The opening chapter of this volume discusses the reasons the original authors saw a need for delineating this area of research. It seemed that a growing number of catastrophes were partially or wholly caused by organizational processes. The chapter then identifies the three organizations that participated in the research and explains how "high reliability organizations research" came by its name. Important characteristics of the original work are discussed such as that it focused on current functioning and not on how the organizations developed reliable processes. Roberts outlines the definitional problem that is still at the heart of this work and goes on to describe initial findings. He chapters concludes with precis of the chapters that follow.
This chapter examines two important trends in the organizational research on reliability. First, the increasingly multi-faceted definition of reliability that encompasses multiple interrelated notions, levels of analysis, organizational capabilities, and assessment standards. Second, the growing recognition that a single model of organizational reliability might not adequately describe or explain the pursuit of reliability in different contexts. The implications of the multiple notions and models of reliability for future research are discussed.
Safety in high-hazard organizations has become an important topic for scholarship, management practice, and policy. There are many approaches to safety management, ranging from formal Safety Management Systems that rely on organizational structures and rules, to High Reliability Organizing concepts that focus on human cognition and organizational culture. This chapter offers three perspectives or lenses on organizations: Strategic Design, Political, and Cultural. The three lenses help to map out and analyze safety approaches so that specific good ideas and improvement efforts can be placed in a broader, more systemic context. The example of SUBSAFE, the US Navy program to assure submarine hull integrity created after the USS Thresher accident, is used to illustrate a comprehensive approach that attends to all three lenses. An example of where problems were not addressed as quickly as they should have been is the Millstone Nuclear Power Station crisis in the 1990s.
A growing stream of organization theory proposes that the ability to perform reliably in real time results from mindful organizing. Mindful organizing, a dynamic process comprising ongoing patterns of action fuels capabilities to more quickly sense and manage complex, ill-structured contingencies. This chapter explores mindful organizing and the associated concept of organizational (collective) mindfulness and accompanying growth of theory and empirical research in this important domain. It begins by examining the conceptual foundations for these ideas in research on high reliability organizations and describe the specific organizing principles and the processes and practices through which mindfulness is thought to be realized. It then reviews some of the more recent empirical research to date, identify gaps in existing literature and propose some avenues for future research. It ends with some implications for practice.
Teams are typically tasked by organizations to craft responses to unexpected critical events. This chapter suggests that team-level resilience, in contrast to event prediction capability, contributes more to long-term organizational reliability. It reviews specific evidence in three areas—internal team emergent states, team boundary dynamics, and simulation-based training—that influence the development and maintenance of team resilience. The chapter offers suggestions for future research and for ways to overcome possible organizational impediments to the development of team resilience.
The tension between reliability goals and efficiency goals is problematic in high-risk work settings where the multiple goals are high in both their performance relatedness as well as their causal ambiguity. Typical approaches to resolving goal conflict such as pursuing a single overriding goal or addressing goals concurrently or sequentially may be inadequate or even infeasible. Processes that enable organizations to continuously assess and resolve such goal conflicts are discussed.
Early work in the HRO tradition minimized the role of learning in the reliability enhancement process due to the view that because HROs experience failure only very rarely, learning could not be a significant explanation for their reliability. However, subsequent HRO theorizing suggests a central place for learning in reliability enhancement. This work suggests four major forms of learning for reliability: experiential learning, vicarious learning, learning from small failures and near-misses, and simulation learning. Together, these forms of organizational learning hold the potential to facilitate such high organizational reliability that organizations may be able to prevent disasters indefinitely. This chapter reviews both the HRO literature and other, related literatures relating to all four of these learning approaches. Integration of the four learning approaches using Turner's (1978) disaster incubation model as a unifying viewpoint is suggested.
Communication has a foundational role in organizations, particularly in enacting norms and values that sustain cultures and maintain social structures related to reliability. This chapter examines five communication metaphors used in high reliability research and explores how each one reveals and obscures meanings and actions embedded in organizational culture. Through distinguishing among these metaphors, HRO scholars can gain a clearer understanding of the strengths and limitations of different approaches to examining communication. In particular, by embracing seldom-used metaphors, researchers can adopt a more complex view of communication and its pivotal role in constituting high reliability cultures.
The scope and timeframe of reliability research needs to be redefined to account for the fact that reliability is, increasingly, the property of an inter-organizational network, not just a single organization as typically assumed. One implication is that public dread of hazard and regulation play a far greater role in the practice of reliability management. Another is that reliability needs to be understood in terms of different standards and different performance states.
This chapter examines assumptions and challenges of high reliability organization (HRO) theory in health care. Building on the literature and reflections from discussion with colleagues, it examines how the search for patient safety solutions in one setting evolved into an "implementation label" for strategies to "become an HRO" and achieve "zero errors" across health care more generally. If health care organizations are striving to "become" high reliability organizations, then it is important to consider what that entails in theory and how it has emerged in practice. A discussion of critical events paired with two brief examples highlights the diffusion of a precluded events approach and underscores the role of various drivers of adoption. Throughout, consider what problem HRO is solving and what constitutes reliability in the broader health care setting. A thoughtful recalibration of HRO theory and health care practice will benefit organizations in their search for organizational reliability.
Although the majority of research on high reliability organizations has been done in single organizations, in fact organizations are nested in various levels of other organizations and systems of organizations creating Complex Adaptive Systems of Systems. This raises the question about how such systems scale up and down to achieve coherent performance. This question is addressed by examining the responses to the 2004 Indonesian earthquake and tsunami, the 2010 Haitian earthquake and the 2011 Japanese, earthquake, tsunami, and nuclear breach. Differences in the planning processes and factors that reduced or increased risk in each case are reviewed. Implications for building global resilience are discussed.
How do HROs become HROs? Is it a state to be achieved or a process of becoming? This chapter provides lessons learned about attempts to implement high reliability principles from successful leaders who manage, regulate and oversee high reliability demanding organizations. Drawing from experiences with commercial nuclear, petro-chemical, and transportation industries, government research laboratories and defense operations, these leaders share what they think about and what they do to operate in some of the world's most hazardous environments. Their shared insights provide five (5) lessons learned about seeking reliability, and offer suggestions on first steps toward nurturing a culture of reliability.
The authors discuss key themes emerging from this volume. What began three decades ago as an effort to understand the impressively error-free performance of three specific organizations has evolved today into an active line of inquiry that informs and is informed by practice across very different organizational contexts. Reliability is an increasingly complex construct that encompasses a wide array of organizational capabilities and outcomes beyond error-free performance. Correspondingly, there is a growing need to study organizational origins of reliability by drawing on diverse theoretical perspectives and context-specific models. The authors also summarize the major questions and opportunities for future research that were identified in the chapters.