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Reliability Leadership: Examples from a Paediatric Intensive Care Unit and the Riverside County EMS

Posted by Daved van Stralen on Tuesday May 19th, 2015

Few people are naturally adept at engaging novel, risky situations, working through the uncertainty, and recovering when events go awry. Through experience they may learn to handle such situations. This is a high reliability person. When an organization performs at this level it is a high reliability organization (HRO).

Faced with impending harm, people respond by self-preservation or collaboration with others. What differentiates leadership for a High Reliability Organization from all other leadership models and situations is the effect of leading against threat. These crucial situations comprise time-compression, uncertainty, and threat. Immediate leadership, in close proximity to the person and situation, is not possible. "Good leadership is invisible and occurs long before it is needed."

We can somewhat divide HROs between "control operator" systems and "emergency response" systems (in press, The Journal of Contingencies and Crisis Management, September 2015.) The control operator system contains hazards in a protected environment by protocols, policies, and processes. Processes differ from procedures – “procedures must be followed precisely while processes involve people and have slack to allow for that,” Earl Carnes, recent director of civilian nuclear power programs for the Department of Energy (personal communication). There is constant vigilance for outliers and deviations from processes; these serve as early heralds of failure within the system.

On the other hand, the emergency response system, responding to a hazard that has escaped control, engages the hazard within an unstable environment. Here, the outlier and deviation herald what is possible or the start of cascading failure. I believe the aircraft carrier synthesizes the two systems, maintaining precise control of processes yet able to respond immediately to a crisis. This is important because HROs do not change approaches between stable and unstable situations though they may shift values (see below). HROs modify the approach they use for unstable environments for use in stable environments. This produces smooth expansion and contraction without changing structure. Organizations using separate approaches, routine and emergency actions, develop problems during this shift. Weick and Sutcliffe have identified five principles present in HROs that apply to both control operator and emergency response systems (see below).

You see the difference when an HRO control operator designs a system to capture possible errors, interprets constrained improvisation as freelancing, and the HRO emergency responder becomes angry at rules and protocols that interfere with unpredicted consequences. An HRO is both and, with effective leadership, moves between the models smoothly and effortlessly.

The risk is to design a system based on the intuitively logical, internally coherent control operator system. This design will not perform in the emergency environment unless the emergency response approach forms the basis of design, learning follows the “lessons learned” approach from the affective domain of learning, and effective leadership occurs before the event.


How an HRO works

Since the initial description and codification of HROs in the 1980s, academics have pursued the deconstruction of the High Reliability Organization to better understand its structure and function. They have been unable to completely identify the mechanisms that make it work and they have been unable to reconstruct an HRO using these principles and elements. This may be the reason so few HROs have been created from scratch but have, instead, been developed from a leader with previous experience in an HRO. (Retired US Navy nuclear propulsion officers reformed civilian nuclear power after the Three-Mile Island incident.) What we miss, in my estimation, is the effect of the environment, the influence of stress on cognition and problem solving, and the role of the HRO leader.

HROs developed as an effective response to an environment of uncertainty, time compression, and threat. In the early 1980s the US Army developed the acronym VUCA for Volatile, Uncertain, Complex, and Ambiguous. While this describes the environment there is little discussion in the military literature on how to overcome these effects on leadership or performance. While HRO principles emerge from hostile, or VUCA, environments we have not clearly addressed how this translates to non-physically threatening environments (e.g. healthcare and finance) or leadership.

A VUCA environment creates both fear responses and stress responses, based on the immediacy and chronicity of the threat. The fear response immediately and involuntarily releases adrenaline or cortisol to create the fight, flight, and freeze responses, manifested behaviorally as anger, frustration, avoidance, freeze, and confusion. We see coning of attention while perception, neuro-anatomically, forces immediate action, compared to cognition where perception induces thought. Stress, from long-term threat and chronicity, impairs cognition at the neuro-anatomical level. Fear and stress responses are amenable to intervention by a good leader.

The HRO leader models specific and selected attitudes and behaviors, reframes the environment and the problem to be solved, guides modulation of the threat or fear response, and provides a supportive presence before, during, and after a crisis.

HROs, as a culture, emerge from the micro-level of interaction with the environment. As rookies we are initially taught to engage the incident rather than observe and understand its structure. We learn what works through action, and there are no wrong actions except not to act. Decision-making involves analysis of rapid feedback loops and, with experience, one evaluates indirect and long feedback loops. As one veteran firefighter told me, “I don’t know what is happening but I know what to do.” To do this, every member must feel supported from the first day on the job, which is heavily influenced by the leader. Criticism, if given, is always supportive to make the individual better. A USMC Colonel told a USMC veteran, “Your failure is my failure; my success is your success” (Dwayne Thomas, CWO, USMC retired, personal communication).

