrations mean that people are now working with a connected tech stack instead of siloed tools and data. They also automate essential reports and dashboards and ensure they are accurate throughout the organization. 

By connecting core metrics with its reporting systems Cascade elevates tracking workflows and visibility by displaying key data in a centralized space. It showcases how data and objectives connect to the focus areas and the high-level strategy. This means people get data in context and can understand the story behind the numbers, which improves decision-making and is key for HROs.

These capabilities were crucial when our customer introduced system departments. These departments centralize specialized, functions like marketing and finance across the health system and all its member organizations. 

Cascade supports them by making their work, projects, capabilities, and progress more transparent, which fosters a holistic understanding of their contributions. By making them observable in a central place it makes it clear the departments are working with the whole system and that they’re not just fragmented entities across specific hospitals.

dashboard example in cascade

Active staff participation is essential to achieve high reliability and ensure the effectiveness of the HRO approach. Cascade is there to provide the entire organization with viewing licenses and embedded dashboards that showcase progress. 

The principles of HROs extend beyond their traditional domains, offering valuable insights for all businesses . We can all learn valuable lessons from organizations that operate with precision and safety in complex and high-risk environments.

Cascade has proven it has the needed capabilities to infuse HRO principles into an organization's DNA. By addressing challenges in alignment, accountability, and visibility, Cascade empowers organizations to proactively manage risks, streamline processes, achieve centralized observability, and accomplish excellence in their respective industries.

If you’re looking to implement HRO principles, sign up today for a free forever plan or book a guided 1:1 product tour with one of our Cascade in-house strategy execution experts.

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Implementing High-Reliability Organization Principles at Biological Diagnostic Laboratories: Case Study at National Institute of Health, Islamabad


  • 1 Department of Virology/Immunology, National Institute of Health, Islamabad, Pakistan.
  • 2 Quality Assurance Department, National Institute of Health, Islamabad, Pakistan.
  • 3 Chrome Biorisk Management Consulting, Washington, District of Columbia, USA.
  • 4 Department of Hematology, National Institute of Health, Islamabad, Pakistan.
  • 5 Department of Microbiology, National Institute of Health, Islamabad, Pakistan.
  • 6 Drugs Control and Traditional Medicine Division, National Institute of Health, Islamabad, Pakistan.
  • 7 Biological Production Division, National Institute of Health, Islamabad, Pakistan.
  • 8 Nutrition Division, National Institute of Health, Islamabad, Pakistan.
  • PMID: 36032320
  • PMCID: PMC9402247
  • DOI: 10.1089/apb.2021.0011

Introduction: Healthcare organizations are complex systems where healthcare professionals, patients, biological materials, and equipment constantly interact and provide feedback with highly consequential outcomes. These are the characteristics of a complex adaptive system. Healthcare delivery requires coordination but it necessarily relies on delegation of essential functions. It is thus essential to have an engaged workforce to ensure optimal outcomes for patients. Thus human performance factors play a key role in ensuring both the presence of excellent healthcare provision and the absence of outcomes that must be avoided-"never events."

Methods: The commitment of management was a precondition for the implementation of the high-reliability organization (HRO) principles. A team from middle management was engaged and provided with appropriate management tools for identifying, prioritizing, assessing, and applying solutions for the safety concern in their operating systems.

Results: This article documents efforts at the National Institute of Health (NIH) to adapt the principles of HROs to diagnostic laboratories and vaccine production facilities at its campus in Islamabad, Pakistan, and seeks to draw some lessons for how this approach can be usefully replicated in such facilities elsewhere.

Conclusion: Public health institutes such as NIH deliver vital products and services that are inherently risky to produce, where the consequence of failure can be catastrophic. Adopting the HRO principles is an approach to improving not just safety, but also the overall organizational performance in any setting, including low-resource settings, and can serve as an implementable process for other institutions.

Keywords: Pareto analysis; biosafety; high-reliability organization; safety culture; safety metrics.

Copyright 2022, ABSA International 2022.

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Conflict of interest statement

No competing financial interests exist.

Pre- and post-Pareto analyses of…

Pre- and post-Pareto analyses of BPD. The numbers in counts on y -axis…

Pre- and post-Pareto analyses of PHLD. The numbers in counts on y -axis…

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  • Implementing High-Reliability Organization Principles Into Practice: A Rapid Evidence Review. Veazie S, Peterson K, Bourne D, Anderson J, Damschroder L, Gunnar W. Veazie S, et al. J Patient Saf. 2022 Jan 1;18(1):e320-e328. doi: 10.1097/PTS.0000000000000768. J Patient Saf. 2022. PMID: 32910041 Review.
  • The future of Cochrane Neonatal. Soll RF, Ovelman C, McGuire W. Soll RF, et al. Early Hum Dev. 2020 Nov;150:105191. doi: 10.1016/j.earlhumdev.2020.105191. Epub 2020 Sep 12. Early Hum Dev. 2020. PMID: 33036834
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Implementing high-reliability organization principles into practice: a rapid evidence review.

Veazie S, Peterson K, Bourne D, et al. Implementing high-reliability organization principles into practice: a rapid evidence review. J Patient Saf. Epub 2020 Sept 11. doi: 10.1097/pts.0000000000000768

This review expands upon previous work evaluating implementation strategies for high-reliability organizations. Review findings indicate that health care system adoption of high-reliability principles is associated with improved outcomes, but the level of evidence is low. Future research should include concurrent control groups to minimize bias and focus on whether certain high-reliability frameworks, metrics, or intervention components lead to greater improvements.  

Patient misidentification events in the Veterans Health Administration: a comprehensive review in the context of high-reliability health care. October 21, 2020

A high-reliability organization framework for health care: a multiyear implementation strategy and associated outcomes. November 4, 2020

Interventions into reliability-seeking health care organizations: a systematic review of their goals and measuring methods. November 30, 2022

Toward zero harm: Mackenzie Health's journey toward becoming a high reliability organization and eliminating avoidable harm. November 16, 2022

COVID-19 and patient safety: time to tap into our investment in high reliability. May 12, 2021

Engaging patients in the use of real-time electronic clinical data to improve the safety and reliability of their own care. May 4, 2022

Review of reported adverse events occurring among the homeless veteran population in the Veterans Health Administration. November 17, 2021

Patient and family involvement in serious incident investigations from the perspectives of key stakeholders: a review of the qualitative evidence. August 17, 2022

Medication-related interventions to improve medication safety and patient outcomes on transition from adult intensive care settings: a systematic review and meta-analysis. February 2, 2022

Closing the loop on test results to reduce communication failures: a rapid review of evidence, practice and patient perspectives. November 25, 2020

Achieving a high-reliability organization through implementation of the ARCC model for systemwide sustainability of evidence-based practice. April 4, 2012

Evidence Brief: Implementation of High Reliability Organization Principles. July 24, 2019

Improving medication appropriateness in nursing homes via structured interprofessional medication-review supported by health information technology: a non-randomized controlled study. February 24, 2021

Factors causing variation in World Health Organization surgical safety checklist effectiveness-a rapid scoping review. December 14, 2022

Physician reporting of clinically significant events through a computerized patient sign-out system. September 14, 2011

Triggers contributing to health care clinicians' disruptive behaviors. September 16, 2020

What do patients and their carers do to support the safety of cancer treatment and care? A scoping review. December 14, 2022

The relationship between high-reliability practice and hospital-acquired conditions among the Solutions for Patient Safety Collaborative. October 20, 2021

A review of adverse event reports from emergency departments in the Veterans Health Administration. March 18, 2020

The use of anatomical side markers in general radiology: a systematic review of the current literature. August 26, 2020

Hemodialysis bleeding events and deaths: an 18-year retrospective analysis of patient safety and root cause analysis reports in the Veterans Health Administration. November 24, 2021

Evolving factors in hospital safety: a systematic review and meta-analysis of hospital adverse events. September 29, 2021

Implementing root cause analysis and action: integrating human factors to create strong interventions and reduce risk of patient harm. July 20, 2022

Patient safety and quality improvement: ethical principles for a regulatory approach to bias in healthcare machine learning. July 22, 2020

The effect of implementing bar-code medication administration in an emergency department on medication administration errors and nursing satisfaction. October 21, 2020

Medication errors in overweight and obese pediatric patients: a systematic review. February 9, 2022

Patient harm during COVID-19 pandemic: using a human factors lens to promote patient and workforce safety. December 23, 2020

The barriers and enhancers to trust in a just culture in hospital settings: a systematic review. August 17, 2022

What safety events are reported for ambulatory care? Analysis of incident reports from a patient safety organization. October 21, 2020

High-risk medication in home care nursing: a Delphi study. September 7, 2022

Rapid-cycle improvement during the COVID-19 pandemic: using safety reports to inform incident command. October 7, 2020

Association of implementation and social network factors with patient safety culture in medical homes: a coincidence analysis. September 2, 2020

A machine learning approach to reclassifying miscellaneous patient safety event reports. July 29, 2020

A safe practice standard for barcode technology. June 3, 2015

Using community detection techniques to identify themes in COVID-19-related patient safety event reports. December 7, 2022

We are not there yet: a qualitative system probing study of a hospital rapid response system. April 20, 2022

Safety culture in the operating room: variability among perioperative healthcare workers. September 13, 2017

Critical care clinicians' experiences of patient safety during the COVID-19 pandemic. November 30, 2022

The impact of the built environment on patient falls in hospital rooms: an integrative review. June 16, 2021

Test-retest reliability of an experienced Global Trigger Tool review team. October 27, 2021

Effects of healthcare organization actions and policies related to COVID-19 on perceived organizational support among U.S. internists: a national study. June 1, 2022

Expert consensus on currently accepted measures of harm. September 9, 2020

Data collection for adverse events reporting by US dental schools. September 30, 2020

Impact of teamwork and communication training interventions on safety culture and patient safety in emergency departments: a systematic review. January 26, 2022

Learning from incident reporting? Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care. December 9, 2020

Collaborative case review: a systems-based approach to patient safety event investigation and analysis. March 30, 2022

Race differences in reported "near miss" patient safety events in health care system high reliability organizations. December 15, 2021

A high-reliability organization mindset. February 22, 2023

Multispecialty physician online survey reveals that burnout related to adverse event involvement may be mitigated by peer support. May 18, 2022

The efficacy of mindful practice in improving diagnosis in healthcare: a systematic review and evidence synthesis. October 13, 2021

A 6-year thematic review of reported incidents associated with cardiopulmonary resuscitation calls in a United Kingdom hospital. April 27, 2022

A mixed methods study examining teamwork shared mental models of interprofessional teams during hospital discharge. January 8, 2020

Systematic review and meta-analysis of interventions for operating room to intensive care unit handoffs. March 10, 2021

Adverse event reporting priorities: an integrative review. June 29, 2022

The Psychological Safety Scale of the Safety, Communication, Operational, Reliability, and Engagement (SCORE) survey: a brief, diagnostic, and actionable metric for the ability to speak up in healthcare settings. September 14, 2022

Situation awareness and the mitigation of risk associated with patient deterioration: a meta-narrative review of theories and models and their relevance to nursing practice. December 1, 2021

Improving administration and documentation of enteral nutrition support therapy in a Veteran Affairs health care system: use of medication administration record and bar code scanning technology. February 1, 2023

Registered nurses' and medical doctors' experiences of patient safety in health information exchange during interorganizational care transitions: a qualitative review. November 10, 2021

Exploring changes in patient safety incidents during the COVID-19 pandemic in a Canadian regional hospital system: a retrospective time series analysis. February 23, 2022

Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study. May 19, 2021

Safe clinical practice for patients hospitalised in mental health wards during a suicidal crisis: qualitative study of patient experiences. December 23, 2020

Defining diagnostic error: a scoping review to assess the impact of the National Academies' report Improving Diagnosis in Health Care. May 25, 2022

Hospital cultural competency and attributes of patient safety culture: a study of U.S. hospitals. November 17, 2021

Identifying hot spots for harm and blind spots across the care pathway from patient complaints about general practice. November 3, 2021

Personality traits and traumatic outcome symptoms in registered nurses in the aftermath of a patient safety incident. July 22, 2020

The impact of a 22-month multistep implementation program on speaking-up behavior in an academic anesthesia department. July 27, 2022

Bedside clinicians' perceptions on the contributing role of diagnostic errors in acutely ill patient presentation: a survey of academic and community practice. March 16, 2022

Prescribing errors with low-molecular-weight heparins. October 13, 2021

Data-driven quality improvement, culture change, and the high reliability journey at a special hospital for people with medically complex developmental disabilities. March 11, 2020

A description of medical malpractice claims involving advanced practice providers. July 15, 2020

Enhancing departmental preparedness for COVID-19 using rapid-cycle in-situ simulation. September 16, 2020

Comparison of a voluntary safety reporting system to a global trigger tool for identifying adverse events in an oncology population. August 3, 2022

A systems approach to analyzing and preventing hospital adverse events. June 24, 2020

Addressing patient safety hazards using critical incident reporting in hospitals: a systematic review. January 18, 2023

A machine learning-based clinical decision support system to identify prescriptions with a high risk of medication error. October 21, 2020

Identifying health information technology usability issues contributing to medication errors across medication process stages. July 7, 2021

Integrating principles of safety culture and just culture into nursing homes: lessons from the pandemic. January 12, 2022

Striving for high reliability in healthcare: a qualitative study of the implementation of a hospital safety programme. June 22, 2022

Detecting patient deterioration using artificial intelligence in a rapid response system. March 25, 2020

Lessons learned in implementing a chronic opioid therapy management system. December 21, 2022

Understanding the "Swiss cheese model" and its application to patient safety. July 21, 2021

Development of rapid response capabilities in a large COVID-19 alternate care site using Failure Modes and Effect Analysis with in situ simulation. November 18, 2020

What can we learn from in-depth analysis of human errors resulting in diagnostic errors in the emergency department: an analysis of serious adverse event reports. May 18, 2022

Institution of just culture physician peer review in an academic medical center. October 13, 2021

Communicating patient safety information through video and oral formats-a comparison. April 5, 2023

Electronic health record use issues and diagnostic error: a scoping review and framework. January 25, 2023

Reduction in omission events after implementing a rapid response system: a mortality review in a department of gastrointestinal surgery. March 15, 2023

Changing hospital organisational culture for improved patient outcomes: developing and implementing the Leadership Saves Lives intervention. August 12, 2020

Impact of the COVID-19 pandemic on the experiences of hospitalized patients: a scoping review. February 22, 2023

Bracing for the storm: one health care system's planning for the COVID-19 surge. November 11, 2020

Root cause analysis of adverse events involving opioid overdoses in the Veterans Health Administration. June 23, 2021

Strength of safety measures introduced by medical practices to prevent a recurrence of patient safety incidents: an observational study. September 7, 2022

Advanced medication reconciliation: a systematic review of the impact on medication errors and adverse drug events associated with transitions of care. June 16, 2021

Keeping patients at risk for self-harm safe in the emergency department: a protocolized approach. December 2, 2020

The necessary leadership skillsets for the high-reliability organization framework adoption within acute healthcare organizations. March 16, 2022

Nurses' perceived causes of medication administration errors: a qualitative systematic review. November 25, 2020

Errors during resuscitation: the impact of perceived authority on delivery of care. March 25, 2020

Examining causes and prevention strategies of adverse events in deceased hospital patients: a retrospective patient record review study in the Netherlands. June 16, 2021

An international perspective on definitions and terminology used to describe serious reportable patient safety incidents: a systematic review. December 8, 2021

Education initiatives in cognitive debiasing to improve diagnostic accuracy in student providers: a scoping review. November 11, 2020

Challenge Competition: Impact of Patient Safety Tools. December 12, 2023

Network of Patient Safety Databases Chartbook. November 8, 2023

An integrative systematic review of employee silence and voice in healthcare: what are we really measuring. June 28, 2023

Room of horrors simulation in healthcare education: a systematic review. June 21, 2023

The association between patient safety culture and adverse events - a scoping review. May 17, 2023

Towards a unified model of accident causation: refining and validating the systems thinking safety tenets. May 10, 2023

Listen to the whispers before they become screams: addressing Black maternal morbidity and mortality in the United States. May 3, 2023

Annual Perspective

Defining avoidable healthcare-associated harm in prisons: a mixed-method development study. April 19, 2023

Systematic review of clinical debriefing tools: attributes and evidence for use. April 19, 2023

Crowding in the Emergency Department: Challenges for the Care of Children. March 15, 2023

For children admitted to hospital, what interventions improve medication safety on ward rounds? March 1, 2023

Examining medication ordering errors using AHRQ Network of Patient Safety Databases. February 22, 2023

Investigating the impact of structural racism on Black birthing people - associations between racialized economic segregation, incarceration inequality, and severe maternal morbidity. February 15, 2023

A scoping review of adverse incidents research in aged care homes: learnings, gaps, and challenges. February 8, 2023

Surveys on Patient Safety Culture Nursing Home Survey: 2023 User Database Report. February 8, 2023

The value of learning from near misses to improve patient safety: a scoping review. January 25, 2023

Incidence and characteristics of adverse events in paediatric inpatient care: a systematic review and meta-analysis. January 25, 2023

Structural racism and adverse maternal health outcomes: a systematic review. December 21, 2022

Prevalence, causes and severity of medication administration errors in the neonatal intensive care unit: a systematic review and meta-analysis. December 14, 2022

Conceptual and practical challenges associated with understanding patient safety within community-based mental health services. December 7, 2022

The neglected barrier to medication use: a systematic review of difficulties associated with opening medication packaging. November 16, 2022

Measuring psychological safety and local learning to enable high reliability organisational change. November 9, 2022

Predictors of response rates of safety culture questionnaires in healthcare: a systematic review and analysis. October 26, 2022

A systematic review of nursing practice workarounds. October 19, 2022

The impact of electronic health record interoperability on safety and quality of care in high-income countries: systematic review. October 5, 2022

Variation in detected adverse events using trigger tools: a systematic review and meta-analysis. September 21, 2022

Exploring the impact of employee engagement and patient safety. September 14, 2022

Organizational factors that promote error reporting in healthcare: a scoping review. September 14, 2022

Patient safety issues from information overload in electronic medical records. September 14, 2022

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  • > 5 Principles of a High Reliability Organization (HRO)

5 Principles of a High Reliability Organization (HRO)

Posted by Greg Jacobson

May 2, 2024 1:57:12 PM


A high-reliability organization (HRO) is an organization that has succeeded in avoiding catastrophes despite a high level of risk and complexity. Specific examples that have been studied, most famously by researchers Karl Weick and Kathleen Sutcliffe , include nuclear power plants, air traffic control systems, and naval aircraft carriers. Recently healthcare organizations have moved to adopt the HRO mindset as well. In each case, even a minor error could have catastrophic consequences.

Yet, adverse outcomes in these organizations are rare. How is that possible?

When something terrible happens within an HRO, the public’s initial response may be shock and anger, but often an insightful observer will point out that it is actually amazing that these types of organizations can succeed with any regularity at all (or not fail more often).

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Researchers at Berkeley wanted to define the commonalities of high-reliability organizations. They did extensive research on United States nuclear aircraft carriers, the Federal Aviation Administration’s Air Traffic Control system , and nuclear power operations at Pacific Gas and Electric’s Diablo Canyon reactor. They uncovered five elements that HROs have in common.

These traits are essential for avoiding significant failure or catastrophic events despite operating in a hazardous environment where lives are at stake. While your organization may not face such complexity and risk, applying the HRO mindset can help your team reach its highest potential and reliably keep its promises.

