Published in Non-Clinical

Creating a High Reliability Organization in Optometry

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11 min read

In every eyecare practice, keeping the culture patient-centric and safety-centric provides the best opportunities for success. Follow these HRO tenants to provide healthcare that is effective, efficient, and predictably safe.

Creating a High Reliability Organization in Optometry
A high reliability organization (HRO) in healthcare is a system that can be relied upon to provide high-quality care in a safe environment. This means reducing medication and patient errors to levels lower than statistically expected. It also means having staff trained in processes that prevent errors and address problems quickly if they do occur. An HRO adapts and works toward continuous improvement. Healthcare is always evolving and so too must the environment in which it is practiced. Eyecare practices can adopt HRO principles in order to ensure quality and safety for patients and staff.

Why are high reliability organizations important?

In medicine, we have the lives and wellbeing of patients on our hands with a mantra of “do no harm.” In eyecare, harm can come in the form of medication mix-ups or missed potential allergy reactions; it can come from more drastic errors like wrong-side surgery or wrong-patient scenarios. While some mishaps can be small and inconsequential to patient outcomes, many have the potential to cause serious harm, illness, or even tragedy for patients and their families. Additionally, these types of errors can lead to hefty lawsuits for providers, practices, facilities, and hospitals.1

Physician and employee burnout is a major culprit of errors in healthcare.

Measures need to be taken to avoid this and identify alternatives to improve workload and workflow. HRO principles have been found to help prevent burnout of healthcare professionals and improve overall job satisfaction. The improvements have been attributed to employee engagement, integration of employee ideas, and increased safety of the work environment. One study found that implementing HRO practices reduced the self-reported burnout rate by 50%.2

HRO culture

The major components of HRO culture have been identified as preoccupation with failure, exploration of operational successes and failures, situational awareness, integration of expert opinions, and ability to be flexible and resilient. An HRO requires a balance of accountability with systems for detection and correction. If and when an error does occur, the root cause should be identified in order to avoid recurrence (rather than assigning blame).

A culture of safety is established by regularly reviewing the expected roles and responsibilities of each team member and adjusting them as needed for continuous improvement.

Organization characteristics

According to HRO experts, there must be a systemwide shift from a reactive stance to a proactive stance and ultimately to a generative stance. A reactive organization takes steps once a problem has already occurred to mitigate damage. In comparison, a proactive stance requires the organization to take measures with the goal of preventing errors and issues in the first place.
This shift requires transparency, employee comfort with and willingness to report and take action, and a system to analyze and anticipate preventable problems.

The ultimate goal is for an organization to meet the generative level.

This is a sign of high organizational maturity and means that safety and planning are integrated into every action. This requires the highest level of transparency, employee participation, and safety monitoring.1


Employees should be encouraged to work as a team with a common goal, to practice in a “zero-harm” environment within a culture of awareness and mindfulness. This sense of mindfulness should be incorporated into every aspect of the eyecare system. This group thought process is referred to as “collective mindfulness.”4
Staff training should emphasize the importance of initiating a quick response to small problems to avoid escalation. Additionally, training should emphasize the importance of speaking up to point out inefficiencies and to report close calls without fear of disciplinary action. When all parties are on the lookout for small potential problems, things can be fixed while still manageable—and less expensive—to improve future outcomes.

Organization leaders should be committed to working toward continuous improvement alongside their staff. Leaders should be involved and available to support the HRO culture.

Performing clinic “walk-arounds” and engaging the staff is a great way to keep up the momentum. Making staff feel involved, heard, and valued are key factors in making this system successful.1

Goal-centric planning

Working toward HRO status in eyecare involves the participation of the entire hospital or practice—from providers and managers to patients and their families to business stakeholders. The foundation of moving toward this type of planning should be the organization’s mission, vision, and goals.
One would not be hard-pressed to assume that the main goal of most eyecare (and healthcare for that matter) facilities is to provide quality care while keeping its staff and patients safe—nor to assume that providing quality care includes prevention of medical errors.
That being said, it is important to keep these most basic tenants in mind while developing a game plan for HRO training and procedures. The HRO mindset should orbit these core values while integrating the more specific mission, vision, and goals to maintain alignment.1 Periodic review should be performed on a timeline by the leadership team to ensure this alignment continues; this could be monthly or quarterly, for example.
At these points, reports analyzing the chosen quality and safety measures are released to executive leadership, shared with staff and other stakeholders, and even made transparent to patients (and the public). This increases the level of accountability of the organization to perform and continually improve.5

