The Journey to High Reliability

SC Safe Care

When you board a flight, you trust that any issues with the plane will be found before takeoff. Not because the pilot, mechanics or fuelers never make errors, but because the system was built to catch those errors. Commercial aviation is an industry where every employee is constantly thinking about what could go wrong, and their collective mindfulness leads to resilience over long periods of time.

This operating philosophy is at the core of Highly Reliable Organizations, a term that describes working in complex and high-risk environments while still delivering exceptionally safe and consistently high-quality results. 

In 2012, SCHA teamed up with The Joint Commission Center for Healthcare Transformation, Health Sciences SC, PHTS Risk Management Services, and 31 hospitals and health centers for The South Carolina Safe Care Commitment, a collaborative designed to help hospitals become high reliability organizations. The goal: deliver dependably excellent healthcare at high levels of safety every time, for every patient.

Guiding this work are the five principles of Highly Reliable Organizations (HROs) that were identified by Karl Weick and Kathleen Sutcliffe:

#1 Preoccupation with Failure

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 and all levels of technical, human or process failure immediately and completely. It’s also important to be fixated on how things could fail, even if they have not yet done so. (See video)

#2 Reluctance to Simplify

HROs are complex and they accept and embrace that complexity.  HROs do not explain away problems; instead, they conduct root cause analyses and reject reductive thinking.  (See video)

#3 Sensitivity to Operations

HROs understand that the most complete picture of a current situation, especially an unexpected one, comes from the front line. Because front line staff are closer to the work than executive leadership, they are better positioned to recognize failure and identify opportunities for improvement. (See video)

#4 Commitment to Resilience

Resilience in HROs means the ability to anticipate points of weakness and improvise when the unexpected occurs. The organization must be able to identify errors for correction while at the same time craft innovative solutions within a dynamic environment. (See video)

#5 Deference to Expertise

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. (See video)

In addition, Weick and Sutcliffe also note the importance of “collective mindfulness” for managing unexpected events in this model through anticipation and containment. Anticipation includes the first three key concepts of high reliability and are those elements of an HRO that identify issues early or before they even occur. Containment is the thought process that drives the HRO through an event to minimize the progression of damage or harm to others during the event. 

While SCHA’s collaboration with The Joint Commission formally came to a close at the end of 2016, we continue to make high reliability a priority, offering assistance to all organizations with setting and achieving zero harm goals. We also offer our Zero Harm Awards as a way of recognizing and celebrating those achievements. 

One of our key initiatives in helping healthcare systems on their journey to high reliability is assisting in the implementation of Patient & Family Advisory Councils (PFACs). These councils are instituted in hospitals with the goal of ensuring that the planning, delivery and evaluation of healthcare is grounded in the understanding that quality care is driven by mutually beneficial partnerships among patients, families, and healthcare practitioners. For more information, consult Caroline Delongchamp's presentation here.

Another initiative is a renewed focus on physician engagement, another crucial aspect of high reliability. For more information, consult Dr. Reinersten's presentation here

Below are a host of resources that guide SCHA’s thinking and work on highly reliable care. To learn more about our efforts to make healthcare in South Carolina the safest in the world, contact Thea Coleman, MSN, RN at

The Duke Endowment Logo

This work is made possible by the generosity of The Duke Endowment. South Carolina’s hospitals are grateful for the vision of James B. Duke, who established The Duke Endowment in December of 1924. For more information on the legacy of Mr. Duke and the work of The Duke Endowment, visit

Documents and Resources