Aviation and nuclear power get held up so often as models for healthcare that the comparison has gone slightly numb. The phrase high-reliability organisation gets printed on posters and strategy decks, admired, and left there, as if reliability were an attitude you could adopt by deciding to. It is not an attitude. It is a set of habits, and the useful thing about the research, most associated with Weick and Sutcliffe, is that it names them concretely enough to check whether you actually have them.
There are five, and three of them are, almost word for word, what proactive risk analysis does. The first is a preoccupation with failure, a chronic, deliberate attention to what could go wrong, and a treatment of small anomalies and near misses as information rather than noise. That is the literal posture of a failure analysis: scheduling the contemplation of failure instead of waiting for it. The second is a reluctance to simplify, a refusal to accept the easy explanation, which shows up in the discipline of writing failures in the language of the system rather than settling for “human error.” The third is a sensitivity to operations, an insistence on knowing how the work actually happens at the front line rather than how it is described in the policy, which is precisely the difference between work-as-done and work-as-imagined that any honest analysis is built on.
The remaining two are about the moment things start to go wrong. A commitment to resilience, the capacity to notice, contain, and recover from the errors that will inevitably occur, and a deference to expertise, the practice of letting decisions migrate to the person with the most relevant knowledge regardless of rank, rather than to the person with the most seniority. That last one is not a value statement pinned to a wall. It is a concrete behaviour: in the room, the person closest to the work is treated as holding the most accurate information about the work, and the structure of the conversation is arranged to let their knowledge win.
Seen this way, the high-reliability literature and the practice of proactive risk analysis are not two separate initiatives competing for a hospital’s attention. One is the philosophy and the other is the practice layer, the recurring, concrete activity in which the abstractions get rehearsed by real teams on real processes. An organisation cannot become preoccupied with failure in the abstract. It becomes so by sitting down, regularly, and examining specific processes for how they might fail, until the habit generalises and people start doing it without being asked.
The gap between admiring reliability and achieving it is the gap between a poster and a practice. The five habits are not inspirational; they are operational, and each one can be turned into something a team does on a Tuesday. Proactive analysis is one of the most direct ways to start doing three of them at once, which is a more useful place to begin than another workshop on culture.
This article accompanies the book Before Harm Happens.