5 Principles of a High Reliability Organization (HRO) Infographic

Principle #1: Preoccupation with Failure 

Process failures are addressed immediately and completely.

Some organizations can ignore or work around small process failures or deviations. HROs can’t. HROs do not ignore any failure, no matter how small, because any deviation from the expected result can snowball into tragedy. It is necessary, therefore for HROs to address any level of technical, human or process failure wholly and immediately. In fact, in an HRO even potential process breakdowns are identified and addressed. HROs are somewhat fixated on how things could fail, even if they have not.

In practice, this means that every employee at every level in a high-reliability organization is tasked with thinking of ways their work processes might break down. This sense of shared alertness is ever present. It applies to small inefficiencies and dangerous failures. Employees are encouraged to report their concerns for potential failures , which can help create best practices across the entire organization. Every person has the tools and language to share the culture, which supports process breakdown information and transparency.

Principle #2:  Reluctance to Simplify

Complex problems get complex solutions.

High-Reliability Organizations are complex by definition, and they accept and embrace that complexity. HROs do not explain away problems; instead, they conduct root cause analysis and reject simple diagnoses.

Leaders in HROs must be willing to challenge long-held beliefs. They continuously look at data , benchmarks and other performance metrics. To prevent simplification, which is tempting when success is not achieved, leaders must constantly seek information that challenges their current beliefs as to why problems exist.

How to Manage Your Improvement Metrics

Principle #3: Sensitivity to Operations

Every voice matters.

HROs understand that the best picture of the current situation, especially an unexpected one, comes from the front line . Because front line employees are closer to the work than executive leadership, they are better positioned to recognize the potential failure and identify opportunities for improvement. There are no assumptions in an HRO. A consistent concentration on processes leads to observations that inform decision-making and new operational initiatives.

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Principle #4:  Commitment to Resilience

Recovery is swift.

Resilience in High-Reliability Organizations means the ability to anticipate trouble spots and improvise when the unexpected occurs. The organization must be able to identify errors that require correction while at the same time innovating solutions within a dynamic environment. They prepare in advance for emergencies and have clear means of communication and control.

To foster resilience, leaders in HROs emphasize the importance of working together in multidisciplinary teams and removing barriers to cross-functional collaboration. They encourage flexibility in team members to accommodate changes in conditions or resources. Team members are explicitly trained on how to manage unexpected events.

Principle #5:  Deference to Expertise

Experts are trusted.

Expertise, rather than authority, takes precedence in an HRO. When conditions are high-risk and circumstances change rapidly, on-the-ground subject matter experts are essential for urgent situational assessment and response.

In order to defer to expertise, leaders must know who in the organization has what specialized knowledge. They also must be in the business of creating experts and helping adept employees keep their skills sharp and up to date.

These five principles form the foundation for the continuous improvement mindset of High-Reliability Organizations. Even if your business doesn’t deal in life and death affairs, there are lessons to be learned from those that do. It makes sense to consider adding these principles to your own approach to improvement.

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Cover of Evidence Brief: Implementation of High Reliability Organization Principles

Evidence Brief: Implementation of High Reliability Organization Principles

Investigators: Stephanie Veazie , MPH, Kim Peterson , MS, and Donald Bourne , MPH.

  • Copyright and Permissions
  • Develop clinical policies informed by evidence;
  • Implement effective services to improve patient outcomes and to support VA clinical practice guidelines and performance measures; and
  • Set the direction for future research to address gaps in clinical knowledge.

The program is comprised of four ESP Centers across the US and a Coordinating Center located in Portland, Oregon. Center Directors are VA clinicians and recognized leaders in the field of evidence synthesis with close ties to the AHRQ Evidence-based Practice Center Program and Cochrane Collaboration. The Coordinating Center was created to manage program operations, ensure methodological consistency and quality of products, and interface with stakeholders. To ensure responsiveness to the needs of decision-makers, the program is governed by a Steering Committee comprised of health system leadership and researchers. The program solicits nominations for review topics several times a year via the program website .

Comments on this evidence report are welcome and can be sent to Nicole Floyd, Deputy Director, ESP Coordinating Center at [email protected] .

  • Executive Summary

The ESP Coordinating Center (ESP CC) is responding to a request from the VA National Center for Patient Safety for a rapid evidence review on implementing High Reliability Organization (HRO) principles into practice. Findings from this review will be used to inform the implementation of the VA’s High Reliability Organization Initiative.

To identify studies, we searched MEDLINE®, PsycInfo, CINAHL, Cochrane Central Register of Controlled Trials, and other sources from Jan. 2010- Jan. 2019. We used prespecified criteria for study selection, data abstraction, and rating internal validity and strength of the evidence. Full methods are available on PROSPERO register of systematic reviews (CRD42019125602)

Objective: To systematically evaluate literature on frameworks for high reliability organization (HRO) implementation, metrics for evaluating a health system’s progress towards becoming an HRO, and effects of HRO implementation on process and patient safety outcomes.

  • We identified 5 common HRO implementation strategies across 8 frameworks. Based on those, the Joint Commission’s High Reliability Health Care Maturity Model (HRHCM) and the Institute for Healthcare Improvement’s Framework for Safe, Reliable, and Effective Care emerged as the most comprehensive, as they included all 5 strategies, contained sufficient detail to guide implementation, and were the most rigorously developed and widely applicable.
  • The Joint Commission’s HRHCM/Oro TM 2.0 is the most rigorously developed and validated tool available for evaluating health care organizations’ progress on becoming an HRO; however, it has some conceptual gaps that may be addressed by incorporating metrics from other evaluation tools.
  • Multicomponent HRO interventions delivered for at least years are associated with improved process outcomes ( eg , staff reporting of safety culture) and patient safety outcomes ( eg , serious safety events). However, the overall strength of evidence is low, as each HRO intervention was only supported by a single fair-quality study.

High Reliability Organizations (HROs) are organizations that achieve safety, quality, and efficiency goals by employing 5 central principles: (1) sensitivity to operations ( ie , heightened awareness of the state of relevant systems and processes); (2) reluctance to simplify ( ie , the acceptance that work is complex, with the potential to fail in new and unexpected ways); (3) preoccupation with failure ( ie , to view near misses as opportunities to improve, rather than proof of success); (4) deference to expertise ( ie , to value insights from staff with the most pertinent safety knowledge over those with greater seniority); (5) and practicing resilience ( ie , to prioritize emergency training for many unlikely, but possible, system failures). Nuclear power and aviation are classic examples of industries that have applied HRO principles to achieve minimal errors, despite highly hazardous and unpredictable conditions. As death due to medical errors are estimated to be the third leading cause of death in the country, a growing number of health care systems are taking interest in adopting HRO principles. In 2008, the Agency for Healthcare Research and Quality (AHRQ) published a seminal white paper that described the application of the 5 key HRO principles in health care settings, including the specific challenges that threaten reliability in health care, such as higher workforce mobility and care of patients rather than machines. Adoption of these HRO principles in health care offers promise of increased excellence; however, major barriers to widespread implementation include difficulty in adopting organization-level safety culture principles into practice; competing priorities between HRO and other large-scale organizational transformation initiatives such as electronic health records; and difficulty in creating and implementing process improvement tools and methods to address complex, system-level problems.

In February 2019, the Department of Veterans Affairs (VA) rolled out a new initiative outlining the definitive steps toward becoming an HRO. As literature has emerged to guide health systems in implementing and evaluating their HRO journey, an understanding of the quality and applicability of existing HRO resources is important to developing best practices, identifying barriers and facilitators to implementation, measuring progress, identifying knowledge gaps, and spreading implementation initiatives to other systems. In this review, we evaluate literature on the frameworks for HRO implementation, metrics for evaluating a health system’s progress towards becoming an HRO, and effects of HRO implementation on process and patient safety outcomes.

We identified 20 articles published on HRO frameworks, metrics, and evidence of effects. Eight articles addressed frameworks, and of these, the Joint Commission’s High Reliability Health Care Maturity Model (HRHCM) and the Institute for Healthcare Improvement’s (IHI) Framework for Safe, Reliable, and Effective Care emerged as the most comprehensive, rigorously developed, applicable, and sufficiently detailed to guide implementation. The most commonly reported implementation strategies across the 8 frameworks were: (1) developing leadership, (2) supporting a culture of safety, (3) building and using data systems to track progress, (4) providing training and learning opportunities for providers and staff, and (5) implementing interventions to address specific patient safety issues. Most of these frameworks were developed via a consensus process – typically with a group of health system leaders and experts in patient safety – and were intended to be implemented by a variety of health care providers and staff. Articles varied in the depth of information provided on how to implement these frameworks, with some providing specific guidance on implementation activities such as workshops and time frames for implementation and others providing overarching, conceptual guidance.

Eight articles and 1 online tool described metrics for measuring a health system’s progress towards becoming an HRO. The Oro TM 2.0 tool emerged as the most rigorously designed and validated, as it was developed by a leading group in health care improvement, informed by industries leaders across HROs, and tested in a total of 52 US hospitals both within and outside of the VA. Otherwise, metrics varied in terms of the concept measured, ranging from surveys on culture of safety to extent of integration of HRO principles into practice. The process for developing these metrics also varied by tool. Many groups relied on a literature review or expert consensus, whereas others underwent rounds of revisions and piloted their tool in multiple hospital settings.

Seven articles evaluated the effects of HRO implementation, primarily in children’s hospitals. The most notable finding is that organizations experienced significant reductions in serious safety events (range, 55% to 100%) following the implementation of the 4 most comprehensive, multicomponent HRO initiatives. Moreover, time since initiation and safety improvements appear to have a dose-response relationship. Only one of these studies explicitly discussed using a framework identified in Key Question 1 ( ie , the IHI framework). Common implementation activities included some form of basic error prevention training for staff and leadership training for leaders, enhanced root cause analysis processes using an electronic tracking system, provider peer safety coaches to coach their peers in the use of error prevention techniques, routine sharing of good catches and lessons learned, and increased communication through safety huddles. Successful facilitators to implementation include hiring an outside consultant ( eg , Healthcare Performance Improvement), leadership commitment to implement HRO principles, and enacting policies to facilitate data-sharing. Barriers to implementation include competing priorities ( eg , widescale implementation of an Electronic Medical Record systems) and high costs.

A major limitation of the literature is that none of these studies compared an HRO intervention to a concurrent control group. Therefore, it is difficult to determine whether these effects are due to HRO implementation or a concurrent intervention or secular trend. Studies also lacked information on whether intervention components were delivered with fidelity over time and whether the interventions were associated with unintended effects on provider workload or efficiency. Future HRO implementation research should utilize quasi-experimental designs, such as natural experiments that deliver HRO interventions at a group of sites with other sites serving as a wait list control, to evaluate the effects of specific intervention components and assess the mechanism of change driving outcomes.

  • Introduction

The ESP Coordinating Center (ESP CC) is responding to a request from the Department of Veterans Affairs (VA) National Center for Patient Safety for a rapid evidence review on implementing High Reliability Organization (HRO) principles into practice. The purpose of this review is to evaluate the literature on frameworks, metrics, and evidence of effects of HRO implementation. Findings from this review will be used to inform the implementation of the VA’s HRO Initiative.

In their 2000 report “To Err is Human,” the Institute of Medicine’s (IOM) Committee on Quality of Health Care in America cited deaths due to medical errors as more common than those due to motor vehicle accidents, breast cancer, or AIDS. 1 Despite continued widespread, discrete process improvement initiatives such as handwashing protocols, patient identification to reduce ‘wrong person’ procedures, protocols for clear communications between care teams and visual indicators for high risks such as fall injury or allergies, a 2016 British Medical Journal report estimated that medical errors continue to be the third leading cause of death in the US. 2 Additionally, the IOM Committee identified care fragmentation as a root cause of medical errors. 1 In response, they called for a comprehensive, system-level approach to improve patient safety, that shifts the focus away from a culture of blame to one of error analysis and process improvement. Therefore, health care organizations have begun to explore system-level approaches to cultivating a culture of safety, with a focus on collaboration, communication, and coordination.

AN HRO IS: “An organization that experiences fewer than anticipated accidents or events of harm, despite operating in highly complex, high-risk environments.”

HRO is one such organizational approach to achieving safety, quality, and efficiency goals. 3 , 4 At the core of HRO is a culture of “‘collective mindfulness’, in which all workers look for, and report, small problems or unsafe conditions before they pose a substantial risk to the organization and when they are easy to fix.” 3 , 5 Use of HRO is designed to change the thinking about patient safety through the following 5 principles: (1) sensitivity to operations ( ie , heightened awareness of the state of relevant systems and processes); (2) reluctance to simplify ( ie , the acceptance that work is complex, with the potential to fail in new and unexpected ways); (3) preoccupation with failure ( ie , to view near misses as opportunities to improve rather than proof of success); (4) deference to expertise ( ie , to value insights from staff with the most pertinent safety knowledge over those with greater seniority); (5) resilience ( ie , to prioritize emergency training for many unlikely but possible system failures). 4 See Figure 1 below.

Five HRO principles.

HRO was originally pioneered in extremely hazardous industries, such as nuclear power and commercial aviation, where even the smallest of errors can lead to tragic results. These industries have achieved and sustained extraordinary safety levels, thereby generating much interest in how to adapt HRO principles to health care and replicate this success. In their 2007 book “Managing the Unexpected,” Weick and Sutcliffe define the 5 principles of HROs and describe how these principles can be applied to improve reliability across diverse industries. 5 In their 2008 seminal Agency for Healthcare Research and Quality (AHRQ) white paper, Hines et al apply these 5 principles to health care settings and describe the specific challenges threatening health care reliability, such as higher workforce mobility and care of patients rather than machines. 4 Implementation of HRO initiatives into health care settings is an inherently complex and costly process that involves organizing people, processes, and resource activities across often large organizations. For example, the Nationwide Children’s Hospital’s HRO journey involved increasing their quality improvement (QI) personnel from 8 in 2007 to 33 in 2012, with a budget increase from $690K to $3.3M. 6 External consultants, such as Healthcare Performance Improvement, LLC, can provide support to organizations undertaking an HRO journey. HRO interventions commonly include activities like basic error prevention education; leadership training in reinforcement approaches; enhanced root cause analysis processes using an electronic tracking system; promotion of a ‘just culture’ – a culture in which providers and staff are fairly penalized for mistakes – that supports routine reporting errors; sharing good catches and lessons learned; and training in error prevention technique by provider peer safety coaches.

Examples of health systems’ successful adoption of HRO principles are already emerging. Providence St. Joseph Health – a national, not-for-profit Catholic health system comprised of more than 50 hospitals, 800 clinics and 5 million patients across 7 states – has had success implementing their HRO program, Caring Reliably. Two years after implementation of the program, which included partnering with an outside consulting firm to coach them through a leader toolkit, which focused on culture, and a toolkit for everyone, which reduced errors, Providence St. Joseph Health experienced a 5% improvement in the safety climate domain of the Safety Attitudes Questionnaire and a 52% decrease in serious safety events (G. Battey, oral communication, February 2019). 7 The VA has also experienced HRO implementation successes. The Harry S. Truman Memorial Veterans Hospital began a 3-year HRO project in March 2015 by partnering with the VA National Center for Patient Safety to deliver Clinical Team Training to every inpatient and outpatient clinical service. This included formal interactive classroom training, application of the principles in a project that was unique for each clinical area, and refresher classroom and simulation training after one year. In May 2016, Truman VA augmented their HRO program using a 23-module HRO Toolkit provided by VISN 15, as part of its HRO initiative rolled out across all 7 of its medical centers. According to Truman VA Associate Director Robert Ritter (R. Ritter, oral communication, February 2019), their HRO program has already resulted in remarkable improvements in staff attitudes and perceptions and significant increased participation in morning multidisciplinary huddles. However, despite the promise of increased excellence as described in the 2013 Joint Commission’s HRO report, 3 major barriers to widespread implementation readiness of HRO at the VA and elsewhere include the complexity of organization-wide incorporation of safety culture principles and practices and prioritizing the adoption of process improvement tools and methods, among other competing priorities.

To reaffirm their commitment to high reliability and zero harm (working to “reduce errors and to ensure that any errors that may occur do not reach our patients and cause harm”), in February 2019, the VA rolled out a new initiative outlining the definitive steps for becoming an HRO. 8 The first step is for HRO activities to begin at 18 lead facilities selected based on greater readiness as demonstrated by higher levels of safety performance, leadership commitment, and staff engagement. Initial HRO activities include the establishment of work groups, performance readiness assessments, and conducting training events and programs. Following analysis of lessons learned from these lead sites, the VA plans a national roll-out to achieve the goal of an VA-wide HRO transformation. To ensure success of HRO-related activities and consistent outcomes across the enterprise, VA is using resources from the Joint Commission Center for Transforming Healthcare resource library, including the Oro 2.0 High Reliability Assessment tool. Additionally, VA is working on developing a standard set of HRO tools, including training, implementation models, and measures.

Emerging literature can guide health systems in implementing and evaluating their HRO journey. 9 , 10 However, an understanding of available frameworks, metrics, and initiatives and their use are currently limited by their complexity and wide variability of their key characteristics, their target participants ( eg , leadership, medical staff), their foundation, their structure, which of the 5 HRO principles they address, and health system setting type. Understanding the quality and applicability of existing HRO resources is important to developing best practices, identifying barriers and facilitators to implementation, spreading implementation initiatives to other systems, measuring progress, and identifying knowledge gaps.

This rapid evidence review will address the following key questions and eligibility criteria:

Key Questions

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. . . , consensus, literature review, )?

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. . , domains, scales) of these metrics?

. , consensus, literature review, )?

. . , number of sites that met goal of 50% reduction in serious safety events)?

. , mean change in number of serious safety events)?

. , mean change in inter-departmental communication, provider or patient satisfaction)?

Eligibility Criteria

The ESP included articles published from January 2010 to January 2019 that describe implementation frameworks, metrics for measuring progress towards becoming an HRO, and its effects. The timeframe of 2010 and onward was selected because it is 2 years after the publication of AHRQ’s 2008 white paper, when one could reasonably expect publication of new research on implementing HRO principles in health care settings. To be included, articles needed to be explicitly grounded in HRO theory and specifically seek to advance organizational or cultural change. We operationalized this by only including articles that evaluated HRO principles at the organization level or higher ( ie , we excluded articles of HRO implementation in individual departments). Outcomes for KQ3 include any that are linked to the pathway between the 5 principles of HROs ( ie , sensitivity to operations, reluctance to simplify, preoccupation with failure, deference to experience, and resilience) and the ultimate goal of health care organizations: exceptionally safe, consistently high-quality care, as outlined in the AHRQ white paper. 4 See Figure 2 below for the logic model linking the 5 HRO principles to the end goal of improved patient safety outcomes, based on the model described in Hines 2008. 4

HRO logic model.

We prioritized articles using a best-evidence approach to accommodate the timeline ( ie , we considered meeting safety goals [ KQ3A ] to be a higher priority than intermediate outcomes [ KQ3B and KQ3C ]). We also prioritized evidence from systematic reviews and multisite comparative studies that adequately controlled for potential patient-, provider-, and system-level confounding factors. We only accepted inferior study designs ( eg , single-site, inadequate control for confounding, noncomparative) to fill gaps in higher-level evidence.

