Medical Articles

Achieving High Reliability in Health Care

Requires Commitment, a Strong Safety Culture, and Continuous Improvement

High reliability in healthcare means “consistently providing safe and quality care over time and across all health care services and settings.”1. While it is the goal of every healthcare delivery organization to deliver safe and quality care, patient harm remains a major global challenge, leading to death and disability. On average, one in ten patients in high-income countries faces adverse events in hospitals.2 In low- and middle-income countries, 60% of deaths due to healthcare conditions result from poor-quality care.3

In response to these challenges, the World Health Organization (WHO) developed the Global Patient Safety Action Plan 2021-2030; two of the ten strategic objectives focus on high reliability:

  1. Make zero harm for patients a state of mind and rule of engagement.
  2. Build high-reliability health systems and health organizations that protect patients daily from harm.

Achieving these objectives requires systematic strategies and leadership commitment to continuous improvement, grounded in data-driven operational rigor and processes. Joint Commission International (JCI) aligns with this mission, offering the High Reliability Health Care Maturity (HRHCM) model. This model, rooted in high reliability science, forms the basis of the Joint Commission International Oro® 2.0 High Reliability Organizational Assessment1. This web-based assessment evaluates a healthcare organization’s performance level for high reliability across three focused domains: 1) Leadership commitment, 2) Fostering Safety Culture, and 3) Continuous performance improvement. The assessment, comprising fourteen performance areas, aids leadership teams in determining their organization’s maturity level (beginning, developing, advancing, approaching) in each domain (See Figure 1).

Figure 1: High Reliability Model including the 3 Domains and 14 Areas of Performance.

Over nine hundred Oro® 2.0 assessments have been completed worldwide. Results highlight areas for improvement in healthcare organizations’ high reliability journey. Nine out of the fourteen areas of performance showed a lower maturity level, beginning or developing, for most healthcare organizations on their journey towards high reliability (See Figure 2).


Figure 2: Nine out of the fourteen areas of performance showed a lower maturity level, beginning or developing, for a majority of health care organizations on their journey towards high reliability.

The lower maturity levels included the Leadership domain (Board/Governing Body, Physicians, Quality Measures, Safe Adoption of Information Technology), the Safety Culture domain (Trust, Strengthening Systems), and the Performance Improvement domain (Methods, Training, and Spread).


Despite progress, these findings underscore opportunities for further advancements on the path to high-reliable healthcare. The first critical step for executive leaders is to dedicate time to assess honestly the current state of their organization in leadership, safety culture, and performance improvement. The data-driven assessment then lays the foundation to clearly identify the organization’s risk areas, prioritize them, and act for transformational change to pursue zero-harm for patients and staff.


  1. Chassin, MR and Loeb, JM. (2013) “High-Reliability Health Care: Getting There from Here.” Millbank Quarterly 91(3): 459-490.
  2. Slawomirski L, Auraaen A, Klazinga N. The economics of patient safety: strengthening a value-based approach to reducing patient harm at national level. OECD Health Working Papers No. 96. Paris: Organisation for Economic Co-operation and Development; 2017 (
  3. Kruk ME, Gage AD, Arsenault C, Jordan K, Leslie HH, Roder-DeWan S et al. High-quality health systems in the Sustainable Development Goals era: time for a revolution. Lancet Glob Health. 2018;6(11): e1196-e1252.
  4. WHO Website –
  5. Global patient safety action plan 2021–2030: towards eliminating avoidable harm in health care. Geneva: World Health Organization; 2021. License: CC BY-NC-SA 3.0 IGO.


The Authors:

Klaus Nether and LuAnn Vis

Klaus Nether, D.H.Sc., MHA, MMI, MT (ASCP) SV

Executive Director, High Reliability Product Delivery


Associate Director, High Reliability Initiatives

Related Articles

Back to top button