Continued monitoring

As staff members implement the new ideas learned through HRO training it is important to follow up to ensure improvement and to provide feedback to ensure continuous learning.
Specific metrics should be selected to help monitor the aforenoted. These can be quality measures and surveys/focus group data from patients, employees, and the leadership team members.

Key performance indicators, or KPIs, allow for organizations to monitor complex data.

They allow for progress monitoring and decision making (for both financial and quality management components though here we focus on the latter).
In terms of HRO measures, KPIs that are patient-centric and related to safety would be chosen. Examples of this would be death, and readmission rates (if in a hospital), medication errors, accidents, safety incidents for patients or staff (in any setting including an eyecare practice).
Being cognizant of staffing is also pertinent; knowing the staff-to-patient ratio ensures coverage and avoids staff burnout (both can lead to errors if not managed properly). The viewpoints of stakeholders, such as patient family members and caregivers, should also be collected and considered; including relevant/recent case studies along with metrics would also be helpful. For example, reviewing “close-call” events or adverse events with an investigation of the cause.5

The primary metrics in which an organization would hope to see improvement are the incidence of medical errors and safety events. Of hospitals working toward HRO reviewed, there were reported improvements of 50-100% in these areas.3


While the above HRO guidance can lead you down the right path to transforming your eyecare practice, there can be challenges along the way. Hospitals already pursuing HRO goals have noticed there is a reluctance to change when things “seem to be working.” Success requires the coordination of many team members; and, changing policy or procedures is not easily accepted when an obvious problem does not exist. This is where HRO training and onboarding come into play.
Additionally, healthcare as a whole is unlike other industries in that the product is not standardized. Every patient case is different and we can only control so much of the patient journey through the system. The greatest challenge is that this process is enduring. Due to ongoing improvements in science and technology, what today is considered “high-quality” may not be tomorrow. Thus we are making a perpetual commitment to HRO practices.5

In conclusion

Patients and families entrust their eyecare to optometry and ophthalmology providers and organizations. Maintaining quality and pursuing quality improvement is just as important as providing top-notch care.
In HRO culture, all members of the eyecare team must remain alert and conscientious; more minds constantly analyzing situations fosters innovation and new ideas for improvement.6 Clinical and non-clinical roles and responsibilities should be defined, updated, and reviewed to foster accountability and improve efficiency.4
By following these HRO tenants, we can strive to provide healthcare that is effective, efficient, and predictably safe.5 Keeping the culture patient-centric and safety-centric provide the best opportunities for success.1


  1. Editors, H. C. (2021, February 26). High-Reliability Organizations in Healthcare: Framework. Health Catalyst.
  2. Isaacks DB, Anderson TM, Moore SC, Patterson W, Govindan S. High Reliability Organization Principles Improve VA Workplace Burnout: The Truman THRIVE2 Model. Am J Med Qual. 2021 May 18. doi: 10.1097/01.JMQ.0000735516.35323.97. Epub ahead of print. PMID: 34010164.
  3. Veazie, S. (2019, May) Evidence Brief: Implementation of High Reliability Organization Principles. National Center for Biotechnology Information.
  4. Kadrie, M. (2017, June 7). High Reliability Organization in the Healthcare Industry: A Model of Performance Excellence and Innovation.
  5. Abrams, K. (2017). Transforming into a high reliability organization in health care. Deloitte.
  6. PSNet.High Reliability. Patient Safety Network.(2019, September 7)
Danielle Kalberer, OD, FAAO
About Danielle Kalberer, OD, FAAO

Dr. Danielle Kalberer is an optometrist practicing on Long Island, NY. She attended the SUNY College of Optometry, completed residency at the Northport VAMC, is a fellow of the American Academy of Optometry and is Board Certified in Medical Optometry.

Danielle Kalberer, OD, FAAO
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