To identify articles relevant to the key questions, our research librarian searched MEDLINE, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials (CCRT) using terms for high reliability and health care from January 2010 to January 2019 (see Supplemental Materials Appendix A for complete search strategies). Additional citations were identified by hand-searching reference lists and consultation with content experts. We limited the search to published and indexed articles involving human subjects available in the English language. Study selection was based on the eligibility criteria described above. Titles, abstracts, and full-text articles were reviewed by one investigator and checked by another. All investigators have expertise in conducting systematic reviews of health services research. Any disagreements were resolved by consensus.

No standard tool is currently available to assess the quality of complex interventions. We therefore culled concepts from reporting checklists for complex interventions, QI initiatives, and implementation interventions – including the Standards for Quality Improvement Reporting Excellence (Squire 2.0), 11 Standards for Reporting Implementation Studies (StaRI), 12 and Template for Intervention Description and Replication TIDieR 13 – to develop a 7-item quality assessment checklist. Through this checklist, we evaluated whether the study adequately reported on (1) the conceptual link between the intervention and HRO principles, (2) intervention components and delivery, (3) implementation fidelity, (4) evaluation of the intervention, (5) adverse events, (6) confounders, and (7) the use of a concurrent control group. We considered items 1-4 to be basic criteria in determining whether the study was reported well enough to be reproduced. We considered items 5-7 to be advanced criteria that would increase our confidence that bias was minimized in the study results (see Supplemental Materials Appendix C for detailed information on the quality assessment checklist). All quality assessments were completed by one reviewer and then checked by another. We did not quantify inter-rater reliability through a kappa statistic; however, qualitatively, our agreement was generally high. Disagreements were generally limited to interpretation of individual risk of bias domains and not overall risk of bias ratings for a study. We resolved all disagreements by consensus.

We abstracted data from all studies and results for each included outcome. All data abstraction and internal validity ratings were first completed by one reviewer and then checked by another. We resolved all disagreements by consensus. We informally graded the strength of the evidence based on the AHRQ Methods Guide for Comparative Effectiveness Reviews by considering study limitations (includes study design and aggregate quality), consistency, directness, and precision of the evidence. 14 Ratings typically range from high to insufficient, reflecting our confidence that the evidence reflects the true effect.

Where studies were appropriately homogenous, we synthesized outcome data quantitatively using StatsDirect statistical software (StatsDirect Ltd. 2013, Altrincham, UK) to conduct random-effects meta-analysis to estimate pooled effects. We assessed heterogeneity using the Q statistic and the I 2 statistic. Where meta-analysis was not suitable due to limited data or heterogeneity, we synthesized the evidence qualitatively.

Throughout the report, we use the following terminology to describe different levels of HRO theory and implementation ( Table 1 ).

Table 1. HRO terminology used throughout report.

HRO terminology used throughout report.

The complete description of our full methods is available on the PROSPERO international prospective register of systematic reviews ( http://www.crd.york.ac.uk/PROSPERO/ ; registration number CRD42019125602). A draft version of this report was reviewed by peer reviewers as well as clinical leadership. Their comments and our responses are presented in the Supplemental Materials (see Appendix D ).

Literature Flow

The literature flow diagram ( Figure 3 ) summarizes the results of search and study selection (see Supplemental Materials Appendix B for full list of excluded studies). Our search identified 525 unique, potentially relevant articles. Of these, we included 20 articles that addressed one or more of our key questions. Eight articles addressed Key Question 1 , 3 , 15 – 21 8 articles addressed Key Question 2 , 3 , 16 , 22 – 27 and 7 articles addressed Key Question 3 . 6 , 17 , 28 – 32

Literature flowchart.

KEY QUESTION 1. What are the frameworks for guiding HRO implementation?

We identified 8 frameworks that guide implementation of HRO principles into a health care system: the Joint Commission’s High Reliability Health Care Maturity Model (HRHCM) 3 ; the Institute for Healthcare Improvement’s (IHI) Framework for Safe, Reliable and Effective Care 18 ; the American College of Healthcare Executives’ (ACHE) Culture of Safety framework 16 ; 2 frameworks developed at Johns Hopkins’ (JH) Armstrong Institute for Patient Safety and Quality including an Operating Management System 17 and a Safety and Quality framework 15 ; the Office of the Air Force Surgeon General’s Trusted Care framework 19 ; Advancing Research and Clinical Practice through close Collaboration (ARCC) Model 20 ; and a framework focused on developing high reliability teams. 21 The Joint Commission’s HRHCM and IHI Framework for Safe, Reliable and Effective Care emerged as the most comprehensive, as they both covered all 5 strategies commonly reported across frameworks ( Figure 4 ); were the most rigorously developed; were broadly applicable; and were sufficiently detailed to inform implementation.

5 Common HRO implementation strategies.

Appendix C of the supplementary materials contains full details on these frameworks’ implementation strategies, development process, and intended settings, as well as staff and processes required for implementation. Highlighted findings appear below.

KQ1A. What are the main implementation strategies of these frameworks?

Table 2 summarizes the 5 commonly reported key HRO implementation strategies from these 8 frameworks.

Table 2. Common HRO implementation strategies across 8 identified frameworks.

Common HRO implementation strategies across 8 identified frameworks.

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In addition, we identified several complementary practices for strengthening implementation . We identified these by looking across the 8 frameworks to see what complementary practices were commonly recommended. These complementary practices are meant to be applied across implementation strategies to strengthen the overall delivery of HRO.

  • Incorporation of justice, equity and patient-centeredness: The ACHE describes building trust, respect and inclusion as a key domain of building a safety of culture. 16 The framework encourages leaders to value diversity and inclusion when selecting leaders and staff and to work towards evaluating and eliminating disparities in patient care. The Air Force selected patient-centeredness as a key domain of its framework. 19 This practice could be integrated into HRO delivery through activities such as hiring a diverse workforce or prioritizing QI initiatives that address safety issues that disproportionately affect patients from racial/ethnic minority groups.
  • Involvement of a variety of stakeholders involved in health care delivery, including patients and families: The JH Operating Management System described establishing patient and family advisory councils as an implementation activity that could be undertaken to advance one of their key implementation strategies. 17 Other possible activities include assessing patient perspectives of culture of safety or inviting patients to serve on HRO leadership committees.
  • Assembling transdisciplinary teams : Several frameworks – including the JH Operating Management System, 17 ARCC model, 20 and high reliability team framework 21 – discuss forming transdisciplinary teams as an important activity towards advancing HRO. This practice could be integrated into HRO delivery through activities like inviting providers from different specialties to attend daily safety huddles; or having nurses, physicians, and staff all attend the same HRO training sessions together.
  • Utilizing change management strategies such as Lean Six Sigma to promote change: Most frameworks recommended health systems use complementary change management strategies – such as Lean Six Sigma, 15 – 17 IHI’s Model for Improvement, 18 or a combination of strategies such as the Joint Commission’s robust process improvement 3 , 19 – to implement HRO principles into practice. This complementary practice could be integrated into several aspects of HRO delivery, such as training staff on Lean Six Sigma, or applying Lean thinking to root cause analysis to identify what is contributing to patient safety events and identifying and implementing solutions.

KQ1B. What were the processes for developing these frameworks ( eg , consensus, literature review, etc )?

The Joint Commission’s HRHCM stood out as being the most rigorously developed framework, as the process involved a literature review, consensus among subject experts, pilot testing among an expert panel, and pilot testing with leadership at 7 US hospitals. However, the latter pilot testing effort was primarily focused on evaluating the tool to measure a health system’s progress on the framework ( KQ2 ). The Air Force 19 and JH Safety and Quality framework 15 were developed through both a literature review and consultation with health care leaders and content experts. The IHI 18 framework was developed specifically for the IHI Patient Safety Executive Development Program curriculum and was informed by an analysis of high-performing, proactive, and generative work settings. The ACHE framework was developed through partnership between the ACHE, the IHI, and the National Patient Safety Foundation (NPSF) Lucian Leape Institute (LLI). It involved consensus-building with industry leaders and experts who have had success in transforming their organizations into system-wide cultures of safety. 16 The ARCC model was initially developed through a strategic planning process on how to rapidly integrate research findings into clinical processes. 20 The 2 remaining articles did not discuss the process of how frameworks were developed (JH Operating Management System, 17 high reliability teams 21 ).

KQ1C. What are the intended settings of these frameworks?

All frameworks were intended to be delivered in any health care delivery setting, except for the Air Force’s framework, which was designed specifically for the Air Force Medical Service. 19 IHI’s framework was initially developed for use in acute care settings, although it has since evolved to be applicable to other settings. 18

KQ1D. Who participates in implementing these frameworks?

Most frameworks were intended to be implemented by a variety of health care leaders, providers, and staff, including frontline providers, local and middle managers, and high-level managers and executives, as well as safety and quality leaders, across a variety of service areas. 3 , 15 , 18 – 20 IHI’s framework also included components to be implemented by patients and families. 18 Exceptions are the ACHE 16 and the JH Operating Management System 17 frameworks, which were specifically designed for health care leadership, 16 and the high reliability team framework which was designed for nursing professionals. 21

KQ1E. What are the processes for implementing these frameworks?

Articles varied in the depth of information provided on how to operationalize the implementation of these frameworks, with the ARCC, Joint Commission, and IHI models emerging as the most comprehensive.

  • The ARCC model provided details on providing learning and training opportunities ( ie , 6 educational workshops, 8 days of educational and skills-building sessions over 1 year), as well as on implementing an intervention to address a specific patient safety issue ( ie , 12-month project focused on improving quality of care, safety, and/or patient outcomes). 20
  • The Joint Commission 3 and IHI 18 provided high-level recommendations for operationalizing HRO implementation, including building and using tools to measure progress ( ie , assess the current state of HRO maturity; develop tools to advance maturity), as well as specific examples of activities that could advance these strategies.

Other frameworks provided some guidance on how to operationalize implementation, although they were less comprehensive.

  • ACHE described 2 levels of implementation practices: foundational practices which focus on laying the groundwork for HRO implementation and sustaining practices which focus on spreading and embedding HRO concepts, specifically a culture of safety. 16
  • The JH Operating Management System suggests approaches to implementing the core concepts of the model, including developing and using data systems ( ie , providing leaders with a standardized reporting format to assist in reporting on department progress), using systems engineering methodology, and convening stakeholder groups. 17
  • The JH Safety and Quality initiative provided recommendations based on the role of a specific health care provider or staff member. For example, they have specific suggestions on training and learning opportunities ( ie , provide front line providers and staff with basic medical school education on safety and quality; provide managers with patient safety certificate programs and workshops on Lean Six Sigma and other change management processes). 15
  • The Air Force’s suggestions for operationalization include standardizing and stabilizing processes, engaging staff in behaviors to continuously improve these processes, mentoring staff, and leadership goal-setting, as well as a description of the desired future state of HRO integration into practice. 19
  • The high reliability team framework described specific approaches that touch on several implementation strategies including learning and training opportunities ( ie , simulation training and provision of a structured HRO curriculum) and supporting a culture of safety ( ie , development of a just culture system for penalizing staff when patient harm occurs). 21

KEY QUESTION 2. What are the metrics for measuring a health system’s progress towards becoming an HRO?

We identified 8 articles 3 , 16 , 22 – 27 on 6 tools for measuring the progress toward becoming an HRO ( Table 3 ). The Joint Commission’s HRHCM/Oro TM 2.0 emerged as the most rigorously developed, validated, and applicable tool for VA settings. However, other tools such as the ACHE’s Culture of Safety Organizational Self-Assessment Tool 16 may be useful in developing specific items missing from the Oro TM 2.0 framework, such as teamwork culture and system-focused tools for learning and improvement. 27 Four additional tools have unclear applicability to the VA, as they were developed in countries outside the US, 22 – 25 did not report measurement items, 23 , 24 or require qualitative expertise to analyze results. 22 Full details on these studies appear in Supplementary Materials, Appendix C , and selected findings appear below.

The tool that most comprehensively addressed all 5 HRO implementation strategies identified in KQ1 was the HRHCM/Oro TM 2.0. 3 , 34 As discussed in KQ1 , the HRHCM is the Joint Commission’s framework for implementing HRO principles. This framework includes 4 levels (beginning, developing, advancing, approaching) for each of the 14 components (56 total) to guide health care leaders in assessing their systems’ level of maturity on becoming an HRO. The Oro TM 2.0 is a web-based application that uses branching logic to guide health care leaders through the HRHCM assessment and produces a visual report that synthesizes data from multiple respondents within a single hospital. 34 Of note, the Oro TM 2.0 was designed to be used at the individual hospital, rather than at a system level, and is only available to Joint Commission-accredited organizations. The tool outputs data into reports that could theoretically be shared between hospitals but it is not an automatic feature.

To develop the metrics used in by the HRHCM/Oro TM 2.0, a team at the Joint Commission spent over 2 years engaging with high reliability experts from academia and industry, leading safety scholars outside of health care, and the published literature. 3 Iterative testing with hospital leaders – first among 5 individuals in executive leadership positions, then among leadership teams from 7 US hospitals – was conducted to finalize the framework and included metrics. The resultant tool has since been validated in peer-reviewed research studies, including 1 study that tested the content validity of the tool at 6 VA sites. 27 Another study tested the internal reliability and discriminative ability in detecting different levels of HRO maturity in 46 hospitals from the Children’s Hospitals’ Solutions for Patient Safety network. 26

The VA study was a secondary analysis of qualitative data from 138 VA employees with patient safety expertise at various levels of leadership ( eg , patient safety managers, executive leadership and service chiefs, infection control nurses) from 6 VA sites. The original study validated the AHRQ-developed patient safety indicator tool; the secondary analysis looked at how well responses mapped onto the Joint Commission’s HRHCM model. Researchers found that 12 of the 14 HRHCM components were represented, indicating good content validity. Two additional HRO components were identified through interviews that were not represented in the HRHCM model: teamwork culture and systems-focused tools for learning and improvement. While less applicable to the VA, the study that tested the HRHCM in 46 children’s hospitals found that the HRHCM had good internal reliability (Cronbach’s alpha = 0.72 to 0.87, depending on the domain), good discriminative ability ( ie , health system average scores on beginning, developing, advancing, and approaching levels of maturity resembled a bell curve), and was responsive to change ( ie , safety culture decreased after major organizational changes), indicating it may perform well at detecting progress on becoming an HRO.

Table 3. Metrics for measuring progress on becoming an HRO.

Metrics for measuring progress on becoming an HRO.

ACHE Culture of Safety Organizational Self-Assessment Tool

While less comprehensive, rigorously developed, or evaluated than the HRHCM/Oro TM 2.0, the ACHE’s Culture of Safety Organizational Self-Assessment Tool is an additional metric for evaluating progress on becoming an HRO. It incorporates additional perspectives ( ie, patients, families) and specific items ( eg , teamwork culture) that may be informative to the VA.

The ACHE tool addresses 3 (leadership, culture of safety, and data systems) of the 5 key HRO implementation strategies. It consists of 18 items concerning an organization’s capabilities and processes scored on a 5-point Likert scale. Lower (worse) scores prompt a review of foundational tactics towards becoming an HRO, moderate scores prompt a review of both foundational and sustaining tactics, and higher (better) scores prompt a review of sustaining tactics. 16

The ACHE tool was developed through partnership with the IHI/NPSF LLI and others as described in KQ1 . 16 The tool has not undergone any formal validation processes. While limited in terms of the number of strategies covered and extent of validity testing, the ACHE tool offers 2 additional features not covered by the HRHCM/Oro TM 2.0. First, it specifically seeks perspectives beyond leadership, including providers and staff, as well as patients and families. However, of note, patients and families may have difficulty completing many of the ACHE tool items, such as the extent to which board members spend discussing patient safety issues in meetings and the extent to which leadership performance assessments and incentives are aligned with patient safety metrics. Second, the ACHE tool includes items related to teamwork and systems, such as the item: “My organization uses and regularly reviews a formal training program and defined processes for teamwork and communication.”

Other tools

We identified 4 additional tools that covered 2 or fewer of the 5 HRO implementation strategies. They have more limited applicability to the VA due to their narrower focus, lack of reporting on the specific tool items, and/or development outside the US.

The Cultural Assessment Survey (CAS) is a metric used to measure culture of patient safety and was designed specifically for use in obstetric units in Canada. 23 The CAS had a rigorous development process, including a literature review to develop a list of over 100 values and practices that support a culture of safety, a short list of prioritized values and practices developed after sending the 300 surveys to employees at 8 hospitals, a pilot test of the short list at 10 hospitals, and testing of its internal reliability and content validity. However, the article did not include a copy of the tool or the items included in the tool. The narrow focus on obstetric units also limits the applicability of the tool to the VA’s broad HRO implementation.

The University of Tehran developed 2 metrics: The first is a 55-item survey assessing a health care system’s readiness for HRO implementation. It was developed through a literature review and pilot-testing among 98 senior or middle managers from 15 hospitals. 24 The second is a 24-item survey and checklist that assesses knowledge of HRO concepts and integration of HRO principles into practice. It was developed through interviews with managers and staff at 80 medical and nonmedical departments. 25 These metrics are notable as being the only ones specifically designed around the 5 HRO principles described by Hines et alia 2008. 4 However, both metrics were limited in terms of the extent to which they covered HRO implementation strategies – with one assessing 2 out of 5 strategies 25 and the other with unclear coverage, as it did not report any specific examples of its metric items. 24 Both of these were evaluated in terms of their content validity and performed well. However, the applicability of these tools to the VA is unclear, as they were developed for a specific health care system in Tehran, Iran.

One additional metric developed by the Delft University of Technology in the Netherlands offers a qualitative framework for assessing level of reliability. 22 This framework resembled the HRHCM/ORO 2.0 in that it has 4 stages of maturity: craft, watchful professional, collective professionalism, and high reliability. It was developed through literature review to identify the common domains that are essential to high reliability hospitals and did not undergo any validity testing. This metric also has unclear applicability to the VA, due to significant differences between the US and Dutch health care systems. Delivering the framework in its current state at the VA would also be challenging, as it has open-ended items to promote thinking about the overall strengths and limitations of a health care system, rather than specific questions to which a provider or health care leader could concretely respond ( eg , under organizational culture, a less reliable hospital would have qualities of “learning by doing” while a more reliable hospital would have “a preoccupation with possible failure.”)

KEY QUESTION 3. What is the evidence on HRO implementation effects?

We identified articles from 7 health care organizations, primarily children’s hospitals, on the effects of HRO initiative implementation on safety culture, HRO process, and patient safety measures. 6 , 17 , 28 – 32 Full details on these articles are available in Supplementary Materials Appendix C , and selected findings appear below.

