Circulation 36,825 • Volume 18, No. 4 • Winter 2003   Issue PDF

APSF Workshop Explores HRO Model

David Gaba, MD; Jeffrey Cooper, PhD

How do some organizations succeed in performing intrinsically hazardous work at an intense pace with ultra-low rates of failure? And what lessons might anesthesiologists and their partners in perioperative health care learn about high reliability from such successful organizations? These were the fundamental topics of the APSF Board of Directors Workshop held on Friday October 10, 2003, at the ASA Meeting in San Francisco. Joining members of the Board of Directors were invited representatives of the American College of Surgeons (Dr. Thomas Russell, Executive Director), the Association of Peri-Operative Registered Nurses (Mr. Thomas Cooper, Executive Director), and the American Society of Post-Anesthesia Nurses (Denise O’Brien, BSN, RN). Also present were academic and private practice anesthesiologists from around the nation.

The goals of the workshop were to:

HRO Brainstorming session results in one of several work product organizational charts.

  • Present the concept of the High Reliability Organization (HRO)
  • Examine the core components of an HRO
  • Consider how the HRO concept applies to perioperative health care
  • Determine what a high reliability perioperative health care organization would look like
  • Outline what steps perioperative health care organizations would need to take to achieve HRO status
  • Predict the obstacles to developing HRO components in perioperative health care
  • Lay out possible programs that APSF could undertake to assist institutions and health care systems to achieve HRO status.

The Workshop consisted of three parts. In Part 1 APSF Secretary, David Gaba, presented the key elements of High Reliability Organizations (HROs) and gave examples of their applicability to perioperative health care. This presentation expanded upon Dr. Gaba’s lead article in the APSF Newsletter Special Issue on High Reliability Perioperative Health Care.1 The Workshop participants then broke into four working groups to facilitate detailed discussion of several key questions including:

  • What is a perioperative HRO? What would it look like in practice?
  • What steps would perioperative health care organizations need to take to achieve HRO status?
  • What are the obstacles that have kept and could keep perioperative institutions from becoming high reliability settings?
  • What can the APSF do via projects or programs to help anesthesiologists and their professional colleagues lead institutions toward achieving HRO status?

This presentation was also accompanied by a draft document outlining a “straw man” example describing some details of a hypothetical high reliability cardiac surgery work system. In the third part of the workshop, led by APSF Executive Vice President Jeffrey Cooper, the groups worked as a whole to synthesize the common and key elements of the breakout sessions.

Breakout discussions resulted in the identification of the following characteristics and suggestions:

Vision: What are characteristics of a Perioperative HRO?

  • Rewards for honesty, positive sanctions, incentives
  • People are rewarded/paid based on outcomes, not just production
  • Practices are multi-disciplinary
  • Personnel have T.I.A. (Total Information Awareness)
  • No wasted work or redundancy
  • Time is made available for training
  • Work is based on the continuum of care as a system (beyond perioperative)
  • Complete information is legibly and readily available
  • Belief at a “molecular level” that patient safety is job one
  • Care providers at the bedside are empowered to do the right thing
  • Ongoing audits of adoption of best practices.

Actions needed to implement HRO concepts in perioperative care:

  • Align incentives for all participants
  • Create demonstration systems as laboratories to study and formulate what works
  • Set up the system to handle specific crises
  • Pre-empt new regulations by adopting defined best practices
  • Rotate personnel through administration and trenches (for all to see learn how the system works)
  • Place one person in charge of perioperative care
  • Publicize information on HRO concepts to the general publicDocument efficiencies
  • Establish HRO metrics
  • Devise methods to ensure competency
  • Incorporate training throughout the system
  • Statement of quality: “Would you operate on your loved one in these conditions?”
  • Bring expert coaches into organizations to facilitate pilot projects
  • Match performance to infrastructure, prioritizing patient care and safety
  • Develop an entity to promote HRO principles and processes.

Challenges: What have been and are the barriers to change?

  • Disparity and autonomy may fragment standardization
  • Lack of knowledge about safety/HRO
  • Reimbursement system is procedure-based, not based on quality or safety
  • Inability to take long-term perspective
  • Hierarchical culture
  • Clinical personnel shortages
  • Competition can result in reduced sharing
  • Financial and production pressures
  • “Whistle Blowers” become pariahs

APSF Programs: What can the APSF do to help others achieve HRO status?

Participants at 2003 HRO Retreat show their enthusiasm during one of the breakout sessions.

  • Joint development, e.g., with ASA, ACS, AORN, ASPAN, of codes of conduct
  • Anesthesiologists need to take leadership positions
  • Provide national peer review of reported data
  • Make the business case for safety
  • Make high profile awards for perioperative HRO organizations
  • Provide a package of resources such as presentations & case studies
  • Develop a roadmap to teamwork, including teamwork training programs
  • Create a model HRO training program (pilot across the country)

Action Plan

  • Working as a whole, the group identified suggestions for possible APSF action for its constituents and their institutions


  • Develop peer review systems to assess HROs
  • Discounts on liability premiums for HRO behaviors


  • Develop HRO curricula and a resource package
  • Provide programs for developing leadership and communication skills
  • Support model HRO training program(s)
  • Train perioperative professionals to be HRO “coaches”

Cross-Discipline Actions

  • Define a clear perioperative goal
  • Develop joint codes-of-conduct
  • Create office-based perioperative teams
  • Develop collaboration between the perioperative disciplines including ACS, AORN, APSF, ASA

Develop HRO Tools

  • Near miss reporting systems
  • Demonstration structured learning systems

Research to Demonstrate Efficacy

  • Conduct demonstration project(s)
  • Target one area, e.g., teamwork training
  • Devices and human factors
  • Define how to measure success
  • Learning how to manage information to reduce errors


  • Baldridge examples
  • Co-sponsor with ACS, AORN, and ASA
  • Teamwork is key.

A caution was raised that the language of HROs is tenuous. It would be easy to “game” measures of HRO and to have only a superficial appearance of action and progress merely by creating a new language by which current actions are labeled as being HRO compliant. The same pattern occurred during previous quality movements.

The APSF Executive Committee will consider the suggestions and select a set of actions to move the HRO agenda forward.


Dr. Gaba is Director of the Patient Safety Center of Inquiry at the VA Palo Alto Health Care System, Professor of Anesthesia at Stanford University School of Medicine, and Secretary of the APSF.

Dr. Cooper is Associate Professor of Anesthesia at Harvard Medical School and Executive Vice President of the APSF.


  1. Gaba DM. Safety first: ensuring quality care in the intensely productive environment—the HRO model. APSF Newsletter 2003;18:1,3,4.