Circulation 36,825 • Volume 18, No. 1 • Spring 2003

Complex OR Environment Ripe for HRO Approach

Christina DeMur, BS, MSM; Yossi Elaz, BSEE

Organizations that consistently operate under very challenging conditions and manage to minimize the impact of unexpected events are referred to as high reliability organizations (HROs). There is no room for error in an HRO. How do you organize for high performance in a setting where the potential for error and disaster is overwhelming? HROs have developed ways of acting that provide a template for all organizations that want to be more reliable in managing the unexpected. HROs create a collective state of mindfulness that produces an enhanced ability to discover and correct errors before they escalate into a crisis.1

HROs Share Many Characteristics

Examples of HROs include aircraft carriers, aviation, air traffic control towers, and nuclear power plants. They share the following characteristics: leadership, the use of teams as building blocks, and a decentralized culture of safety, redundancy, and learning. Continuous learning occurs at all levels of the organization through simulation, education, and training and is incorporated into daily operations. Safety is not something that can be put on top of existing systems; rather, it must be the core on which everything is built.2 Many other industries are taking notes from these organizations and cultivating a state of mindfulness to minimize the impact of errors and using multi-disciplinary teams as a key unit of analysis. By instituting a system of checks and balances (or multiplicity) the likelihood of any one event causing a major catastrophe is minimized. Manufacturing facilities that practice HRO principles are able to organize themselves to notice the unexpected and stop or contain it before it adversely impacts operations.1 The use of cross-functional teams allows the development of a product to be monitored from several perspectives with the goal of anticipating any operational delays and mitigating them.

The operating room (OR) environment (like that of an Emergency Room) is extremely complex and full of variables that cannot always be planned or scheduled (patient turnover, provider turnover, and interaction with off-site areas critical for patient treatment such as laboratories and imaging). One OR manager succinctly puts it as, “It’s not an airplane, it’s a person, and the one thing that always complicates health care is that there is a patient at the end of it all, and that person becomes a completely unpredictable issue.”

Hospitals (in general) have detailed processes and strategic goals. Having a list of goals is much different than having an atmosphere that actively pursues meeting the goals. These health care institutions are not typically thought of as HROs. But given the level of complexity and very fast pace, one must assume that there are many opportunities for errors; therefore, HRO concepts should apply. At a minimum, going through the exercise of thinking of the OR as an HRO has a huge potential to create a more efficient, better run environment that minimizes the likelihood of errors (thereby increasing patient safety). HROs can teach hospitals what to pay attention to, how to process such information and how to maintain alertness.1

The OR (in many if not all institutions) is the “cash cow” for the hospital. Everyone who works in the OR is acutely aware of this, including the surgeons. Their perspective is often one of just “getting it done,” and that is a problem. They wield a lot of political power with the administration because they can always say they’ll take their cases next door (to another hospital) and treat their patients there. So, the motivation is to increase surgical volume, at any cost. The idea of reviewing the processes or policies that are in place is often viewed as a waste of time. Ultimately, a constant focus on speed in the OR environment is apt to contribute to an increase in medical errors (including those related to medication administration).

Anesthesiologists Should Champion Change

Assuming we agree that the OR should be perceived and managed as an HRO, who should champion this change? It should be the anesthesiologists because, as one anesthesiologist put it, “Surgeons aren’t here every day. Surgeons come and do their case and go back to work to their office. This is our office, and we’re here from 7:30 a.m. to 5:30 p.m., 6 days a week. We interact with all areas of the hospital (the ER, central processing, billing, scheduling, etc.). We’re the folks that really know what’s going on. We’re in the best position to move forward with change. Remember, we are problem solvers, trained to think at a very fast pace.” There is an inherent struggle in health care between the clinical and non-clinical people. Hospital administration (typically made up of non-clinical leaders) wants to make the hospital more profitable by cutting costs. The clinical leaders feel they have much to contribute to this effort, but a power struggle ensues between the two groups. In many places it’s business as usual with an acceptance of inefficiency and mismanagement.

From a scheduling point of view, the OR environment is very complex and difficult to manage. In any given day there are emergency cases from off-site areas, trauma cases from the ER, add-on cases, pieces of equipment “down” or not available (they may be broken, out for repair, or a kit may be stuck in a sterilizer). There may be issues with locating anesthesia providers or members of the surgical staff (someone may be “off the floor” or trying to locate a surgical supply). Additionally, there can be completely unplanned events that contribute significantly to the ability to complete a full case load (a blizzard or a flood).

Teams Should Be Empowered

Now, if the OR is really an HRO then Anesthesia should champion changing it to be managed as such. How is this achieved? There is a need for a “team” to be identified for managing and addressing the OR environment. In many places, these teams, committees, or task forces are already in place, so what stops them from effecting change? They are not empowered to do so. There is already much discussion about changes and improvements that could be made to minimize the impact of delays; however, those changes would cut across many different groups of people, and that is where the Catch-22 exists. Hospitals ultimately want to be more efficient (it is in their financial interest to do so); but in order to achieve this, system-wide change is needed, which, in most places is the true challenge. Attempts at comprehensive reform can be further complicated by outside agencies such as employee unions. Another hospital manager says, “The OR (or hospital) has many different sections, like those in an orchestra, but there is not a conductor. The different sections know what they need to do, and the challenge is getting the sections to play nicely and work together, and most of the time, despite the chaos, that happens.”

In addition to the need for a “conductor” to facilitate changes, there are other issues related to implementing system-wide changes. Financial and personnel resource constraints affect how change is implemented. Additionally, health care systems usually cannot afford to buy the latest and greatest technology. Changes may also be required to hospital infrastructure to support the management of information and communication.

These challenges do not stop us from making the OR environment a highly reliable one. First and foremost a “conductor” is needed, someone internally with the power to see that the different sections (nursing, surgical staff, stakeholders) “play nicely.” Hospitals must push to change the environment. Using incentives to reward behavior that promotes safety is a worthy approach. Changing the OR environment to be more like that of an HRO will create a heightened awareness that facilitates error discovery and correction before escalation into a crisis that results in an adverse outcome. Ms. DeMur and Mr. Elaz are both with Siemens Medical Solutions, Electromedical Systems Group, Patient Care Systems in Danvers, MA.

Ms. DeMur is a Senior Clinical Product Manager, and Mr. Elaz is Vice President of Research and Development and Vice President of Information Systems.


  1. Weick K, Sutcliffe K. Managing the Unexpected, Hoboken, NJ: John Wiley & Sons, Inc., 2001.
  2. Agency for Healthcare Research and Quality, Emerging Issues, November 2000.