The most notable finding is that organizations experienced significant reductions in serious safety events (SSEs) (range, 55% to 100%) following the implementation of the 4 most comprehensive, multicomponent HRO initiatives. 6 , 29 – 31 Moreover, time since initiation and safety improvements appear to have a dose-response relationship, and the improvements were maintained for upwards of 9 years ( Table 4 ). 6 , 29 – 31 Of note, only one of these studies explicitly discussed using one of the frameworks discussed in KQ1 ( ie , the IHI framework). 6 Two years after implementation, SSE reductions were 55% and 83%, respectively, in hospitals with a 12-month average of 0.9 (Ohio Children’s Hospital Association) 30 and 1.15 (Nationwide Children’s Hospital) 6 SSEs per 10,000 adjusted patient days. At 4 years, Cincinnati Children’s Hospital Medical Center reported a 67% reduction in SSE rates and a baseline 12-month average of 0.9 events per 10,000 adjusted patient days. 31 After 9 years, Genesis Health System reported achieving its goal of zero SSE (100% reduction). 29 In these studies, SSE was typically defined as “the most serious harm events that occur in hospitals and are defined by serious patient harm events that directly results from a deviation in best practice or standard of care.” 30 Improvements in safety culture were also reported, including improvement in safety attitudes 6 and an increase in safety success story reporting, 29 but changes across various other safety culture dimensions had mixed results. 31 At Cincinnati Children’s Hospital Medical Center, 31 responses to the AHRQ Hospital Survey on Patient Safety Culture indicated improvements in organizational learning and continuous improvement, feedback and communication about error, and staffing. However, they reported no change in supervisor/manager expectations and actions promoting safety, teamwork within hospital units, nonpunitive responses to error, and a decline in communication openness.

A commonality across the 4 hospitals that reported SSE reductions is that they implemented their HRO initiative with the help of the same external consultant, Healthcare Performance Improvement (HPI), LLC. 6 , 29 – 31 Although the components varied somewhat across these 4 hospitals, they generally aligned with the 5 strategies discussed in KQ1 : (1) developing leadership ( eg , leadership training); (2) supporting a culture of safety ( eg , increased communication through safety huddles; routine sharing of good catches and lessons learned); (3) providing training and learning opportunities for providers and staff ( eg , error prevention training for staff; provider peer safety coaches coached their peers in use of the error prevention techniques); (4) building and using data systems to track progress ( eg , enhanced root cause analysis processes using an electronic tracking system); and (5) implementing interventions to address specific patient safety issues ( eg , embedding “time outs” and “debriefs” into standard surgical processes, using standardized checklists). Despite these similarities, initiatives conceptualized their goals of zero patient harm in different ways: one initiative’s board encouraged management to “aspire to eliminate preventable harm” by reducing the preventable harm index to zero 6 ; one aimed to reduce SSEs to zero 29 ; and 2 others aimed to reduce SSEs by 75%-80%. 30 , 31 In addition, the structure of the Ohio Children’s Hospital Association was unique in that it is a state-wide collaboration of 8 tertiary pediatric referral centers that specifically refuse to compete on matters related to patient safety. 30 To promote transparent sharing of critical safety data among the collaborative to facilitate lessons learned without fear of undue liability, Ohio House Bill 153 was passed in 2010 to provide a legal framework expressly providing peer review protection for the 8 participating hospitals.

In addition to the 4 HPI-assisted initiatives, we also identified a similarly comprehensive initiative independently implemented by JH Hospital and Health System: the Operating Management System. 17 Although the study did not report on SSEs, the authors reported improved compliance in Joint Commission process measures and a 79% reduction in potential preventable harms.

Finally, we found that process improvements are possible even with less intensive HRO initiatives that are more focused in scope. 28 , 32 When the Riley Hospital for Children at Indiana University Health implemented a Daily Safety Brief, they found improvement in communication, awareness, and working relationships, but not in comfortability in sharing errors. 32 The Children’s National Medical Center experienced an increase in Apparent Cause Analysis (ACA) reliability scores following implementation of 13 interventions across education, process, and culture categories. They also reported an increase in efficiency (4 fewer days to turn around ACA) and increased satisfaction with the process. 28

While the results of these studies are promising, the overall strength of this evidence is low. Each initiative was only evaluated in a single study (consistency unknown), and each study was fair quality (common methodological weaknesses included lack of reporting on implementation fidelity and no concurrent control groups), with generally indirect outcomes and populations (few reported whether they met their goal of zero harm; none were conducted in Veterans). The main strengths of these studies were that they generally provided sufficient detail on how the intervention is conceptually linked to HRO, their main intervention components, and how they evaluated effects. Their main limitation was that a cause-effect relationship could not be established between these HRO initiatives and outcomes, because no study used a concurrent control group that would have ruled out the possibility that the effect was due to concurrent interventions ( eg , implementation of an Electronic Medical Record [EMR]) or improved specialty-specific disease management). 6

Table 4. Key findings from studies assessing effects of HRO implementation.

Key findings from studies assessing effects of HRO implementation.

  • Summary and Discussion

To our knowledge, this is the first evidence review to systematically evaluate primary research on the effects of HRO implementation in health care settings. Furthermore, although much has been written about the concepts of HRO and individual health care systems’ experience with HRO implementation, few have looked across different systems to describe similarities and differences in frameworks and metrics, and what lessons might be learned based on the successes and challenges encountered using different approaches. Gaining a better sense of how HRO has been successfully delivered is critical to informing the work of the VA and other health systems as each embarks on its HRO journey.

Although a variety of frameworks for implementation of HRO principles are available, the Joint Commission’s HRHCM and the IHI’s Framework for Safe, Reliable, and Effective Care stand out as being the most comprehensive, applicable, and sufficiently descriptive to be used by the VA. Both of these frameworks cover 5 common HRO implementation strategies seen across frameworks, including (1) developing leadership, (2) supporting a culture of safety, (3) building and using data systems to track progress, (4) providing training and learning opportunities for providers and staff, and (5) implementing interventions to address specific patient safety issues. Complementary practices to strengthen implementation seen across these frameworks include the need to incorporate an awareness of justice, equity, and patient-centeredness into all elements of HRO implementation; the importance of involving a variety of stakeholders involved in health care delivery, including patients and families; and the value of integrating change management strategies into HRO delivery. The selection of one of these frameworks – or development of a new framework – should be informed by the staff being targeted for HRO implementation ( eg , all providers and staff, only leadership, only nursing professionals); the approach desired ( eg , developing a high-level operations management system vs training staff and providers on HRO principles and practices); and the capacity of the system in implementing certain components of the HRO framework ( eg , a system that does not have strong leaders in evidence-based medicine may not want to implement the ARCC model).

Of the metrics available to evaluate a health system’s progress towards becoming an HRO, the Joint Commission’s HRHCM/Oro 2.0 TM is the most comprehensive, rigorously developed, and applicable to the VA HRO initiative, given that its content validity has been evaluated at 6 VA hospitals. 27 This tool was not designed to facilitate sharing data across hospitals; however, the tool outputs data into reports that could be shared. Of note, findings from the VA validation study 27 indicate that certain concepts (teamwork culture and system-focused tools) are missing from the HRHCM framework and should be added. An example from the ACHE tool that might address these concepts include: “My organization uses and regularly reviews a formal training program and defined processes for teamwork and communication.” 16 The VA HRO Initiative may consider adding these or similar concepts to the current tool being used to assess VA sites’ progress on becoming HROs. Additionally, other tools published prior to 2010 may be appropriate for capturing process outcomes on the pathway between the 5 HRO concepts and the end-goal of improved safety outcomes, such as the Safety Attitudes Questionnaire 35 and the Safety Organizing Scale. 36

Multicomponent HRO interventions that incorporate some of the 5 common HRO implementation strategies identified in KQ1 and that are delivered for at least 2 years are associated with improved process outcomes ( eg , staff reporting of safety culture) and patient safety outcomes ( eg , SSEs). However, the overall strength of evidence is low, as each HRO intervention was only evaluated in a single fair-quality study. Successful facilitators to implementation may include hiring an outside consultant ( eg, HPI) to assist in the implementation, enacting of policies to facilitate data sharing ( eg , passage of a state house bill to enable a collaborative of children’s hospitals to share critical safety data 30 ), and leadership committing to implementing HRO principles. Barriers to implementation may include competing priorities, such as widescale implementation of an EMR system 30 , and costs ( eg , one system increased quality improvement staff from 8 to 33, with a budget increase of over $2 million 6 ).


Primary study limitations.

HRO interventions and other complex interventions are inherently difficult to study, because many interventions are implemented by many different people across multiple time points. Each hospital may also choose to implement different components of HRO interventions, depending on their individual needs and context. As a result, isolating the specific components of an HRO intervention that cause a specific effect on process and patient safety outcomes is difficult. 37 Furthermore, without a control group, we cannot conclude that the HRO intervention, rather than another concurrent intervention or secular trend, caused the change. One study commented that other simultaneously implemented interventions, including EMR implementation and improved specialty-specific disease management, may have contributed to improved outcomes. 6 EMR implementation is likely to be a confounder across multiple studies and could improve patient safety by making it easier to find and use patient health information, to collaborate with colleagues in other departments, and by building checklists and other automated processes into patient appointments. Other plausible confounders include utilization of other change management strategies, such as Lean Six Sigma, before or during the HRO implementation. Therefore, while promising, evidence of improved outcomes after HRO implementation should be interpreted cautiously.

Many studies commented that HRO was delivered among high-performing hospitals. Whether or not lower-performing hospitals would have the same outcomes is unclear. In addition, few studies commented on the fidelity of implementation or compliance, such as whether providers attended the required number of trainings or continually maintained safety event reporting systems. Therefore, we cannot determine whether health care staff continued to be invested in HRO implementation over time. Studies that reported some compliance measures reported that staff responses to culture surveys increased over time and the number (but not percent) of providers that completed trainings. Only 1 study described the potential unintended consequences of HRO implementation ( ie, ACA turnaround time decreased). 28 Study authors hypothesized that reasons for this increased efficiency included the availability of a standardized toolkit, clear rubrics to follow, and the availability of additional resources facilitated completion of the process. The effect of HRO implementation on provider and staff workload and efficiency is an important research question that should be the subject of future research.

Rapid review limitations

First, searching from 2010 forward means that we did not include earlier publications on HRO framework design and implementation. However, our search strategy and consultation with topic experts likely resulted in identification of the most recent and relevant articles that incorporated AHRQ’s conceptualization of the 5 HRO principles in healthcare settings. Second, our use of a single investigator to review articles, with second reviewer checking, may also have resulted in missing eligible studies. However, we used objective criteria to minimize the potential for differences between investigators. Finally, our quality assessment checklist on complex interventions was not designed to conduct a comprehensive assessment of all areas of bias, but rather to ascertain whether the study authors reported enough information that the intervention and evaluation could be reproduced and to highlight common issues in reporting and methodology seen across studies. Therefore, while it may not have captured all areas of bias seen in these studies, the use of another more formal tool would likely not have changed our conclusions.

Gaps and Future Research

The biggest gaps in knowledge on HRO implementation are (1) whether the improvements in process and safety outcomes are truly caused by HRO interventions or due to concurrent interventions or secular trends; (2) if HRO does indeed lead to improved outcomes, which components of HRO interventions are causing the effects; (3) whether certain implementation frameworks lead to better outcomes; and (4) what are the contextual factors (such as barriers and facilitators) affecting successful HRO implementation. Randomized controlled trial study designs are not a practical option for evaluating HRO interventions due to both the complexity of intervention as well as the delivery; therefore, other study designs such as quasi-experimental or natural experiments should be utilized instead. The VA HRO initiative is in a unique position to conduct these types of experiments. Implementing HRO principles at a select number of VA sites while other sites serve as a “wait-list” control would create a natural experiment to see if HRO implementation leads to improved outcomes. If this approach is taken, consideration should be given to how much wait-list control sites have begun implementing HRO concepts on their own or whether they’re implementing similar initiatives such as Lean Six Sigma. In addition, the widescale implementation of HRO across different sites likely means that each site will deliver slightly different interventions based on their individual contexts. Careful recording of the intervention components, when they were delivered, where they were delivered ( eg , medical or surgical service areas), and whether they continued to be delivered may help to elucidate the effects of some of these individual intervention components on outcomes. This can inform where to invest future resources, and to tailor HRO delivery to specific contexts.

In addition, we were unable to determine what the mechanism of change was between HRO implementation and improvement in outcomes. While HRO delivery is theorized to lead to change in thinking about patient safety , resulting in improved processes and outcomes, this was not empirically examined in any of our included studies. Instead, some studies suggested that the impact of HRO on other process measures, such as safety culture, is mixed. 31 This indicates that the mechanism of action driving changes in outcomes is more complex. Future studies should evaluate what is the mechanism of change, such as improved mindfulness or safety culture, to help answer both the how and why HRO implementation may lead to improved patient safety outcomes. Future studies may also want to consider the extent to which HRO implementation overlaps – or doesn’t – with system redesign strategies, as these are complementary approaches to improving quality of care.


A variety of frameworks and evaluation tools are available for HRO implementation and evaluation, with the Joint Commission’s High Reliability Health Care Maturity (HRHCM)/ORO 2.0 among the most rigorously developed and validated. Multicomponent HRO interventions that include several of the 5 common implementation strategies and that are delivered for at least 2 years are associated with improved process outcomes, such as staff perceptions of safety culture, and important patient safety outcomes, such as reduced SSEs. Future research studies should incorporate concurrent control groups through quasi-experimental designs to rule out the possibility that the effects are due to other interventions or secular trends. Future research should also focus on identifying whether certain frameworks, metrics, or components of interventions lead to greater improvements.

  • Acknowledgments

This topic was developed in response to a nomination by the VA National Center for Patient Safety for the purpose of informing the implementation of the VA’s High Reliability Organization Initiative. The scope was further developed with input from the topic nominators ( ie , Operational Partners), the ESP Coordinating Center, and the technical expert panel.

In designing the study questions and methodology at the outset of this report, the ESP consulted several technical and content experts. Broad expertise and perspectives were sought. Divergent and conflicting opinions are common and perceived as healthy scientific discourse that results in a thoughtful, relevant systematic review. Therefore, in the end, study questions, design, methodologic approaches, and/or conclusions do not necessarily represent the views of individual technical and content experts.

The authors gratefully acknowledge Emilie Chen and Julia Haskin for editorial support, Scott Grey for his expertise on HRO research, and the following individuals for their contributions to this project:

Operational Partners

Operational partners are system-level stakeholders who have requested the report to inform decision-making. They recommend Technical Expert Panel participants; assure VA relevance; help develop and approve final project scope and timeframe for completion; provide feedback on draft report; and provide consultation on strategies for dissemination of the report to field and relevant groups.

  • William Gunnar, MD Executive Director National Center for Patient Safety
  • Amy Kilbourne, PhD, MPH Director Quality Enhancement Research Initiative

Technical Expert Panel

  • Laura Damschroder, MPH, MS Center for Clinical Management Research Ann Arbor, MI

Key Informants

The ESP sought input from 2 Key Informants with diverse experiences and perspectives in implementing HRO interventions into large, integrated health care systems.

  • Glenda J. L. Battey, PhD Providence St Joseph Health Renton, WA
  • Robert G. Ritter, FACHE Harry S. Truman Memorial Veterans’ Hospital Columbia, MO

Peer Reviewers

The Coordinating Center sought input from external peer reviewers to review the draft report and provide feedback on the objectives, scope, methods used, perception of bias, and omitted evidence. Peer reviewers must disclose any relevant financial or non-financial conflicts of interest. Because of their unique clinical or content expertise, individuals with potential conflicts may be retained. The Coordinating Center and the ESP Center work to balance, manage, or mitigate any potential nonfinancial conflicts of interest identified.

  • Supplemental Materials

APPENDIX A. Search Strategies

1. Search for current systematic reviews

Date Searched: 1/31/19

Search: High-reliability
Search: High-reliability

(NHS Evidence)

Search: “High-reliability”
VA Products: VATAP, PBM, HSR&D publications, VA ART Database ​.hsrd.research ​.va.gov/research/default.cfm ​.research.va ​.gov/research_topics/ ​.puget-sound ​.med.va.gov/default.cfm ​.hsrd.research ​.va.gov/publications/esp/ Search: High-reliability
Cochrane Database of Systematic Reviews

Database: EBM Reviews - Cochrane Database of Systematic Reviews <2005 to January 30, 2019>

Search Strategy:


1 (High-reliability organization* or High-reliability practice* or High-reliability principle* or High-reliability healthcare or High-reliability health care).mp. (0)


Search: High-reliability

Relevant Results:

Search: High-reliability
Search: High-reliability
Search: High-reliability
Search: High-reliability

(formerly IOM)

Search: High-reliability
Search: High-reliability
Search: High-reliability
Search: High-reliability
Search: High-reliability

2. Systematic reviews currently under development (forthcoming reviews & protocols)

Date Searched: 1/31/19


(SR registry)

Search: High-reliability

(SR Protocols)

Search: High-reliability

3. Current primary literature

Date Searched: 1/31/19


Database: Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions(R) <1946 to January 28, 2019>

Search Strategy:


1 (High-reliability organization* or High-reliability practice* or High-reliability principle* or High-reliability healthcare or High-reliability health care).mp. (211)



Database: CINAHL Plus with Full Text

Search Strategy:


1 TX (High-reliability organization* or High-reliability practice* or High-reliability principle* or High-reliability healthcare or High-reliability health care) (370)

2 Limit Source Type: Academic Journals (217)



Database: PsycINFO <1806 to January Week 3 2019>

Search Strategy:


1 (High-reliability organization* or High-reliability practice* or High-reliability principle* or High-reliability healthcare or High-reliability health care).mp. (175)



Database: EBM Reviews - Cochrane Central Register of Controlled Trials <December 2018>

Search Strategy:


1 (High-reliability organization* or High-reliability practice* or High-reliability principle* or High-reliability healthcare or High-reliability health care).mp. (1)


Search: “High-reliability organization*”[All Fields] or “High-reliability practice*”[All Fields] or “High-reliability principle*”[All Fields] or “High-reliability healthcare”[All Fields] or “High-reliability health care”[All Fields]

APPENDIX B. List of Excluded Studies

Exclude reasons: 1=Ineligible population, 2=Ineligible intervention, 3=Ineligible comparator, 4=Ineligible outcome, 5=Ineligible timing, 6=Ineligible study design, 7=Ineligible publication type 8=Outdated or ineligible systematic review