The rookie is also guided in how to make sense of the incident, how to give meaning to observations, and to identify what is salient. Any anomaly or outlier is an early herald or indicator of what is possible vs. a random, independent rare event that others might disregard. This forms the basis of information flow and authority migration – salient information must flow up the chain of command, and the authority to quickly respond must flow down the chain. A steep authority gradient impedes information flow and impairs responsiveness, resilience, and agility in the dangerous, highly dynamic incident. Communication is a behavior and subjective to whether it occurred.

Leadership as coaching follows the model of top-rated athletes. The psychotherapeutic model applies to those with emotional or cognitive dissonance leading the patient to therapy. It may move along the model of “you have areas of improper belief or behavior one must correct.” The teaching approach follows the track of the teacher having greater knowledge and transmitting this information to the student. For the athlete, no matter how high the performance or how high the most recent score, one can always improve and one works on what is hard or difficult.

Overall, I see HRO as a response to vulnerability of and the possibility of failure by individuals and the organization. Vulnerability comes from near-death experiences or devastating loss to the individual and is felt by that individual. Failure comes from the near-death experience of a colleague or severe loss to the colleague where you have some responsibility. Resistance to HRO generally arises from people who either have not felt such loss or have experienced such loss but passed blame to others. “The organization that does not plan to fail, will fail,” Todd LaPorte, former USMC fighter pilot, author of one of the first books on the complex organization, and the UC Berkeley sociologist who led the initial HRO project.


The Five Principles of High Reliability (Karl Weick and Kathleen Sutcliffe)


  1. Ignoring small failures leads to cascading failure and even larger catastrophic events. We respond to early heralds of failure and are vigilant to failures in the covert, compensated state.


  1. When we accept simple explanations we stop looking deeper or further. We are reluctant to accept these simplifications. In our environment we experience ambiguity, complexity, and imperfect information making it necessary to simplify. We also recognize the risk of simplification, hence the term “reluctant.” We simplify because we choose to not because it is easier or it is our only method of analysis.


  1. Taking frontline operations for granted, not supporting them, and not accepting the complex interactions necessary to work in dynamic, hazardous environments contributes to avoidable failures. The frontline performs the real work where the “big picture” is less strategic and focuses on changes in the situation. We must have free flow of information, something most easily lost when we fear speaking up or giving disconfirming evidence.


  1. Neglecting the capabilities the system or individuals have for resilience contributes to inability to work the problem to completion. Resilience is the ability to maintain or regain a dynamic event. As the situation unfolds, the demands of the situation exceed the performance of individuals or the system. To continue operations the organization must identify errors early for correction while improvising solutions within our constraints.


  1. Deferring to authorities, especially because of higher status or rank and rigid hierarchy, disrupts use of local or situational knowledge and subject matter experts. This interferes with anticipating and containing the situation. In dynamic, high-risk situations, circumstances change, and may change significantly, while information reaches a distant, higher authority. Those with intimate knowledge of the circumstances and those with expertise in the necessary subject matter must make rapid decisions using short feedback loops. We reduce the authority gradient that interferes with communication and we facilitate migration of authority to those with the knowledge to make the best decisions.


Weick K, Sutcliffe K. Managing the Unexpected: Resilient Performance in an Age of Uncertainty, 2nd ed. Jossey-Bass. San Francisco, CA” 2007.


HRO Core Values (Daved van Stralen and Thomas A. Mercer)

(We identified these values to make HRO operational.)

Dignity- Acknowledgement of andvalue everybody’s contribution. (When you discipline, do not take away the person’s dignity.) I do not use respect because respect is generally earned and can easily be lost. Some individuals will search for reasons to justify not respecting other people.

Honesty- What is said represents the circumstances. This is not honesty as in telling or not telling “white” lies or when someone intrudes on your boundaries. I do not use trust because it is a transaction that can be based on bias and experience.

Humility-The unexpected can happen to any of us, we can all fail. This is in contradistinction to hubris and cognitive dissonance- “I am a good person with good intentions, therefore I would not act that way or cause such a failure.”

Empathy- HROs work in tough situations, people are going to fail and it could be us. There but for the grace of God go I. I do not use compassion here this compassion focuses on the other individual in response towards that individual. Empathy is our internal belief system.

