Aug & Sep Issue 2018


Bangalore Columbia Asia Msk Imaging Course

Managing the Unexpected

The principle of high reliability organisation is a paramount necessity to ensure a safe healthcare ecosystem

By: Dr AK Khandelwal

Healthcare organisations are very complex and in spite standardisation of most processes, failure and catastrophes do occur. Sudden death in an imaging room, fall of patients, suicide of patients, wrong site, wrong patient surgery, wrong investigations, failure of treatment, failure of equipment are some examples of unexpected events. So, it is important to recognise that standardisation is necessary but not sufficient for achieving resilient and reliable healthcare systems.
Managing the expected is the paramount for a healthcare organisation.
Industries like airline, gas and oil, nuclear power are working in high hazard domains without serious events and catastrophic failure by implementing principle of high reliability organisation. This principle of high reliability organisation is a paramount necessity to ensure safe healthcare ecosystem and healthcare organisations should adopt lessons about safety management practices in safety-critical industries. Examples include the introduction of incident reporting systems and the WHO Surgical Safety Check List.

Joy Chakraborty

Literature mentions that high reliability organisations are those that manage to have few or no significant accidents even though they operate complex technology in highly hazardous environments, such as aircraft carriers and nuclear power plants

What is High Reliability organisation?

Literature mentions that high reliability organisations are those that
manage to have few or no significant accidents even though they operate complex technology in highly hazardous environments, such as aircraft carriers and nuclear power plants.
It is based on the principle of persistent mindfulness in the organisation of deficiency or failure of services resulting in damage or death. Literature mentions that high reliability organisations cultivate resilience by relentlessly priotising safety over the performance pressure. High reliability organisations consider safety as a dynamic culture changing with the new emerging threats in the healthcare ecosystem. An administrator in a high reliability healthcare organisation should anticipate emerging safety threat, detect early and act early to mitigate catastrophic damage.

Characteristics of a High Reliability organisation

Preoccupation with failure: All stakeholders should be aware of and think about the potential for failure. They should not forget that unexpected failure and deficiency emerge regularly in the ever-changing healthcare ecosystem. All stakeholders, healthcare providers, healthcare recipient, payors and healthcare organisations should actively think about what could go wrong and are alert to small signs of potential problems. It should be emphasised among all levels of healthcare providers that the absence of errors or accidents leads not to complacency but to a heightened sense of vigilance for the next possible failure. The organisation culture should encourage to learn from near misses.

Reluctance to simplify: High reliable healthcare organisations consider that all processes are complex and dynamic and prone to error and failure. Healthcare organisations should create a system that provides resource to investigate and pursue potential problems proactively and more widely.

Sensitivity to operations: All stakeholders in a high reliability healthcare organisation should maintain a high vigilance on all operations. They should understand what they are doing/where they are doing/who is doing/what wrong can occur.

Deference to expertise: Hierarchy in a high reliable healthcare organisation should be flat. Organisations should give importance to the front-line staff who are directly involved in the process in decision making specially in crisis situation.

Commitment to resilience: Literature mentions that resilience is the intrinsic ability of a high reliable organisation to adjust its functioning according to the dynamic healthcare ecosystem and continue to function even after a major mishap or in the presence of continuous stress. High reliable organisations invest in resilience engineering to cope with and recover from unpredicted, unforeseen, unexpected demands and situations.

Characteristics of a High Reliability organisation

Healthcare organisations can implement the above-mentioned behaviours toward their journey for becoming a highly reliable organisation. Needless to mention that this journey may be faster in some areas and slower and difficult in other areas of a healthcare organisation.
The success of implementation depends upon three main abilities of healthcare organisation: risk analysis and control, adapting capacity to changes, and learning continuously.

Risk analysis

Experts suggest that there is large variation in the reliability of different care processes, and that overall, care process have a significant failure rate that can be improved upon.
Healthcare organisations should identify high risk process like CPR, IV cannulation, oxygen administration, operations, invasive procedures, identifications, blood transfusions, sedations, anesthesia etc. and anticipate the probability of failure and severity of outcome of failure by most effective quality tool like failure mode and effect analysis (FMEA).

Risk control

In order to improve the reliability of processes, organisations usually attempt to exert greater managerial control over how care is delivered. This can be achieved by simplification and standardisation of processes by using a management tool like process mapping, lean method, care bundle etc.
Investing in such activities is a prerequisite for enhancing the reliability of care processes to higher levels, and it is a key component of mindful organising.

Learning continuously

A healthcare organisation should develop culture of learning organisation to provide safe and reliable healthcare. Safe and reliable care is facilitated by individual learning, team learning and organisation learning.


Managing the unexpected in a healthcare organisation is a challenging and arduous task. Experience of other industries like aviation, nuclear power etc. have proved that it is possible to achieve this. A healthcare organisation can start its journey towards becoming an HRO with vision, leadership and safety culture.

About the author

Dr. Ashok Kumar Khandelwal is the VP & Medical Director, Anandaloke Hospital & Neurosciences Centre, West Bengal. He is a trained Assessor from the National Accreditation Board for Hospital and Health Care Provider (NABH). He carries around two decades of experience in the hospital industry and 20 years of experience as a hospital administrator.