#CitationExclude reason
1Brass SD, Olney G, Glimp R, Lemaire A, Kingston M. Using the Patient Safety Huddle as a Tool for High Reliability. Joint Commission journal on quality and patient safety. 2018;44(4):219-226.E4
2Carrico R. The Joint Commission aims for high-reliability health care, unveils framework to move hospitals toward zero harm. ED management : the monthly update on emergency department management. 2013;25(12):suppl 3-4, 139.E7
3Clements K. High-reliability and the I-PASS communication tool. Nursing management. 2017;48(3):12-13.E4
4Davenport PB, Carter KF, Echternach JM, Tuck CR. Integrating High-Reliability Principles to Transform Access and Throughput by Creating a Centralized Operations Center. Journal of Nursing Administration. 2018;48(2):93-99.E2
5Deloitte. Transforming into a high reliability organization in health care. 2017.E2
6Eriksson N. Followership for organizational resilience in health care. In: The resilience framework: Organizing for sustained viability. New York, NY: Springer Science + Business Media; US; 2018:163-179.E10
7Fieldston E, Tsarouhas N. CT hospital slashes door-to-balloon times to reduce patient harm. ED Management. 2014;26(7):80-83.E7
8Gabriel PE, Bergendahl HW, Burke SV, Solberg TD, Maity A, Hahn SM. Incident Learning in Pursuit of High Reliability: Implementing a Comprehensive, Low-Threshold Reporting Program in a Large, Multisite Radiation Oncology Department. Joint Commission Journal on Quality & Patient Safety. 2015;41(4):160-168.E5
9Griffith JR. Understanding High-Reliability Organizations: Are Baldrige Recipients Models? Journal of Healthcare Management. 2015;60(1):44-61.E2
10Hales DN, Chakravorty SS. Creating high reliability organizations using mindfulness. Journal of Business Research. 2016;69(8):2873-2881.E5
11Hendrich A, Haydar Z. Building a High-Reliability Organization: One System’s Patient Safety Journey. Journal of healthcare management / American College of Healthcare Executives. 2017;62(1):13-17.E2
12Hershey K. Culture of safety. Nurs Clin North Am. 2015;50(1):139-152.E7
13Jones WS. Military Graduate Medical Education: Training the Military Health System into a High-Reliability Organization. Military medicine. 2015;180(11):1121-1123.E7
14Knox GE, Simpson KR. Perinatal high reliability. Am J Obstet Gynecol. 2011;204(5):373-377.E7
15Lyren A, Brilli RJ, Zieker K, Marino M, Muething S, Sharek PJ. Children’s Hospitals’ Solutions for Patient Safety Collaborative Impact on Hospital-Acquired Harm. Pediatrics. 2017;140(3).E2
16Magnano P, Platania S, Ramaci T, Santisi G, Di Nuovo S. Validation of the Italian version of the Mindfulness Organizing Scale (MOS) in organizational contexts. TPM-Testing, Psychometrics, Methodology in Applied Psychology. 2017;24(1):45-64.E5
17May EL. The power of zero: steps toward high reliability healthcare. South Carolina Safe Care Commitment. Healthcare executive. 2013;28(2):26.E7
18McCraw B, Crutcher T, Polancich S, Jones P. Preventing Central Line-Associated Bloodstream Infections in the Intensive Care Unit: Application of High-Reliability Principles. Journal for Healthcare Quality. 2018;40(6):392-397.E2
19McFarland DM, Doucette JN. Impact of High-Reliability Education on Adverse Event Reporting by Registered Nurses. Journal of nursing care quality. 2018;33(3):285-290.E5
20Middleton LP, Phipps R, Routbort M, et al. Fifteen-Year Journey to High Reliability in Pathology and Laboratory Medicine. American Journal of Medical Quality. 2018;33(5):530-539.E2
21Mossburg SE, Weaver SJ, Pillari M, Daugherty Biddison E. Manifestations of High-Reliability Principles on Hospital Units With Varying Safety Profiles: A Qualitative Analysis. Journal of nursing care quality. 2018;21:21.E4
22Oster CA, Deakins S. Practical Application of High-Reliability Principles in Healthcare to Optimize Quality and Safety Outcomes. Journal of Nursing Administration. 2018;48(1):50-55.E7
23Prasanna P, Nagy P. Learning from high-reliability organizations. J. 2011;8(10):725-726.E7
24Pronovost PJ, Armstrong CM, Demski R, et al. Creating a high-reliability health care system: improving performance on core processes of care at Johns Hopkins Medicine. Academic medicine : journal of the Association of American Medical Colleges. 2015;90(2):165-172.E2
25Provost SM, Lanham HJ, Leykum LK, McDaniel RR, Jr., Pugh J. Health care huddles: managing complexity to achieve high reliability. Health care management review. 2015;40(1):2-12.E2
26Quigley PA, White SV. Hospital-based fall program measurement and improvement in high reliability organizations. Online journal of issues in nursing. 2013;18(2):5.E2
27Roney L, Sumpio C, Beauvais AM, O’Shea ER. Describing clinical faculty experiences with patient safety and quality care in acute care settings: A mixed methods study. Nurse education today. 2017;49:45-50.E2
28Saunders CL, Brennan JA. Achieving High Reliability with People, Processes, and Technology. Frontiers of health services management. 2017;33(4):16-25.E2
29Shabot MM. New tools for high reliability healthcare. BMJ quality & safety. 2015;24(7):423-424.E2
30Sitterding M. Overview and Summary: Creating a Culture of Safety: The Next Steps. Online journal of issues in nursing. 2011;16(3):1-1.E7
31The Health Foundation. Evidence Scan: High reliability organisations. 2011.E6
32Thomas AD, Pandit C, Krevat SA. Race Differences in Reported Harmful Patient Safety Events in Healthcare System High Reliability Organizations. Journal of patient safety. 2018.E4
33Van Spall H, Kassam A, Tollefson TT. Near-misses are an opportunity to improve patient safety: adapting strategies of high reliability organizations to healthcare. Curr. 2015;23(4):292-296.E7
34Vogus TJ, Singer SJ. Creating Highly Reliable Accountable Care Organizations. Medical Care Research & Review. 2016;73(6):660-672.E7
35Wasden ML. High-Reliability Principles Must Be Tied to Value-Based Outcomes. Frontiers of health services management. 2017;33(4):26-32.E7
36Wentlandt K, Degendorfer N, Clarke C, et al. The Physician Quality Improvement Initiative: Engaging Physicians in Quality Improvement, Patient Safety, Accountability and their Provision of High-Quality Patient Care. Healthcare quarterly (Toronto, Ont). 2016;18(4):36-41.E7
37Woodhouse KD, Volz E, Maity A, et al. Journey Toward High Reliability: A Comprehensive Safety Program to Improve Quality of Care and Safety Culture in a Large, Multisite Radiation Oncology Department. Journal of oncology practice/American Society of Clinical Oncology. 2016;12(5):e603-612.E2

APPENDIX C. Evidence Tables

Data Abstraction: Key Question 1 Studies (PDF, 111K)

Data Abstraction: Key Question 2 Studies (PDF, 77K)

Data Abstraction: Key Question 3 Studies (Part 1) (PDF, 49K)

Data Abstraction: Key Question 3 Studies (Part 2) (PDF, 80K)

Quality Assessment Of Included Primary Studies (PDF, 61K)

APPENDIX D. Peer Review Comments

Comment #Reviewer #CommentAuthor Response
or studies that we may have overlooked?
195Yes - Zero Harm: how to achieve patient and workforce safety in health care, 2019, Clapper, Merlino & Stockmeier (editors). Press Ganey associates inc.
217No - I think that ESP was very thorough in their literature search and found all the relevant articles for this review. There is a book titled Managing the Unexpected: Sustained performance in a complex world, by Karl Weick & Kathleen Sutcliffe, 3rd Edition, Wiley & Sons, New York, NY., that has a Mindful Organizing Scale (p. 43) that is noteworthy. This scale was originally published in 2007, so it fell outside of the scope of this review. It is one of the few such scales and may be worth mentioning in the review.
221This is an excellent and well-written report of a difficult topic (because of it’s “fuzzy” definitions) in a quick timeframe. I would say it’s quite responsive to our partners’ request for state of published knowledge on HRO. It will provide an excellent starting point to inform VA’s push toward more mature HROs throughout the system. My comments below are suggested in the spirit of further strengthening the report.

1. The authors seem to rely on the AHRQ report on HRO as the “core” or “standard” definition for HRO. This is implied by the timeframe for review starting with 2008 (2 years after AHRQ’s 2008 report). If this is the case, then this should be stated at the beginning and reinforced throughout.

1a. E.g., L40, p1: needs a citation… AHRQ?

2412. The authors need to more clearly differentiate the domains of HRO (as listed in the AHRQ report) versus the components (or strategies) for ‘implementation*. This language needs to be set forth early in the report. The KQs all relate to information about ‘implementation* (of the AHRQ-defined HRO framework with the 5 domains)…and measurement from “implementation domains” to “implementation strategies.” The 5 components of the AHRQ HRO model are described as “principles.”
2512a. Starting L10, P2 and L8/P10 and and elsewhere: Terminology around “Implementation frameworks” needs clarification. For example, referring to five “domains” across the implementation frameworks and five domains of AHRQ’s HRO. My suggestion is this: refer to implementation frameworks that are comprised of high-level strategies for implementing HRO. (you could cite Nilsen 2015, who would characterize these frameworks as “prescriptive” “which are frameworks that help guide implementations). The five strategies listed all have active verbs except the first one which should be reworded slightly to: “Developing leadership”


2b. L47, P2: use the term “strategies” instead of “components”

Nilsen P. Making sense of implementation theories, models and frameworks. Implementation science. 2015 Dec;10(1):53.

Changed “components” to “strategies.”
2713. P1/L51 - (and again later in the report) the authors cite lack of leadership commitment to “zero patient harm.” Is this how the goal is worded/conceptualized in the literature? There is much discussion about how singular focus on zero harm may cause unintended negative consequences. Some refer to this goal as “zero avoidable harm” - or link it to key cultural goals (e.g., just or safety culture). Can something be said about this, or is the literature (the 20 articles) silent on this important point?

Yes, we agree that we should add something about this variation of ‘zero harm characterization and to illustrate this variation, we also added a sentence about how the 4 most comprehensive HRO initiatives defined their goals of zero harm to the “Findings” section.

2813a. What about leaders’ lack of “managerial patience” – i.e., are leaders lacking commitment to zero harm as an end goal altogether, or do focus at first and then lose interest? I ask this in context of the finding related to dose-response relationship with time. This linkage could be made more clear even in EXEC SUMMARY bullets by acknowledging the 2-year outcomes based on the articles, but that 2-year horizon may be limited by the lack literature; though there may have been good initial effects in focused areas, this timeframe may be too short for lasting, meaningful effects. Is 2 years realistic…are there indications that longer timeframe is needed to achieve more lasting effects - especially related to changes in culture?

2914. L42, p2 (and elsewhere). Authors refer to strategies working in “primarily children’s hospitals.” It’s not that these findings only work in children’s hospitals…rather that these findings come from studies only done in children’s hospitals (a potential limitation). It’s notable that a couple of different systems/networks of children’s hospitals (Nationwide and CHSPS Network) have led the way with HRO - they are early adopters.
3015. L9/P3: authors should acknowledge the impracticality of RCTs to test HRO because of its complexity and complex implementation. Highlight the need for pragmatic, quasi-experimental study designs with full transparent reporting as a way to more feasibly build the knowledge base needed.
3116. L37/P4: Build the history of HRO more clearly. It started within the nuclear and aviation industries and then AHRQ is the seminal report introducing/defining HRO for healthcare, yes? Did AHRQ describe the same 5 domains as used in nuclear and aviation industries?
3217. L5/P5. Lists of “components” (should be strategies) seem to be differently described in different places. Be consistent
3318. Paragraph starting L13/p5: suggest flipping the order of the Providence St Joseph case with the VA to better segue into the next paragraph about VA.
3419. L10/P13: I’m not sure how differs from the overall goal to ID frameworks to guide implementation of HRO. This paragraph muddles concepts: intervention, process, implementing. I think this can be clarified by providing more detailed descriptions for how to operationalize the 5 high-level strategies in the implementation frameworks. For example, educational workshops might be a way to “Provide training and learning.”
35110. We have found that it’s impossible to use JC’s Oro system for measurement because participants are told not to share with anyone outside their organization, and the questions seem to shift. Is there any reference to this in the literature? Sullivan’s article seems to have the best open definitions/operationalization of their domains.
36110a. Their “RPI” domain relies on a trademarked (proprietary?) program, I think.
37110b. These are all limitations to using this system for measurement.though the development and intent of it, is the best developed.
38111. Love !
39112. L60/P16: It would be clearer to refer to AHRQ HRO rather than Hines 2008 - this is first mention of Hines other than in the reference list
442Great report!

I thought this Evidence Brief was well written and describes my intuitive understanding of the current state of HRO frameworks, metrics, and effects. I thought the authors did a nice job of simplifying what can sometimes be very complicated concepts.

I’ve provided several questions and clarifying comments below.

474Page ii: title capitalization looks off
484EXECUTIVE SUMMARY page 1 lines 40-52: might mention how HROs differ for health care (similar to background section)

page 2

line 3-5: may move “spreading implementation initiatives” to the last thing mentioned in the sentence.

504lines 17-20: although there were 5 common domains, it would be interesting to mention some of the other domains not reported as commonly.
514line 21: might say a little more about what consensus process means here
524line 32: how many does multiple hospitals refer to?
534line 33-34: might give an example of “the variation in concepts measured” also I think the phrase “types of measures” is missing from that sentence. I might also define what levels of practice refers to
544lines 55-58: It’s striking that there are so few barriers to implementation in the literature given all we know about implementation and organizing for quality. This seems like a major limitation.



page 4

line 55-56: add “in health care organization” or hospitals after the phrase “Implementation of HRO initiatives… is an


page 5

lines 3-10: I do not see provide training in systems redesign (e.g. LEAN six sigma, Kaizen events, hFEMA, etc) or robust process improvement tools listed

574lines29-33: Could the caring reliably program assess if it was the toolkit or the consulting which made the differences or was it bundled?
584line 36-40: Were the barriers reported in a particular type of service (e.g. focus on medical or surgical) or more general?

page 7

line 13-15: might outline the 5 HRO principles again here.


page 8

line 9-10: what was the rational for hand-searching references lists and consulting with content experts?

614line 15-15: describe the types of expertise the investigator/staff had Experiences health services research, HROs, evidence briefs, etc.
624line 34-35: What was the level of disagreements which needed to be resolved by consensus?

page 10

lines 37-60: seeing the table made me think about what were the other domains highlighted in the articles but not shown here.

in response to an earlier comment.

page 11

lines 50-53: might define what robust process improvement means. It can be a confusing term.


page 12

line 58-59: say more about what variety of health care leaders, providers and staff means… what service areas do they cover ? what type of managers? are safety and quality leaders executive level leaders or middle level managers?


page 13

lines 24-46: There is a lot of information in this paragraph and it’s easier to get lost in the details. It might be easier to comprehend it if it was provided in a bulleted format to allow easier comparison across frameworks.


page 14

line 42-42: “VA sites were interviewed about integration of HRO into their health care systems” is not an accurate depiction of this study. I believe the study assessed patient safety practices aligned with HRO principles. It was a secondary analysis of data collected for a study focused on patient safety indicators.

An important shortcoming of the ORO 2.0 tool is that it is not meant to compare results across multiple hospitals. As it has developed, I’m not sure if Joint Commission’s opinion has moved on this. I’m not certain if any of the tools presented have tried to compare cross-hospital progress.

684page 17 line 38: term SSE hasn’t been used in awhile, may want to define here again.


A few discussion points come to mind as I read this section.

1) it is critical to think about context

7042) How do these tools allow for cross-hospital comparisons? Is this the goal of VA’s HRO initiative?
7143) the need for training on HRO principles may not be enough to move an organization. I did not see training on system redesign tools and methodologies listed
7244) It’s unclear how HRO frameworks deal with differences in HRO practices across different service (e.g. medical, surgical). Should they? Have frameworks focused on this?
7345) Have HRO frameworks been developed and aligned with organizational transformation models or other frameworks for improving quality? There may be other measures or concepts to assess which have not been presented in this evidence-brief.


page 23

lines 12-14:

I might mention HRO intervention are inherently difficult to study because they can have many different components (potentially with different foci across different hospitals)



page 24

line 7-8: “3) whether certain implementation frameworks or facilitators lead to better outcomes” could be separated out to 3) whether implementation or other frameworks for improving quality frameworks are applied and lead to better outcomes and 4) what the factors affecting HRO implementation are.

764line 10-11: the wait-list control point is a good one BUT many facilities already have in place high reliability practices at baseline which will need to be assessed. Many sites could also have already participated in initiatives so they are more prepared for the journey (Improvement capacity/adoption of Lean Six Sigma, old Clinical Teams training, etc). How do we account for these on-going or older initiatives?
774line 27-28: say more about mechanism for change…. is this organizational transformation? something else?


I might mention something about measurement here as it is a key aim of the brief.

795P1 L47: I would be cautious in stating that medical error is the 3rd leading cause of death in the affirmative and/or saying continues to be as the Makary & Daniel article was a commentary based off of extrapolated data from current literature attempting to articulate how big a problem it is. Since medical errors are not listed as the cause of death this number is difficult to find and the assessment of death from harm is not as black and white in all cases. I would recommend stating something along the lines of if we were to document medical error as cause of death, Makary and Daniel have ascertained that it would be the 3rd leading cause of death in the country.
805P2 L10: remove total, reads as if there are only a total of 20 articles published which is not the case.
815P5 L33: In review of the additional reviews of measurement, I don’t recall if I mentioned that we also improved on the Safety Climate Domain of the Safety Attitudes Questionnaire (SAQ) from 2016 to 2017 (during the time of everyone up and running on training) by 5 percentage points with a sample size greater than 68,000 respondents so it was found to be quite significant. In addition, when drilling down to our regions, all showed improvements from 3 to 10 percentage points. Your option to add if you so choose.
825P5 L37: “lack of leadership commitment to zero patient harm” I would revise to indicate that it is lack of what it takes to get to zero harm. Most leaders would agree yes we need to get to zero patient harm and even indicate that they are doing work to do so. What doesn’t happen from my experience is they believe in it but do not provide the resources (people, money, skills) that it takes to get there. This sentence also needs a colon and some comas to separate the ideas of the list.
835P16 L35 Many who assess HRO use some form of Safety Climate survey as part of the assessment such as Safety Attitudes Questionnaire (SAQ) which was created by Sexton and team at Univ Texas and reflects similarities to the Flight Management Attitudes Questionnaire used in aviation to assess some of its HRO components. Something to consider adding as a measurement perhaps.

Thank you for providing me the opportunity to review this report. Excellent rapid review on a complex topic. See some suggested revisions below:

For the Key Findings box contained within the Executive Summary, it would have been helpful to have an initial bullet that succinctly listed the goals of the report, such as the aims described in the last sentence of the second paragraph of the Executive Summary. It would have also been helpful to have the 5 domains listed in the first bullet of the Key Findings box.

856In the Background section of the Introduction, in the fourth paragraph, the Joint Commission’s 2013 HRO report is noted, but should also be cited/referenced.
866In the Background section of the Introduction, in the sixth paragraph, the second sentence states that an understanding of available frameworks and their use is limited, but what about our understanding of available measures, and the impact of initiatives on those measures? Given the aims of this report, should note these areas as well.
876Under Eligibility Criteria, why not extend the search from 2008 to present, instead of 2010? Seems like if AHRQ is publishing a white paper in 2008, others may have also begun publishing on this topic at this time.
886In the Oro 2.0 section, third paragraph, last sentence, did safety culture decrease as described, or is this a mistake, and did it increase?
896In , please include abbreviation for PHI in the Table legend; in the third row of the Table, “zero SSE rate achieved in 2017” seems redundant with the statement directly above; in the fourth row of the Table, in the last column, please include Month and Year for the baseline

906In the first paragraph in the Summary and Discussion, in the second sentence, please change the order to “frameworks and metrics”, rather than “metrics and frameworks”, to better match the aims.
916In the Limitations section, in the first paragraph, second sentence, please consider citing: J Clin Epidemiol. 2014;67(11):1181-91. PMID: 25438663
926In the Conclusions, please change the order of the first sentence to read: “frameworks and evaluation tools”. The second sentence should probably read “reduction in SSEs” rather than simply “SSEs”.