Duty- We will not let others down, we have duty to our larger community. This is not duty described by tasks and job description. I do not use responsibility or accountability, which can be limiting. This has a larger, spiritual component that is internalized and comes from within.

There are negative attitudes, beliefs, and values that undermine an HRO such as self-interest, self-justification, cognitive dissonance, and intimidation.



Indirect leadership (Howard Gardner)

HROs are constantly changing, growing, and organizing. I have found it useful to use Gardner’s model of indirect leadership to create and sustain an HRO. This model of leadership rests on the narrative you use, the questions you ask, and the answers you accept.

The questions I ask are directed to appreciate complexity and ambiguity. They must develop alternative explanations for events and circumstances. When they offer plans they must have descriptions to identify undesired consequences and how to interpret the absence of a response. This also forms a “decision space” within which they can act freely – effective acting too soon or too late and the effect of using too much or too little.

To bring my perspective to the individual’s view when someone errs I take the view that the individual did the right thing, did what I would have done. Everyone acts in a manner that makes sense to him or her; I must look for what would justify the individual’s actions. If I can see this, I can learn where and what I need to teach. Error, here, is gold, it helps identify vulnerabilities to the system. “Once you find out who did it, then you begin your investigation,” Christopher A. Hart, Chairman, NTSB (personal communication).

For descriptions I require them to be objective, articulate, and succinct. Objective descriptions are the most difficult as people do not realize when they insert opinion, interpretation, of persuasion. I learned from family conferences in the pediatric ICU regarding withdrawal support of a child that one couldn’t be totally objective; the first word said always has the greatest influence. The choice of words is subjective. Articulate means the words must come together in some form of structure that makes sense. A US Marshall told me that he teaches “articulate describing” by telling his students that when you articulate the problem you have identified half the solution. For example, if you find a white male in an expensive car in Watts at 2:00 AM, he is lost, looking for drugs, or looking for prostitutes. You now have probable cause to pull him over. Succinct, from a Roman gladiator’s method of girding for combat, says enough without saying too much.

People say that we should tell a story, and that is true. But in time-constrained events we may want to describe a scene. A German film director described to me the differences between a story and a scene: a story has a beginning, middle, and end while a scene take us from A to B, containing, at most, two story arcs.

The second most difficult thing to teach, and most frustrating for the student, is to be concrete as they do not see, nor can they recognize, its importance until they are in a crisis. Concrete descriptions reduce ambiguity.

I like Howard Gardner’s preface to Leading Minds: An Anatomy of Leadership:

“A leader is an individual (or, rarely, a set of individuals) who significantly affects the thoughts, feelings, and/or behaviors of a significant number of individuals". Most acknowledged leaders are "direct." They address their public face-to-face. But I have called attention to an unrecognized phenomenon: indirect leadership. In this variety of leading, individuals exert impact through the works that they create.

Whether direct or indirect, leaders fashion stories: principally stories of identity. It is important that a leader be a good storyteller, but equally crucial that the leader embody that story in his or her life. When a leader tells stories to experts, the stories can be quite sophisticated; but when the leader is dealing with a diverse, heterogeneous group, the story must be sufficiently elemental to be understood by the untutored, or 'unschooled,' mind.”

Culture is social knowledge, the social response to the environment, and is passed down through stories. Gardner’s approach is also how culture changes from the indirect leader. There must be a relationship between the stories leaders tell and the traits they embody. Every story has a purpose and a principle.


The Purpose of Leadership

"Good leadership is invisible and occurs long before it is needed." Leadership occurs, and is most effective, during the downtime as there is little time available during time-compressed action to communicate verbally. A good example here is the orchestra, the conductor leads only during practice. He or she is not needed during the performance; the conductor’s presence is only for show. (A Long Beach Symphony Conductor told me this.)

What helps most is to identify every organization’s purpose and to have his purpose identified and translated to everyone involved. This must occur during times of high emotion and stress. The leader identifies purpose for the organization and translates that purpose throughout the hierarchy.

There is discussion in the management literature about leader-follower, which I find distracting for the purpose of an HRO. Stanley A. McChrystal, General, US Army (retired), commanded the Joint Special Operations Command and described the importance of leader-leader. In an HRO, every individual who identifies a problem leads the solution until relieved of responsibility for the problem. This is leader-leader. [Command is not discussed in leadership literature. In discussions with RAdm Mercer, he believes it is because command has an authoritative connotation, coming from the military where command consists of those duties that you cannot legally delegate. For example, in medicine the physician cannot legally delegate diagnosis and prescriptive authority, a misconception that interferes with the ability to migrate authority to those in the best position to act.]

