Patient and clinician perspectives of high-reliability organizing in practice: A qualitative study of cancer teams

Background: Health care organizations have failed to replicate the performance of high-reliability organizations (HROs), systems that operate nearly error-free despite inherently complex, interdependent, and time-pressured environments. Purposes: We sought to better understand conditions that facilitate and inhibit HRO in health care by expanding the conceptualization of who contributes to high reliability to include patients. We also examine how cancer care teams and patients describe jointly enacting (or failing to enact) each of the five HRO principles. Methodology/Approach: We conducted a qualitative field study, interviewing 25 oncology clinicians from diverse roles (e.g., surgery, nursing, dentistry) (17 interviews) and eight cancer patients. Interviews were audio-recorded, transcribed, and deductively coded for barriers and facilitators to the five HRO principles. Findings: We identified conditions that supported and hindered high-reliability cancer care. HRO principles commonly overlapped to support or hinder system resilience. A common barrier was insufficient processes to proactively identify clinical deterioration. Patients and their family caregiver(s) were primarily responsible for monitoring their health and identifying and communicating any signs of deterioration. Cancer patients and caregivers were routinely engaged as team members, and patients developed expertise throughout treatment, thereby supporting system safety. Conclusions: These findings expand the conceptualization of how high reliability is produced. Specifically, we highlight the key role that patients play in preventing errors and monitoring care. Practice Implications: Our findings expand our understanding of how HRO principles interact to promote cancer care system safety and elucidate how patients and their family caregivers contribute to system resilience. This work can inform the redesign of care processes to optimize patient safety.