937Overall, I think this evidence brief is excellent. It is thorough, thoughtful, and very well done! The ESP team identified their Key Questions, which were tied to the request from the Office of the National Center for Patient Safety. The method was clearly laid out and executed. The Key Questions were answered, gaps identified, and plans for future research addressed.
947I found “ . Common HRO implementation domains across 8 identified frameworks,” very useful. This table quickly identified all 8 HRO frameworks and their included components. Only 3 of the 8 contained all 5 HRO components.
957 . - Metrics for measuring progress on becoming an HRO - was also extremely enlightening. This side-by-side comparison of the 6 methods identified by the ESP group will be helpful for VHA Leadership to understand the differences between these methods, and then select the best one.
967 highlighted the challenge of comparing studies of disparate quality, methods, measures, and results reporting. This is a shortcoming in the HRO literature and was clearly communicated in this table.
977I agree with the ESP assessment of the gaps in the research. It is theorized that the implementation of HRO principles leads to improved safety outcomes and a culture of safety. This has not been validated by the research, nor has the mechanism by which these changes and improvements occur. The secular trends mentioned on page 24, which cannot be ruled out as contributing to improvements in patient safety outcomes, could be expanded on. What are these secular trends, and how are they impacting patients safety outcomes?
987I also agree with the statement about the VA being in a unique position to conduct a natural experiment with the current HRO Initiative. This is an excellent insight on the part of the ESP team. I am not criticizing, only providing additional information. The HRO Initiative is limited to 18 lead sites, but many other sites are clamoring to be part of it. I am not clear on the criteria VISN Directors used to select the lead sites, but it is likely that other sites within their VISNs, and across the VHA, are not experimentally naive. 1 am aware of 2 other sites within VISN 15 that are on HRO journeys already, and were not selected as the lead site for that VISN. I imagine that is may be true for other VISNs as well. There is no “perfect” way to conduct this type of research, and all research has limitations of some kind. I personally would love the opportunity to be involved in that kind of research.

Suggested citation:

Veazie S, Peterson K, Bourne D. Evidence Brief: Implementation of High Reliability Organization Principles. Washington, DC: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #09-199; 2019. Available at: https://www.hsrd.research.va.gov/publications/esp/reports.cfm .

This report is based on research conducted by the Evidence Synthesis Program (ESP) Center located at the Portland VA Health Care System, Portland, OR , funded by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development. The findings and conclusions in this document are those of the author(s) who are responsible for its contents; the findings and conclusions do not necessarily represent the views of the Department of Veterans Affairs or the United States government. Therefore, no statement in this article should be construed as an official position of the Department of Veterans Affairs. No investigators have any affiliations or financial involvement ( eg , employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties) that conflict with material presented in the report.

This publication is in the public domain and is therefore without copyright. All text from this work may be reprinted freely. Use of these materials should be acknowledged.

  • Cite this Page Veazie S, Peterson K, Bourne D. Evidence Brief: Implementation of High Reliability Organization Principles. Washington (DC): Department of Veterans Affairs (US); 2019 May.
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Transforming the Veterans Health Administration into a High Reliability Organization

How does an agency of 400,000 employees create systemic change to provide better care for veterans.

The Veterans Health Administration (VHA) is the largest health care system in the United States, providing medical care to nearly nine million Veterans. Inspired by proven safety practices in the nuclear and aviation industries, VHA is on a “journey” to become a high reliability organization (HRO). HROs experience fewer accidents despite operating in highly complex, high-risk environments by cultivating and spreading procedures and protocols to maximize safety and minimize harm. VHA is transforming its culture by ingraining principles and practices of high reliability and specific safety behaviors.


Clinical subject matter experts

Thought leadership

High reliability expertise


  • 300,000 employees completed the first HRO training
  • 90% of executives completed their curriculum

VHA hospitals nationwide are implementing tailored plans

VHA was ready for a seismic cultural shift

VHA maintains hospitals and health care systems across the United States and its territories. In such a large, complex system, hospitals develop different processes and procedures. In the health care industry, where people care for the lives and well-being of others, a lack of standard processes creates an environment for inconsistent care, errors and patient harm (e.g., falls and hospital acquired infections).

To maximize safety and minimize harm to Veterans and employees, VHA embarked on a journey to transform its culture by embracing safety practices and the following five principles of high reliability:

  • Deference to Expertise — Value expertise and diversity of perspectives and insights, relying on those with the most knowledge of the situation at hand, regardless of rank, hierarchy, position or other factors
  • Reluctance to Simplify — Get to the root cause of a problem rather than settling for simple explanations
  • Sensitivity to Operations — Be mindful of people, processes and systems that impact patient care
  • Commitment to Resilience — Bounce back from mistakes, get back on track and prevent those mistakes from happening again
  • Preoccupation with Failure — Have a laser-sharp focus on catching errors before they happen and predicting and eliminating risks before they cause harm

Employing these guiding HRO principles, organizations that manage high-risk operations significantly reduce error and patient harm. VHA’s partnership with Aptive provides comprehensive, evidence-based expertise to support enterprise-wide HRO transformation and implementation efforts that focus on clinical and non-clinical end-user needs and feasibility.

A top-down and bottom-up approach for the Journey to High Reliability: Aptive partnered with VHA to orchestrate multiple work streams; enable close collaborations, within and across teams; manage budgets; and support delivery. The Aptive team’s experts collaborated with VHA to design comprehensive strategies and approaches to realize the vision for transformation. Aptive helped hospitals define, design, implement and continuously improve the approach. In addition, Aptive’s dynamic team worked to change VHA employee behavior and agency culture to advance the organization’s vision for transformation and improved patient safety.

Baseline Training

Aptive partnered with VA Employee Education Services to develop scripts and storyboards for eLearning modules: HRO 101 (completed by 323,917) and HRO 201 (completed by 252,970); developed and delivered VHA Central Office HRO Training (completed by 90% of Senior Executive Service, 65% of VHACO supervisors and 20% of staff members from August 2019 to present); supported the National Center for Patient Safety and Office of Systems Redesign in the administration and execution of Clinical Team Training and Lean Management training offerings; and developed and executed one-day HRO baseline training for executives (8 hours), supervisors (120 minutes) and front line staff members (90 minutes).

Site-Specific Assessment

VHA and Aptive assessed each hospital’s application of HRO principles and practices to determine the level of HRO maturity. The Aptive team completed 134 site-specific assessments in FY20 through FY22. The team then delivered 134 site-specific diagnostic assessment reports, detailing site strengths and improvement opportunities. Assessment reports provided recommendations for methods, tools and strategies to drive culture change and improvements enabling fewer errors and improved patient safety (e.g., fewer infections, fewer falls and fewer medication administration errors). The team also provided implementation plans accompanied by implementation advisory support and an HRO Site-specific Implementation Plan.

The team is currently refining the VHA HRO Maturity Matrix to ensure it is a rubric that VHA organizations at all levels (not just VA hospitals) can use to understand their HRO maturity and identify next steps on the Journey to High Reliability.

Continuous Learning

Aptive stood up HRO learning workgroups to support the spread and sustainment of HRO principles and practices throughout VHA. The team led planning, development, coordination and execution of a new education pilot — called HRO in Practice (HIP) — which focuses on sharing and applying the foundational HRO practices across different facilities. The team is developing an HRO Community of Practice to provide user-friendly access to curated materials, experiential learning opportunities and a network of peer-to-peer connections. Continuous process improvement training advances staff member understanding of practical use cases and enables employees to apply that knowledge to operationalize HRO concepts through improvement projects in their everyday work, improving patient and employee safety and reliability.

Aptive also stood up a High Reliability Academy work group to develop learning objectives, curriculum, content and activities for HRO foundational training for HRO leads and champions — those responsible for influencing, mentoring and coaching others to accelerate VHA’s Journey to High Reliability. This work group also examines the essential behaviors and competencies needed to lead with vulnerability, empathy and accountability while influencing, coaching and mentoring others; resolving conflicts with an HRO mindset; and modeling a non-punitive (otherwise known as Just Culture) response to mistakes. Aptive delivered a pilot session of HRO Leads and Champions Foundational Training, with an anticipated launch of the final course in FY23.

Strategic Communications

VHA and Aptive developed a robust communications plan to engage and inspire VHA staff members during all phases of the Journey to High Reliability. The Aptive team developed and maintains the VHA HRO SharePoint site for disseminating communications to leaders, front line staff members and VHA’s Central Office. VHA and Aptive also work together to launch several employee engagement campaigns to engage VHA staff members and inspire them to celebrate high reliability practices in their daily work. One such campaign, the HRO Safety Story Video Challenge, which invited individuals and groups to submit widely applicable “Good Catch” and “Close Call” stories of error avoidance, resulted in 84 videos submitted from across VHA. The Aptive team also developed a monthly HRO blog, newsletter and poster to highlight staff member success stories; fact sheets and videos to showcase HRO principles and values, foundational practices and implementation activities; and a semi-annual award ceremony to celebrate HRO successes.

VHA is embracing the Journey to High Reliability

VHA’s Journey to High Reliability continues to accelerate and expand. Reception was so successful at VHA hospitals that leadership decided to roll out the journey to VHA Central Office (VHACO) program offices as well.

The Aptive team stood up and facilitated the VHACO Journey to High Reliability work group to plan, develop and execute a pilot to expand and integrate HRO activities across VHACO program offices. During the planning phase, Aptive conducted stakeholder interviews with VHACO representatives to refine the pilot approach, develop training materials and partner with VHA leadership to identify pilot offices and HRO pilot champions. Aptive launched the pilot with nine program offices and approximately 1,880 participants via targeted communications and kickoff sessions.

As of November 2022, Aptive hosted facilitated leader training for over 250 leaders, launched HRO improvement projects to enhance internal operations and service delivery in five offices, distributed 31 weekly HRO learning videos with resources, and conducted approximately 60 listening sessions and eight action plans to identify HRO opportunities to integrate HRO principles and practices into VHACO culture and operations.

VHA staff members are embracing the change on VHA’s Journey to High Reliability that will provide a stronger culture of safety and better patient care.

Results at a Glance

  • VHA hospitals nationwide are implementing their tailored plans

high reliability organization case study

HRO Implementation:

 stories, case studies, metaphors and examples, aspects of implementation: what we do.

General Tips

"What I teach today must explain yesterday or be used tomorrow. It could be called the 72 hour rule. People come back to me later, sometimes the same day, sometimes as long as 15 years later, and describe something I had taught them and how it helped. The material they describe works its way permanently into what I teach. Teaching methods of thinking and problem solving to those without public safety or military experience has some difficulty. How to think and solve problems in uncertainty is difficult in civilian education. This material grows slowly and the novice may not see its importance. However, senior students or recently graduated students have advised me to continue teaching this material slowly and not leave anything out. New material that does not seem to make sense will make sense later after new lessons. New material also builds on previous material and the experience of the student. It does take more time as they do not learn the material in their didactic education. This is the challenge of teaching a new culture to those who do not see themselves as being in a new culture. When physicians begin working with paramedics they have asked me how to teach paramedics. I recommended that the physician learn from the paramedics. Soon enough the paramedics would be learning from the physician."

Daved van Stralen, MD, writes on  Aspects of HRO Implementation , including:

The Individual, The In-determinant Problem, The Fear response, Decision Making, Vulnerability, Collaboration, Information Flow, Credibility: The Theory of Knowledge, and Functional Leadership.

Behavior Matters in Building Trust

"What you do has greater impact than anything you say. If your behavior does not demonstrate what you said you believe, value, or will do, then credibility will suffer and people will see you as insincere. Words declare intent and can create enormous hope. When the words are followed by validating behavior, they increase trust. People can and do change their behavior. Behavior shifts, changes in doing, can actually change the way you think."

These documents written by David Christenson, MA, based upon the works of Covey, Weck & Sutcliffe.

  • Straight Talk Balanced by Demonstrating Mutual Respect
  • Getting Better Balanced by Delivering Results
  • Incident Management Team's HRO Behaviors

Boyd's OOD Loop

Building a healthy culture.

David Christenson, MA, A paper presented at the Wildfire 2007 international conference of wildland firefighters in Seville, Spain, May 2007 and the Bridging the Gap Between Theory and Practice, European HRO Conference, April/May 2007. Deauville, Normandy, France

Build a Healthy Safety Culture Using Organizational Learning and High Reliability Organizing

Case Studies Of HRO Implementation in Organizations

The following have been produced by the U.S. Wildland Fire Lessons Learned Center in 2008 and 2009:

  • Sequoia & Kings Canyon National Park
  • Shoshone National Forest
  • Incident Management Teams
  • Prescribed Fire Management
  • Staff Rides

Historical Application of HRO Principles

HRO Principles in History :

Standardization for Adaptability: Maurice of Nassau and the Dutch Army, 1590

Standardization of equipment, actions, and responses enable predictability in behavior of others in the same organization at sites distant in time or location from the event. This standardization contributes to predictability and gives the organization the ability to plan for contingencies...This paper discusses how Maurice of Nassau used standardization in the Dutch Army to make it more mobile, flexible, and effective when fighting the larger Spanish Army.

When the event continues past our plans we must somehow figure out what to do. At this point we act without preparation, we improvise. While it seems we cannot study this we can look to the arts where improvisation is not only routine, it is an art form. Here we will study Comedy Improv and Jazz Improv to better understand what Karl Weick terms “Constrained Improvisation.”

Comedy Improv

In Comedy Improvisation the players spontaneously interact with each other, not fully knowing where the other players are going as each plays off the other. Comedians and actors learn this as an art form which has developed rules since the 1950s. One of the first, and more basic rules, is to accept the information. This involves trust, avoiding judging what is happening, and not negating or denying the line presented. Add new information. Make statements, don’t always ask questions. When you do ask questions remember that questions can also give information. Give information to your partner, be specific and add details. Look beyond the words. Words carry a large amount of information. If this is true, what else is true? There is unspoken dialogue in what the other actors say and don’t say along with how they say it. There is unspoken dialogue within the dialogue. The actor must maintain awareness of other actors and their actions. Observe the impact of your response. Actors will each listen, watch, and concentrate. They are all part of the scene, meaning you save your fellow actor during the improvisation. This does not mean you enter the scene without reason. You must subdue your impulse to act solely for the reason to enter the scene. When you do act, you act to advance the scene.

Ballroom Dancing

"Ballroom Dancing has many elements found in High Reliability Organizations (HRO) but on the scale of two individuals in the immediacy of a performance. Without trivializing live-or-die situations, ballroom dancing, as many activities such as rock climbing, team sports, and mountaineering, uses the same methods as HROs which underscores the part the human mind has in reliability. Isolated from the danger and melodrama of high-stakes activities, ballroom dancing provides a heuristic and metaphor for descriptions and discussions of highly reliable behaviors." - By Daved van Stralen, MD  Dance Lead & Follow

Why does story telling work? Stories give context and meaning. Stories teach, transmit values and beliefs, guide behavior, and give support. This document written by Daved van Stralen, MD, also includes, "Types of stories," "How to Learn a Story for Story Telling," and "Elements and Structure of a Story for Telling," written by Linda Aldridge, MS, Member Florida Storytellers Guild, and Story Telling Assistant Professor, St. Petersburg College, St. Petersburg, Florida, in March 2009.  Story Telling

HRO Before We Knew It Was Called HRO , (7/24/2009) by David A. Christenson, MA, on HRO implementation in a jet fighter squadron's quick reaction alert force operations in 1980.

Four HRO Implementation Stories from the Wildland Fire Lessons Learned Center's Staff Writer Jonetta T. Holt:

Mindfulness: Are We Managing Our Expectations?  (7/2/2009) Incident management teams bring order to chaos. We believe order is a good thing. But when does order create blind spots for us? Challenge your routine of thinking that LCES is "in place" and we are good to go. What other routines are we susceptible to? (A related article written by Brad Mayhew titled  "The Intent of LCES"  was published in the FireRescue magazine in April 2009.)

Creating Resilience on a Fire Assignment  (5/12/2009) Managers that lead crews and teams into high risk environments want to believe the group they are leading is skilled, capable, strong...resilient even. Do we know what we mean when we are talking about having resilience or behaving resiliently? Morning Briefings Reinforce Deference to Expertise  (9/14/2008) Briefing crew leaders about the potential hazards they face and actions to take when they become realities. Tracking and Responding to Small Errors in High Risk Environments  (7/25/2008) Responding to small system failures before they become big problems, even deadly catastrophes, without being able to pinpoint the actual cause is confusing and often creates hesitation.

high reliability organization case study

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What is a High Reliability Organization?

Everyone seems to agree that root cause analysis is about solving problems, but there’s no agreement as to how a root cause analysis is done.

No organization wants problems. But some organizations are better at avoiding them than others.  Some are significantly better. High Reliability Organizations (HROs) are examples of high-risk operations involving multiple people and multiple decisions that perform at an exceptionally high level.  High Reliability Organizations are not in one specific industry, but their approach to risk and mindset are similar. Operating a nuclear aircraft carrier, coordinating commercial flight operations and delivering medication in a hospital all share an extremely low tolerance for error.

HRO Origins

High reliability organizations are high quality operations that are relatively error free over long periods of time. That definition summarizes points made by Karlene H. Roberts, a professor at the Haas School of Business at the University of California. She, along with Todd R. LaPorte and Gene I. Rochlin, both political science professors, led the original ‘High-Reliability Organizations’ project at Berkeley in 1984. They studied the complex operations of air traffic control, electric utility grid management and a US Navy aircraft carrier. The lessons of high reliability can be applied within any organization.

Measuring Unreliability

Reliability is a number. It’s a probability. Each task within your operations has a reliability regardless of whether it’s measured. Like any other indicator, measuring it will provide a reference point for improving it. If you don’t measure the reliability, you’ll have no baseline. Are there any tasks that would add value to your organization if their reliability improved? Determining that value can reveal the annual cost (or risk) of unreliability for that task in your operations.

Reliability Varies Significantly

No organization wants problems, but results vary. There is a wide range of reliabilities across industries. Some operations have a 90% success rate. Others are at 99.999% depending on the task. Consider the differences in operations with a defect rate of 1 in 10 versus 1 in 100,000. Both numbers measure the reliability of a task. But one is 10,000 times more reliable than the other. The objective isn’t to reach the same level of reliability everywhere, but to ensure your operations are as reliable as they need to be to meet the overall goals.

What is your organization's risk tolerance? Is it 1 in 10, or 1 in 100,000? Whatever the current reliability is, is what the organization tolerates. But it can be changed. Consider the example of medication delivery. A hospital may dispense 1,000 doses of medication each day. A 99.9% success rate reflects an average of one medication error per day. The table below shows what different medication rates look like for 1,000 doses per day.

90% 10% 100 errors per day
99% 1% 10 errors per day
99.9% 0.1% 1 error per day
99.99% 0.01% 1 error every 10 days
99.999% 0.001% 1 error every 100 days
99.9999% 0.0001% 1 error every 1000 days

It’s important to understand the reliability of a company’s work processes. Does your organization do something that is potentially life threatening, that involves multiple people in different departments, a thousand times per day? The expectation of every patient and family member is the medication will be correct. Zero errors is the goal.

Error Reduction as a Process

Error reduction is well understood in some sectors of some industries, but it remains an unknown in too many organizations. It’s not done by telling people to “stop making mistakes.” The effective design of medication delivery requires insight from doctors, nurses, pharmacists and technicians.  Many industries are orders of magnitude away from the reliability mindset of how medication is delivered in hospitals. For reference, in 2016 there were ~4.45 billion medication prescriptions in the U.S.

When a problem does occur, the sections of the process that contributed to the incident must be dissected. The discussion must be an in-depth review of where and how the process broke down with the people who were involved. There may be unique situations that are addressed with the individual, but solutions that improve the reliability of the task will be implemented within the task.