Another purpose of leadership is to bring the organization up to a level of expert performance. Malcolm Gladwell in his book Outliers popularized the idea that it takes 10,000 hours to reach expertise. That is actually a minor issue, reaching expertise also involves whom you compare yourself to and working on what is hard. The role of the leader is to identify industries and other organizations to which individuals can compare themselves. Also, the leader guides development in those areas that are difficult to improve.

Stress impairs cognitive function; HROs address this directly. The pediatric residents told us the pediatric ICU was their hardest rotation but the least stressful, one of our successes. Problem solving releases dopamine in the locus accumbens within the brain giving pleasure. Low levels of dopamine are associated with depression. One purpose of leadership, then, is to reduce gratuitous stress that interferes with performance.

A significant cause of stress is isolation, or the feeling of isolation. We are social animals who physiologically and psychologically need contact with other humans. In fact, a form of bullying in children occurs when classmates isolate a child from playmates. This is also found in adults. No one should feel isolated in an organization; particularly organizations working in high-stress situations or that strive to be an HRO.

Failure is an option. Life is not a movie- failure happens and we must be prepared to fail. One purpose of leadership is to prepare the organization for failure as a method to prevent failure, not just in training but also in mindset.

In firefighting and fire-based EMS, the most important person on scene was a firefighter at the end of the nozzle or the paramedic treating a patient. All efforts were directed at supporting an individual to do the job properly and with adequate resources. The role of the captain was to ensure this happened. There was sometimes an urge for the captain to perform some of the work of firefighters and medics but there is an accepted rule, "When a fire Captain picks up the fire hose he becomes a firefighter, he is no longer a fire captain." It is important to maintain some detachment from the action for observation and leadership.

The leader must interpret, identify, and translate information and events. HROs engage complex, time compressed situations in constant flux. Individuals are immersed in action, leaving it to the leader to identify evolving threats, interpret the situation to better understand what is happening, and translate this information to various organizations and professionals using language in words that the other people understand. This also means identifying objectives for decision-making and the problem space.

For example, to relieve smoke and heat in a house fire a firefighter climbed to the roof of a house using an attached fence, with him was the captain. A Battalion Chief arrived and demanded to know why they were on the roof without a ladder when department policy was to have ladder on the roof for emergencies. The captain responded, "Isn't it also department policy to put out the fire?"

Ambiguous information

This is from my guest editorial Ambiguity in the current issue of The Journal of Contingencies and Crisis Management:

The authors who discussed leadership commonly described elements of a bottom-up approach or, at the least, transformative and supportive leaders at the top. Weick discusses the ‘group writ small’, which I think is critical as it describes the dynamics of a bottom-up approach. It supports the idea that safety and reliability are self-organizing responding to local context. ‘Empowering expert people closest to a problem and shifting leadership to people who have the answer to the problem at hand’ (Meshkati & Khashe, 2015) is central to success.

Leadership in ambiguity also has a top-down element. Vidal urges caution with the Engineer’s Stance of leadership – ‘when lessons learned by organizations translate into the refinement of procedures, protocols, and the proliferation of rules’. ‘Managing uncertainty by an inflation of rules is typical of the engineer’s stance.’ Rather, successful leaders seek out diverse perspectives and discrepancy (Barton et al., 2015), engage diverse participants from inside and outside the organization to provide multiple perspectives and innovative suggestions that contribute to learning-by-doing (Carroll, 1995, 2015), and a shuffling of power and influence to those who can make sense of the ambiguous situation. Only the Captain of the ship could say no, giving a bias for action to make the system work (van Stralen & Mercer, 2015). A deeper understanding of ‘only the Captain can say no’ is the Captain sees a larger picture of the events (Mercer, personal communication). Carroll describes the CNO [Chief Nuclear Officer] who reversed the firings of two contract workers who voiced safety concerns. The CNO saw the larger picture and, by acting into ambiguity, increased not only safety in the program but transformed leadership in the ranks of management.

Bea described the importance of corporate leadership: when the leaders who developed the program retired, “the pipes started leaking again.”


Methods of Leading

These are independent leadership points I have accrued from various HROs.

Special Operations Forces, Joint Operations Command:

The importance of relationships within the organization. Friction will occur when units come together with independent objectives and purposes. We must maintain interoperability permission success in a common purpose. Own your own error, if you do not identify an error you made somebody else will. If somebody else notices, it reduces the trust within the system.

