What does HRO do?

Marc Flitter, MD, was questioning me about why I did HRO in the pediatric intensive care unit (PICU). We were writing an article on physician sensemaking and he wanted to know if I was looking for reliability or safety. This frustrated me because I was doing neither and I had never really thought about my initial reasons.

During my medical education I observed behaviors in many healthcare providers that I recognized from my experiences on the rescue ambulance as fear and stress responses. As a physician in the PICU I now had the opportunity to address this. I worked to reduce the effect of fear on my staff.

Also during my medical education I paid attention to the criticisms of paramedics made by healthcare providers and the criticisms given me for how I made decisions. I wanted to understand better the differences between how public safety professionals made decisions under time pressure in the face of grave threat compared to healthcare providers, particularly physicians.

So my goal was to reduce the effect of unrecognized fear in the hospital and to improve decision-making with imperfect information under time pressure.

Ron Perkin, MD, my partner and director of the PICU, wanted to support the bedside caregiver and simplify for staff the objectives and decisions necessary for medical treatment.

After this discussion with Dr. Flitter, I asked Thomas A. Mercer, RAdm, USN (retired), why he “did” HRO. He was Captain of the USS Carl Vinson where Dr. Karlene Roberts conducted her early studies when she codified HRO. He told me that he wanted to improve the crew's performance and make the ship stronger.

None of us had the focus of reliability or safety, as we believe that was a part of our work.

The focus of HRO as a means to achieve safety is misplaced. We cannot have operations in a hazardous environment without the possibility of injury to somebody. To do nothing will increase the amount of injury to workers and the community. The goal is more of achieving safety through good operations and having good operations through safe actions.

We accomplish this by reducing the effect of fear, making better decisions with imperfect information, supporting those at the point of impact, and directing our efforts to improve the performance of our teams. When we do this we have a strong organization. HRO describes those organizations that maintain productivity despite time pressures, hazards, and uncertainty.



HRO makes the organization stronger through better crew performance. That is what it does.