Organizational Know-How

Highly reliable organizations have highly reliable work processes. But they are not rigid and prescriptive. They must be comprehensive and account for special circumstances. There’s not a one size fits all for a work process. Contingencies need to be captured as part of organizational know-how and included in people’s training. And if specific people make a significant positive impact on operations, then what they’re doing needs to be captured in the work process so that others can learn what to do. Having an incident because someone took a day of vacation reveals a low reliability organization.

Getting Started

If you’d like to learn more about how we help organizations improve the reliability of their work processes , contact our office or send us an email. Any work process or task within your organization that has costly, recurring issues is an obvious place for you to start.  We can present a  High Reliability Leadership   session online or in person to your and your groups, or you can attend one of our High-Reliability Leadership Online Short Courses .  

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Exploring barriers in the transition toward an established e-waste management system in Brazil: a multiple-case study of the formal sector

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  • Published: 17 July 2024

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high reliability organization case study

  • Alice Frantz Schneider   ORCID: orcid.org/0000-0002-5985-3863 1 ,
  • Margunn Aanestad 1 , 2 &
  • Tereza Cristina Carvalho 3  

Brazil is the largest generator of electrical and electronic waste (e-waste) in Latin America but faces significant challenges with its management. This study investigates barriers to the growth of the formal sector in transitioning toward an established e-waste management system in the country. Driven by sustainability transitions research, it applies a transition management approach to e-waste management. The study presents the results of field studies conducted in four organizations with different levels of recycling operations. The results show several barriers, for instance, a lack of processes for the complete separation of metals, high reverse logistics cost, a lack of transparency throughout the supply chains, concern with data security, and a lack of financial incentives and policy integration. The study highlights various initiatives from the organizations that assist in tackling some of the identified barriers and shed light on possible transition pathways. The study provides a perspective from e-waste management organizations and policy insights to strengthen e-waste management in the country.

Avoid common mistakes on your manuscript.

1 Introduction

Rapid technological advancements have led to a significant rise in the consumption of electronics. Fast-growing tech-oriented societies combined with high rates of appliance substitution have resulted in an increasing generation of waste from electrical and electronic equipment, known as WEEE or e-waste. Worldwide, 44.7 million tonnes (Mt) of e-waste were generated in 2016 (Baldé et al., 2017 ), an amount that increased to 62 Mt in 2022 (Baldé et al., 2024 ).

Electronics contain hazardous materials to the environment and human health if managed improperly at the end of their product lifecycle (end-of-life phase). For instance, brominated flame retardants, added to plastics in electronic equipment, are persistent organic pollutants (Morf et al., 2005 ). Other hazardous materials in electronics include lead found in cathode-ray tube glass and older printed circuit boards (PCBs), in addition to the mercury contained in liquid-crystal displays (Althaf et al., 2021 ).

In countries lacking proper waste management infrastructure, e-waste management is primarily performed by the informal sector (Parajuly et al., 2019 ). According to The Global E-waste Monitor (Baldé et al., 2024 ), only 22.3% of the e-waste generated in 2022 worldwide was collected and recycled through formal channels, and less than 3% in South America. Techniques highly detrimental to the environment (e.g., acid leaching and open burning of cables) are often performed by the informal sector when extracting valuable minerals (Awasthi & Li, 2017 ).

Brazil is the largest e-waste generator in Latin America and the second largest in the Americas, with 2.4 Mt of e-waste generated in 2022 (Baldé et al., 2024 ). The country has a legislative framework for e-waste management (Brasil, 2010 ) but still faces challenges with a lack of an established e-waste management system (Xavier et al., 2021b ) and a strong presence of unregulated activities performed by the informal sector (Mancini et al., 2021 ). Strengthening activities within the formal sector is a critical aspect of moving toward an established system. For this, it is essential to understand the central challenges that e-waste management organizations face.

This study explores the main barriers to the growth of the formal sector in Brazil in the transition toward an established e-waste management system. It is theoretically driven by sustainability transitions research (Köhler et al., 2019 ), specifically transition management (Loorbach, 2007 ). The study gathers the results of field studies in four critical organizations in the country and applies a multi-level perspective (MLP) (Geels, 2002 ) as an analytical framework.

The following Sect. ( 2 ) presents the background literature on e-waste management in Brazil. First, it highlights the main aspects of the legal framework, followed by some barriers to transitions in the country and remaining knowledge gaps. Section  3 presents the conceptual framework, and Sect.  4 addresses the research methodology. Section  5 presents a brief overview of the four case studies. The results and analysis Sect. ( 6 ) focuses on the main barriers identified in the case studies. In Sect.  7 , the discussion highlights initiatives from the organizations and the main novelties in the literature. The last Sect. ( 8 ) presents the concluding remarks.

2 Background

2.1 legislative framework for e-waste management in brazil.

The National Policy on Solid Waste, PNRS Footnote 1 , instituted by Law nº 12.305 of 2010 (Brasil, 2010 ) and regulated by Decree nº 10.936 of 2022 (Brasil, 2022 ), is the main legislative framework for the management of e-waste in Brazil at the Federal level. The PNRS addresses critical points for improving solid waste management from an economic, social, and environmental perspective. The policy emphasizes the principles of waste reduction, reuse, and recycling (Dias et al., 2018 ).

E-waste management is one point addressed in the policy. The PNRS has commonalities with the extended producer responsibility (EPR) proposed in the WEEE Directive adopted in the European Union by connecting the e-waste management responsibilities through the supply chain (European Commission, 2016 ). However, unlike the EPR (which places the responsibility on the producer), the PNRS is based on the principle of shared responsibility for the life cycle of products (Dias et al., 2022 ; Xavier et al., 2023 ). The policy also addresses the need for a reverse logistics system of products at the end-of-life phase. Article 33 of Chapter III of the PNRS states that manufacturers, importers, distributors, and resellers are responsible for implementing the reverse logistics of batteries, fluorescent lamps, and electronic equipment, independent of the urban cleaning service for solid waste (Brasil, 2010 ).

The individual states in Brazil have the autonomy to create and implement their own set of regulations for solid waste management, which is often the case for e-waste (Dias et al., 2018 ). The Global E-waste Statistics Partnership (ITU and UNITAR 2022 ) details many of the state regulations implemented in Brazil. Some states, such as São Paulo, already had laws for e-waste management before the PNRS. São Paulo is also one of the states at the forefront of implementing specific regulations contributing to the transition toward an established e-waste management system (Souza, 2020 ).

The PNRS, although instituted in 2010, was only regulated in January 2022 through Decree nº 10.936 (Brasil, 2022 ). The latter sets a national reverse logistics program under the coordination of the Ministry of Environment (Brasil, 2022 ). The proposed program addresses several challenges of waste management activities in the country. Decree nº 10.240 of 2020 focuses on e-waste management, specifically on implementing a reverse logistics system for e-waste at the Federal level (Brasil, 2020 ).

Various associations assist in implementing such a reverse logistics system in the country. For instance, the Brazilian Association for Recycling Electronics and Household Appliances, Abree Footnote 2 , was founded in 2011 by manufacturers of electronics and household appliances to manage the reverse logistics of such appliances once reaching the post-consumer phase (Abree, 2024 ).

The National Association of Manufacturers of Electrical and Electronic Products, Eletros Footnote 3 , and the Brazilian Association of the Electric and Electronic Industry, Abinee Footnote 4 , also assist in implementing reverse logistics for the various e-waste categories through different initiatives (Abinee, 2024 ; Eletros, 2024 ). One example is Green Eletron, a national initiative created by Abinee in 2016 that focuses on reverse logistics and recycling for small e-waste categories (Green Eletron, 2024 ). Green Eletron is in full swing with increasing voluntary collection points installed to attend the Business-to-Consumer market (B2C).

2.2 Barriers to transitions in e-waste management in Brazil

Studies on e-waste management in Brazil are still emergent but have gained strength in recent years. The studies often point out challenges in the activity, many of which translate into barriers to transitions toward more established systems. This subsection presents some of the critical factors identified in the literature.

Brazil has a large territorial area and a diverse economy. Despite the advancements in legislation, there is a lack of a nationwide system for collecting and recycling e-waste (De Sousa et al., 2023 ; Xavier et al., 2021b ). Solutions in metropolitan regions are among the most needed due to the large e-waste generation combined with an emerging recycling industry (Ottoni et al., 2020 ).

Exportation is a predominant activity surrounding e-waste recycling in Brazil (Ottoni et al., 2020 ). Due to a lack of adequate infrastructure for the complete processing, recycling facilities in the country focus on the pre-processing of e-waste (Azevedo et al., 2017 ; de Albuquerque et al., 2020 ; Dias et al., 2022 ; Santos & Ogunseitan, 2022 ). Components that are among the most valuable (e.g., PCBs) tend to be recycled in facilities abroad (e.g., Europe, Asia, and North America) that have the required technology to extract the precious metals (de Oliveira Neto et al., 2017 ; Neto et al., 2019 ).

Most e-waste recycling facilities are concentrated in the South and Southeast regions, primarily in the state of São Paulo, the most populated in the country (Dias et al., 2018 ). E-waste is often transported over long distances to reach processing facilities (Xavier et al., 2021b ). Despite the continental dimensions, the country has a poorly developed rail network (Georgiou, 2009 ), and road transport remains the primary infrastructure for inland transportation (Souza, 2020 ). Therefore, costs related to the reverse logistics of e-waste and the expansion of recycling activities to municipalities that are not yet covered tend to be high.

Incorrect disposal contributes to the e-waste challenge. Storing obsolete appliances at home and sorting e-waste as recyclable household waste are regular practices (de Oliveira et al., 2020 ; Santos & Ogunseitan, 2022 ). The latter represents a challenge because the management of recyclable household waste in Brazil comprises regular waste types (e.g., plastic, cardboard, and glass) and does not include e-waste. E-waste disposed of as household waste often has as destination solid waste landfills or open dumpsites (Abbondanza & Souza, 2019 ; Xavier et al., 2021b ). Incorrect disposal is prevalent in the case of small appliances, indicating that the size influences the destination once reaching the end-of-life phase (Rodrigues et al., 2020 ).

As in several countries in the Global South, Brazil faces several social and economic problems, and the informal sector has significant participation in the national economy (Pedro et al., 2021 ; Xavier et al., 2021b ). Landfill sites and open dumpsites are often sources of e-waste to the informal sector (Mancini et al., 2021 ). The strong presence of the informal sector represents a critical factor since the activities are often difficult to trace while conducted in precarious and environmentally hazardous settings (Neto et al., 2019 ; Xavier et al., 2021b ).

Implementing organizations such as cooperatives and associations is one way to move toward an established system while gradually integrating workers from the informal sector. Organizing e-waste management into cooperatives potentially increases workers’ skills and productivity while safeguarding their health and the surrounding environment through more sustainable practices (ILO, 2014 ). This kind of initiative also tends to provide workers with social and economic support and reduce the possibilities for exploitation (Dutra et al., 2018 ). For example, a training project offered to waste pickers in the greater area of São Paulo showed positive results (Portela, 2015 ). Through the project, the workers became more aware of the importance of correct e-waste handling for their health and the benefits of proper sorting and pre-processing to increase their income.

Unfortunately, studies on e-waste management in Brazil also indicate the presence of cooperatives operating without proper documentation and working conditions (Mancini et al., 2021 ; Souza, 2020 ; Xavier et al., 2021b ). Gutberlet ( 2016 ) further explores challenges regarding the implementation of waste cooperatives and also mentions that certain Brazilian cooperatives do not abide by the principles of collectiveness and transparency. The lack of credibility associated with non-compliant cooperatives incurs an extra challenge in bridging the gap between the informal and formal sectors.

2.3 Remaining knowledge gaps

The PNRS presents a significant milestone for improving e-waste management in Brazil. However, several challenges remain. For example, there is little enforcement of legislation (Dias et al., 2018 ; Echegaray & Hansstein, 2017 ) and a lack of data on statistics related to e-waste activities (Santos & Ogunseitan, 2022 ). Additionally, governmental information on the topic (e.g., the number of e-waste management facilities and the material flows in the country) remains scarce (Dias et al., 2018 ; Mancini et al., 2021 ; Pedro et al., 2021 ).

The literature also mentions specific gaps in the legal framework and divergence in interpretation (de Souza et al., 2016 ). This divergence includes uncertainties regarding responsibilities for e-waste activities and coverage of associated costs (Vieira et al., 2020 ). It is often unclear for governmental bodies how to tackle aspects such as e-waste management activities within the informal sector and the collection of taxes (Souza, 2020 ).

A relevant study from Vieira et al. ( 2020 ) identifies the main barriers to implementing reverse logistics for e-waste in Brazil. It addresses the perspectives of the Ministry of Environment, technical assistance companies, and consumers of repaired and refurbished electro-electronic equipment. However, the study does not address the perception of e-waste management organizations. Studying barriers in e-waste management from the perspective of different stakeholders can potentially identify critical factors and assist in finding solutions for policymaking. Therefore, this study presents a view of organizations performing various e-waste management operations in the country, from collection to end-processing.

3 Conceptual framework

This study is framed within the interdisciplinary field of sustainability transitions. The research field perceives many of the current environmental challenges as the result of unsustainable patterns established in socio-technical systems and recognizes the need to move toward new, more sustainable types of systems (Köhler et al., 2019 ).

Socio-technical systems are understood to encompass multiple heterogeneous subjects. The MLP (Geels, 2002 , 2019 ) is a well-known framework for conceptualizing the multiplicity of subjects in a system and exploring the connections among various levels. The framework looks at three levels of transitions: the landscape, regime, and niche. The landscape (macro-level) consists of heterogeneous and system-external developments (Geels, 2002 ). The regime (meso-level) relates to practices and structures that prevail in an existing system (Kemp et al., 1998 ). The niche (micro-level) comprehends individual subjects in a system and the way these interact with each other. Radical innovations often emerge at the micro-level, and some successfully develop into regime practices (Geels, 2019 ).

The meso-level comprehends various dimensions. Table  1 (columns 1–4) shows regime dimensions addressed in the literature through different nomenclatures (Geels, 2002 , 2004 , 2006 ; Loorbach, 2007 ). The table combines similar dimensions addressed differently in the literature. After comparing these nomenclatures with the data obtained in the empirical research, this study defines the following regime dimensions (cf. Table  1 , column 5): technology & infrastructure, economy & market, society & culture, and policy. Data analysis applies the latter. The first dimension relates to the technologies and physical infrastructures available. The second dimension addresses economic conditions, distribution networks, and user preferences in a specific market. The third dimension relates to socio-cultural values (e.g., traditions, habits, symbolic meanings, and beliefs). Lastly, the fourth dimension concerns the current legislation and regulatory conditions (e.g., financial incentives versus related taxes).

Transition management (Loorbach, 2007 ) is a prominent theoretical approach in sustainability transitions research. It focuses on developing governance strategies for transitions toward sustainable development (Loorbach, 2010 ). A primary objective in sustainability transitions research is to explore how transitions happen and, specifically within transition management, to investigate ways of encouraging and achieving the desired ones.

When applying the MLP framework from a transition management perspective, the analysis focuses on governance rather than the technology per se. Studies with this perspective can focus on various systems, such as the fashion industry (Buchel et al., 2022 ). Applying such a perspective to the case studies presented in this study helps provide new insights for future policy implementation and contributes to e-waste management research.

4 Research methodology

This study presents four cases of e-waste management organizations operating in the formal sector in different municipalities in Brazil. The selection of cases represents a sample of critical organizations focusing on various levels of e-waste management operations in the country. Such selection relied on a combination of searches on the internet and literature that signalized such organizations as representative cases.

The reasoning for the specific choice of the organizations was to present representative cases within the Brazilian context and cover the various operational levels (i.e., from collection to end-processing) of e-waste management. The importance of their operations in the Brazilian context provides significant insights for this study. In addition, the variety of operational levels in each case study contributes to identifying some nuances within the e-waste management system in the country. The following briefly introduces the organizations.

Case 1 relates to a university center for the reuse and disposal of electronics. It represents a pioneer project in the country, acting as a national reference for take-back initiatives at universities (Souza, 2020 ). Case 2 refers to a company with an established structure for e-waste collection, working in cooperation with a non-governmental organization (NGO). Case 3 presents a branch of the multinational company Umicore, known for the largest e-waste recycling capacity worldwide (Kaya, 2019 ). Lastly, Case 4 focuses on a company with an innovative process in the country for recovering minerals from e-waste.

For the data collection, initial contact was established with the organizations by email to present the aim of the study and identify the possibility of data collection. Data collection with the agreed organizations was scheduled in advance, comprising one visit to the facilities of each organization and one interview. On-site observations were conducted in June and July 2018 and included interviews, notes, and photography. During the visits, more than 100 pictures were taken to document the recycling processes of various appliances. Face-to-face semi-structured interviews were conducted with a representative allocated by each organization. Specifically, these involved the operations technician in Case 1, the chief executive officer in Case 2, the commercial manager in Case 3, and the commercial director in Case 4. Audio recordings and notes assisted in documenting the interviews. The organizations were contacted by email and video again between August and September 2022 to check for possible updates.

Data collected in the interviews were transcribed and analyzed through thematic analysis, following the steps proposed by Braun and Clarke ( 2006 ). The data analysis focused on statements from the interviewees referring to perceived barriers in the context of sustainability transitions associated with the e-waste management activity. The process included three main steps. First, the transcriptions of the interviews were manually coded to identify perceived barriers from the organizations. This deductive coding process was theoretically driven by and focused on the MLP framework (Geels, 2002 ). Second, the barriers mentioned by more than one organization were identified. The third step included allocating the barriers to groups according to the regime dimensions (as defined in Sect.  3 and described in Table  1 ). The results comprise the identified barriers categorized into four regime dimensions.

The study applies the MLP as the analytical framework for its potential to study several layers of complexity (from the micro to macro-level) within a system. The framework helps analyze the behavior of specific subjects in a system while establishing connections with the more extensive system (i.e., in the context of this study, the e-waste management system in Brazil). The MLP framework also assists in better visualizing the interactions among the various levels and the potential of different approaches within these analytical levels in driving the desired transitions.

The study focuses on identifying barriers (at the meso-level of the MLP framework) from the perspective of critical organizations (placed at the micro-level) within the e-waste management system in the country. Additionally, it identifies certain activities from the interviewed organizations that represent innovative approaches from the niche to tackle specific regime barriers.

5 Case studies

This section presents a brief overview of the four organizations participating in the study.

5.1 Case 1 – CEDIR

CEDIR Footnote 5 is a center for the reuse and disposal of electronics located in the São Paulo municipality in the São Paulo state (Carvalho, 2018 ; CEDIR, 2024 ). The center, inaugurated in 2009, is operated by and receives funding from the University of São Paulo (USP). Its operations motivated the implementation of an electronics sustainability laboratory Footnote 6 in the university the following year after a need for further research was identified (LASSU, 2024 ).

The center accepts several appliances (e.g., computers, printers, and mobile phones) from USP, the local community, and organizations. These are handed in directly at the center. Some (e.g., monitors cf. Figure  1 a) are sorted and assessed for the possibility of repair and potential for reuse. Others (e.g., mobile phones) are sorted directly for recycling. CEDIR sends the repaired appliances and sometimes spare parts to the university for education and research purposes (e.g., hard disk motors are often used in robotics research), as well as to other organizations with social intent (e.g., public schools, NGOs, public hospitals, and police stations). In addition, the refurbished computers support social initiatives at USP, such as the Paideia project aiming to train low-income young adults in computer programming (Paideia, 2024 ).

figure 1

E-waste recycling at CEDIR: ( a ) Storage of monitors ( b ) Storage of sorted PCBs for recycling (photographs by A.F.S.)

The sorting of non-repaired appliances is according to type. Some undergo an initial separation of components (e.g., in the case of mobile phones, the process separates the batteries from the devices). CEDIR sends the appliances and sorted components (e.g., cf. Figure  1 b) to recycling companies for specific dismantling and processing.

5.2 Case 2 – Weee.do

Weee.do is a private company located in the Palhoça municipality in the Santa Catarina state, working with reverse logistics of electronic appliances since 2016 (Weee.do, 2024 ). The company collects e-waste from companies in different locations, primarily within the South Region (i.e., Rio Grande do Sul, Santa Catarina, and Paraná). In addition, Weee.do has more than 100 voluntary delivery points for the community installed in several locations in Santa Catarina and Paraná.

Electronics usually arrive unsorted at Weee.do (cf. Figure  2 a). The company has partnered with a non-profit organization, CPDI Footnote 7 , intending to reuse computers (CPDI, 2024 ). An initial assessment of the computers collected through the voluntary delivery points identifies the possibility of repair and, if positive, forwards the appliances to CPDI for reuse.

figure 2

E-waste recycling at Weee.do: ( a ) Overview of the working space (photograph provided by Weee.do) ( b ) Storage of sorted and dismantled equipment (photograph by A.F.S.)

Weee.do sorts the non-repaired electronics for recycling. The company performs a manual dismantling that separates different components (cf. Figure  2 b). Dismantling mobile phones separates only the batteries from the devices. These components are sent to recycling companies abroad or in the country for end-processing.

5.3 Case 3 – Umicore Brasil

Umicore Brasil is a branch of the multinational Umicore headquartered in Belgium (Umicore, 2024a ). Umicore Brasil started operations in 2003 and has industrial units in the municipalities of Americana/São Paulo, Guarulhos/São Paulo, and Manaus/Amazonas (Umicore, 2024b ). The facility in Americana receives waste containing precious metals from companies in several regions of the country.

The material is accepted pre-dismantled from the suppliers (e.g., mobile phones separated from the batteries). The facility receives only specific components from certain appliances (e.g., only the PCBs from desktop computers). Batteries of different kinds (e.g., mobile phones, notebooks, and cameras) are received pre-sorted and forwarded to the headquarters in Belgium for recycling.

The facility in Americana focuses on a sampling and analysis process. First, the material is processed by a shredder into fine pieces, retrieving several samples. The samples are processed in various ways (e.g., burning and smelting) and forwarded to the laboratory within the company. The laboratory measures the percentages of different kinds of precious metals to pay the suppliers accordingly. Lastly, Umicore Brasil sends the material to the headquarters in Belgium for final processing.

5.4 Case 4 – Vertas

Vertas is a private company located in the Mauá municipality in the São Paulo state. The company has worked with e-waste dismantling and processing since 2009 (Vertas, 2024 ). It focuses on the corporate sector and receives appliances from companies in several states in Brazil.

The initial process is a manual sorting of appliances, followed by a manual dismantling that separates the main components (e.g., batteries, cables, and computer chassis). Some require a more detailed and time-consuming manual dismantling than others. In the case of mobile phones, the manual process only separates the batteries. Specialized companies in the country recycle phone batteries. Vertas processes the phones (without the batteries) with a shredder (cf. Figure  3 a).

figure 3

E-waste recycling at Vertas: ( a ) The e-waste shredder ( b ) Grain material obtained from the shredder (photographs by A.F.S.)

The shredder applies sieves of different thicknesses depending on the components (e.g., cables, PCBs) and obtains various grain materials (cf. Figure  3 b). The mix is sent to foundry companies in the country, resulting in different kinds of alloys as end-product.

6 Results & analysis

This section presents the results of the case studies, specifically focused on the main barriers to the growth of the formal sector in the transition toward an established e-waste management system in Brazil as perceived by the informants in the case organizations. The analysis is at the meso-level, represented as the regime in the MLP framework (Geels, 2002 ).

Through a thematic analysis of the interview data, the study identified concrete instances of perceived barriers from the organizations’ perspective. These were grouped into categories corresponding to the regime dimensions, as defined in Sect.  3 .

Table  2 summarizes the main identified barriers and connects them to the specific cases. These barriers have complex dynamics and often link to more than one dimension. They are placed at the meso-level of the MLP framework, impacted by the macro-level and influencing the micro-level. The following presents the main identified barriers sorted into the most predominant regime dimensions in the context of the MLP framework.

6.1 Technology & infrastructure

In the technology & infrastructure dimension at the meso-level, one of the barriers identified from the case studies is the lack of a comprehensive infrastructure for e-waste processing in Brazil. As mentioned in one of the interviews, installing a state-of-the-art recycling facility (capable of recovering the metals from e-waste at high yields) in the country would require a very high investment in technology and infrastructure.

The lack of processes for completely separating metals is also a barrier. Fine refining for certain metals (e.g., gold) demands high investments in the processing technology, which would only be economically viable if processing very high amounts of e-waste.

In addition, proper recycling of certain types of e-waste results in financial loss with the currently installed technology, which represents another regime barrier. An example of the latter case is refrigerators, which have high costs associated with reverse logistics and processing. Due to the high costs involved, the interviewed companies that accept refrigerators charge for collection and recycling to enable their activities. Alkaline batteries are also costly to recycle and commonly sent to industrial landfills.

In the context of the MLP framework, technological innovation in the landscape can have unintended consequences for the regime, such as in the technology & infrastructure dimension. For example, the high speed of innovation to insert electronic products into the market (at the macro-level) seems disconnected from the degree of technological innovation for managing e-waste (at the meso-level). Such is demonstrated by, for instance, the identified barriers of lack of comprehensive e-waste processing infrastructure and lack of processes for the complete separation of metals from e-waste.

6.2 Economy & market

Economy & market is another dimension at the meso-level of the MLP framework applied to this study. The high transportation cost is one of the identified barriers within such a regime dimension that impacts the recycling activity and the expansion of operations to other locations in the country. Specifically, this is challenging for large appliances that require an established reverse logistics system for efficient and safe transportation.

The lack of knowledge from the suppliers in handling e-waste is also a barrier in Business-to-Business (B2B). For instance, appliances are often delivered unsorted. In a manual process, mixed batches have a clear disadvantage because of the low speed for dismantling. They are also not preferred in mechanical processing since resulting in less pure and less valuable refining than the one from uniform batches.

The lack of transparency throughout the supply chains is also an identified barrier. Specifically, it is required in the B2B that supplying companies comply with several credentials to forward e-waste for recycling. One of the interviewed companies highlighted that it often must deny batches because the supplier companies cannot present such credentials. Another company indicated a similar concern on the need for a more transparent process that allows for the traceability of appliances throughout the chain.

Developments at the macro-level influence practices at the meso-level of the MLP framework. For example, the declining life span of products within the landscape impacts various regime practices, which can act as barriers or drivers toward transitions. As identified in the case studies, one of such barriers is the lack of transparency throughout the supply chains. The traditional linear economy (based on a take-make-dispose model) promotes high production and consumption patterns and does not align with various sustainability principles. The lack of transparency throughout the supply chains evidences a disconnection between the life cycle phases in a linear economy, unlike the connections among life cycle phases promoted by a circular economy.

6.3 Society & culture

The third regime dimension from the MLP framework defined and applied in this study is the socio-cultural. A critical barrier identified from the case studies and included in such regime dimension is the lack of environmental awareness toward e-waste disposal. For example, the organizations that collect e-waste through B2B and B2C mentioned that e-waste is sometimes delivered mixed with other waste categories. Such a barrier is particularly challenging in the B2C market because it depends on the consumers’ awareness to sort and bring the e-waste to collection points. The Green Eletron initiative (as mentioned in Sect.  2 ) helps to tackle the barrier mentioned by providing collection points within the B2C and assisting in the B2B market.

Another barrier is a concern with data security combined with a lack of knowledge regarding the storage and disposal of appliances. According to the interviews, many of the computers collected via B2C come without the hard disk drive, while others arrive with the component destroyed, usually hammered. In B2B, similar concerns also pose challenges for the collection. One of the interviewees recalled an episode in which one of the supplying companies had hammered an entire batch of mobile phones without previously removing the batteries. As the interviewee highlighted, this poses severe risks of accidents and explosions.

Embedded societal practices toward fast-paced technological innovations (at the macro-level of the MLP framework) can influence a preference for brand-new products rather than promoting repair and recycling practices. Indeed, cultural resistance to acquiring repaired and recycled products represents a barrier at the meso-level. One of the companies pointed out that repair is conducted primarily for computers because of market resistance toward buying second-hand appliances of other types (e.g., blenders, mixers). Another company remarked on the cultural resistance toward recycled products and the misconception about the low quality of recycled products.

The influence of the COVID-19 pandemic (as a landscape development) in regime practices is also an example that connects the macro and meso-level of the MLP framework. More specifically, the pandemic has fostered a change in consumer behavior and the emergence of market opportunities. For instance, social classes A and B acquired new computers, and classes C and D second-hand computers (from donations and loans) with the adoption of remote and hybrid work (CETIC.BR 2023 ). As a result, new companies appeared on the second-hand market to meet the increasing demand.

The last regime dimension applied in this study in the context of the MLP framework (cf. Table  1 ) is the policy dimension. One of the main identified barriers within this dimension is the lack of financial incentives. Instead, e-waste management companies must pay taxes for transporting e-waste through different regions in the country. The Tax on the Movement of Goods and Provision of Services, ICMS Footnote 8 , is applied once the appliance enters the market as a product and again when it becomes e-waste.

Another barrier pointed out in the interviews is the lack of policy integration. As highlighted, some states have specific policies that differ in certain aspects. For instance, not all state policies interpret e-waste as hazardous waste. In addition, the state of the appliance (e.g., if already dismantled) and the intended purpose (e.g., repair or recycling) also influence the potential classification as hazardous waste. The same appliance could be classified as a product if transported for repair and as hazardous waste if forwarded for recycling. Fortunately, Decree nº 10.936 of 2022, which in article 72 defines what is considered hazardous material (Brasil, 2022 ), is currently mitigating this identified barrier.

The high bureaucracy for governmental initiatives also represents a barrier to transitions. The implementation of governmental partnerships for e-waste collection campaigns as B2C and the e-waste collection from the public sector are two examples. As pointed out, attempts at such initiatives are often time-consuming and not implemented.

Another barrier is the lack of standardization and proper labeling of appliances, which influences the processes and quality of the recovered material. One company mentioned that a manual process is initially necessary to separate certain parts due to the lack of a standard electronics design. Another company highlighted that a lack of labeling on the types of plastic used in the products impacts the material recovery levels. Due to a lack of knowledge, the components are often not sorted into different plastic types, which results in downcycling.

In the context of the MLP framework, increasing consumption patterns is an example of a landscape development influencing regime practices, such as within the policy dimension. More specifically, the elevated consumption rates of technological devices potentially lead to a focus on producing new devices rather than promoting holistic thinking throughout the devices’ life cycle. Such a landscape development might trigger an unintended consequence that appears as a barrier at the meso-level, that is, a lack of standardization and proper labeling of appliances.

7 Discussion

Brazil generates most of the e-waste in Latin America but only recycles a small portion through the formal sector (Baldé et al., 2024 ). The results of the case studies show that none of the organizations operate at the optimal capacity, which indicates opportunities for expanding activities within the formal sector.

This section discusses the results from a transition management perspective (Loorbach, 2007 ). Despite the several barriers identified at the meso-level, the empirical cases also demonstrate the presence of innovative approaches. Such a presence aligns with earlier findings of MLP studies that locate the source of innovation at the micro-level. The first subsection focuses on these innovative approaches. The second subsection combines the main results with the Brazilian e-waste literature and highlights the main novelties within such a context.

7.1 Identifying innovations from the niche

Section  6 presented some barriers (at the meso-level) to initiatives within the formal sector in Brazil in the transition toward an established e-waste management system. These barriers often prevent innovation and more sustainable practices, and many connect to the low e-waste collection levels prevailing in the country. However, the case studies showed that, despite the barriers, several initiatives (at the micro-level) took place in the formal sector. These initiatives are positive examples that illustrate ways of tackling specific barriers. The following discusses such initiatives from the organizations.

The high bureaucracy for governmental initiatives is one of the barriers to e-waste management identified within the policy dimension. In Case 1, a center that is part of a public university performs the activities. The university provides financial support for infrastructure and personnel costs. Nonetheless, the center has partnered with recycling companies that support social university projects in exchange for e-waste supply. The partnership between the private and public sectors fostered various social initiatives, such as the Paideia project mentioned earlier.

A barrier in the economy & market dimension is the high cost of reverse logistics. Nonetheless, the organization associated with Case 2 collects e-waste in several locations in the state of Santa Catarina through the implementation of voluntary collection points. The various collection points reduce the reverse logistics cost by picking up large amounts of e-waste each time. In addition, there is a possibility to optimize the collection through planning for the most efficient routes for pick-up from several locations.

The concern with data security is one of the barriers identified in the society & culture dimension. This concern often stops consumers from forwarding the appliances for recycling, thus preventing closing the loop for circularity. However, the sampling processes performed in the country before exporting the material for the end-processing (cf. presented in Case 3) is an approach that tackles such a barrier. The sampling processes destroy the appliances, thus preventing any data restoration.

Another barrier is the lack of a comprehensive processing infrastructure within the technology & infrastructure dimension. Nevertheless, Case 4 presents an innovative approach that tackles the lack of infrastructure by implementing complete e-waste processing in the country. The end-processing performed by this organization does not separate all the metals but results in alloys of different kinds used for several purposes. The approach is particularly relevant in a transition period to allow processing on a national basis.

Figure  4 shows a visual representation of sustainability transitions in the context of e-waste management in Brazil through an MLP framework (Geels, 2019 ). As presented in Sect.  3 , such a framework is well-known within sustainability transitions research for helping to depict various subjects in a system and explore related interactions. Here, the focus is on the two levels of the MLP framework upon which this study centers (i.e., the micro and meso-level). The figure incorporates the notion of complex systems theory, applied to transition studies by Loorbach ( 2007 , 2010 ), by framing the boundaries of the societal system (here represented as the e-waste management system).

figure 4

A multi-level perspective on the sustainability transitions in e-waste management in Brazil (Based on Geels, 2019 )

Landscape developments at the macro-level (e.g., increasing consumption patterns, technological innovation, and declining life span of products) put pressure on both the micro and meso-level. Regime practices at the meso-level can act as drivers or barriers toward transitions. The main barriers identified in this study, as previously shown in Table  2 , form part of such regime practices and impact the micro-level. Initiatives, such as the ones discussed in this section, manifest as niche innovations at the micro-level and tackle some identified barriers (as presented in Sect.  6 ).

7.2 Highlighting the main novelties

This study looks at e-waste management in Brazil from a systemic perspective. Not only one organization performs all recycling activities, but a combination of organizations acting at different levels of e-waste processing (e.g., collection, pre-, and end-processing), as well as organizations working with varied types of materials (e.g., plastics, ferrous material, and non-ferrous material). E-waste management organizations also interact with other subjects in the system (e.g., consumers disposing of electronics). The several interactions create a system network. Therefore, the e-waste management system emerges and is maintained not by isolated behavior but through several connections and respective activities.

The barriers identified in the case studies provide a perspective from the organizations analyzed, many of which are also found in the e-waste management literature in Brazil. Table  3 presents the connections between the identified barriers in the case studies and examples from the e-waste management literature in Brazil raising similar concerns.

Nevertheless, some identified barriers seem novel in the Brazilian context of e-waste management literature, namely, the high recycling cost for certain e-waste types, the lack of knowledge from the suppliers in handling e-waste, and the lack of standardization and proper labeling of appliances. The three barriers strongly connect to the recycling process, for instance, the types of e-waste forwarded for recycling and the output of recycled materials.

Despite the barriers imposed by the regime, several niche innovations have appeared in the e-waste management system in the country. Literature has not yet widely recognized some of these innovations. For example, studies often point out that the formal sector only conducts pre-processing of e-waste in Brazil and that end-processing is performed abroad (de Albuquerque et al., 2020 ; Neto et al., 2019 ). Although this seems to be the case for most organizations, the results from this study show one example in which the end-processing, resulting in alloys of different kinds, is conducted in the country.

8 Conclusion

This study focuses on identifying barriers in the formal sector within e-waste management in Brazil for transitioning toward an established system. It provides a perspective from four critical e-waste management organizations focusing on e-waste collection and recycling in the country. Their different levels of operations, from collection to end-processing, provide insights into some challenges and opportunities of sustainability transitions.

The study applies an MLP framework to analyze the data from a transition management perspective. The framework assists in establishing connections among the micro-, meso-, and macro-level within the e-waste management system in Brazil. The identified barriers at the meso-level represent the results, impacted by the macro-level (e.g., increasing consumption patterns) and influencing initiatives at the micro-level.

The case studies indicate that e-waste management in Brazil is undergoing several transformations at the meso-level, such as a gradual shift from manual to mechanical processes. Process mechanization is a common trend in countries advancing in e-waste recycling technologies, contrary to countries where labor-intensive pre-processing technologies are prevalent due to labor costs. As indicated in the literature, e-waste recycling in Brazil seems to remain primarily focused on pre-processing and export. Nevertheless, the case studies show initiatives at the micro-level for further processing: one organization conducting a sampling process of e-waste in the country and another performing end-processing resulting in alloys. These examples present some avenues for future consideration in implementing complete processing on the national scale.

The restriction of the collected data is a limitation, and future research on a larger scale is suggested (e.g., a survey of e-waste management organizations). Such has the potential to identify additional barriers and initiatives within the formal sector. Moreover, studies focusing on the impact of local e-waste management policies could yield new insights into the regional diversities of the country.

Given a high level of e-waste generation and a low recycling rate through formal channels in Brazil, the study is timely. Applying the MLP as an analytical framework to the study has assisted in focusing on specific subjects while considering their impact on the system. The study highlights disconnections in the system (from micro to macro-level) and between the life cycle phases of devices.

Establishing a more holistic approach may help tackle several of the identified barriers. For instance, initiatives focusing on transparency through process monitoring and traceability of origin could lead to a more reliable and connected e-waste management system. Additionally, the national reverse logistics program proposed through the new decree has the potential to mitigate several of the current barriers and, therefore, help to move toward a more established system in the country.

Data availability

The data that support the findings of this study are available from the authors upon reasonable request.

PNRS: Política Nacional de Resíduos Sólidos.

Abree: Associação Brasileira de Reciclagem de Eletroeletrônicos e Eletrodomésticos.

Eletros: Associação Nacional de Fabricantes de Produtos Eletroeletrônicos.

Abinee: Associação Brasileira da Indústria Elétrica e Eletrônica.

CEDIR: Centro de Descarte e Reúso de Resíduos de Informática.

LaSSu: Laboratório de Sustentabilidade em TIC.

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Alice Frantz Schneider & Margunn Aanestad

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Frantz Schneider, A., Aanestad, M. & Carvalho, T.C. Exploring barriers in the transition toward an established e-waste management system in Brazil: a multiple-case study of the formal sector. Environ Dev Sustain (2024). https://doi.org/10.1007/s10668-024-05188-y

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Published : 17 July 2024

DOI : https://doi.org/10.1007/s10668-024-05188-y

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