What to do when an error occurs:

A fire captain, counseling a novice firefighter over a life-threatening error, supported the young firefighter. "You where the best firefighter for this incident. Because of that, the fire department will support you and I will support you. There may be other firefighters more experienced than you, but they were not available, making you the best firefighter available. There are 1000 things that happen on scene. You can only see maybe 100 and act on only one or two. I may see a different 100, and I may act on a different one or two. It does not mean I am better than you, it only means I am different than you. You were the most qualified firefighter we had for that incident and we will support you.”

Veteran firefighters would often give a piece of advice to the rookie and appear to leave. Actually, the veteran firefighter stood off a short distance and watched the rookie struggle. Not for amusement, but to see how the rookie solves problems. At a given moment the veteran would step in and, without passing judgment, would give whatever additional assistance was necessary. This is how the rookie learned – he must work on his own but help is always nearby, and that help is watching.

"Never tell a good man how to do something, tell him what to do and he will surprise you with his ingenuity." George S. Patton, GEN, US Army (OK, so he was not a great leader, it is still a great quote.)

In an HRO we work in the Affective Domain of Bloom's Taxonomy. When I first started in the pediatric ICU I was concerned how to combat that phrase, "I know this is what Dr. van Stralen taught you, but let me tell you how it really works." Jim Holbrook, my educator guide, told me to teach in the Affective Domain, to only teach what works. I did this, and people would tell me what worked, from the next day to 30 years later. They knew precisely what I said and the circumstances around the lesson. Over time I found the student filled in the space between what I taught, this is the Cognitive Domain.

Because people respond to the environment in a way that makes sense to them it is important for the leader to give meaning and context to information and events.

The leader also models attitudes, selecting attitudes necessary for an HRO.

RAdm Mercer, USN, retired, was noted for his leadership methods on the USS Carl Vinson:

During the routine and unscheduled walks along the carrier flight deck looking for debris, he would walk with the sailors. At some point during the walk the sailor would have to talk to the ship's Captain. In this way he maintained a connection with the crew and they felt connected with him. He also told me that there were often three cake celebrations a day on the ship. (I had asked him how big the kitchen was and he told me it was large enough for the cook to bake three large cakes daily. Please don’t think all he did was eat cake.) He found that the presence of the captain at the celebrations was more important than anything else he could do for the crew.

As noted in the article for this lecture, only the Captain of the ship could say “No.” In this manner, everyone on board the ship learned how to solve problems. If they couldn't solve the problem between contemporaries or equals they moved it up the command. This prevented people from blocking information or problems from moving upward in the hierarchy.

Foreign Object Debris could be lethal on an aircraft carrier flight deck. There is the story of a mechanic who lost the tool and announced it, which caused a delay in recovering aircraft, a dangerous situation if they are low on fuel. Eventually they found the tool in a different location, and the mechanic was thanked for stopping operations. If a tool had been lost, it could have led to the loss of an aircraft and pilot death. The lesson is “Don’t shoot the messenger, even if the messenger is wrong, or the messages will disappear.”

The Captain of the ship has a larger view of events on the ship. At that distance the Captain is more likely to resolve ambiguous information and assist in decision-making.

My fire station commander valued everyone in his command and in the department. I asked why several firefighters were not promoted to fire engineer before they retired. They had 30 years of time and veterans credits from fighting in World War II. He told me they were successful; they lived through the depression and fought in the war and could now provide for their families, provide a roof over their head and food on the stove. They were successful. I used this concept in a nursing home where many people were dismissive of CNAs. I told them the CNA was likely the most successful person in their family, he or she may be the only one who completed some schooling or had a job. Recently, a woman contacted me through LinkedIn. I had to read through her credits to find out how I was connected to her. She was in management and had a Master’s degree. She worked as a respiratory care practitioner. Down at the bottom of the resume I saw she had been a CNA at the nursing home where I was the medical director.

Tone comes from the top, as a leader we set the tone for the organization. When we created the pediatric intensive care unit we had three simple rules: do not criticize, support the better caregiver, and you have a duty to the larger community. We modeled the attitudes we sought in our staff.

Creating the Pediatric ICU as an HRO, I had a set series of lectures: Day One I helped sort out the complex patient, reducing a myriad of problems to three elements: what would kill the patient, what would keep the patient in the ICU, and what would resolve with time and treatment. Day Two we discussed decision-making. Day Three we discussed stress. Day Four we learned to take a break, even at the most busy time we can rest. The two of us that ran the ICU also routinely walked through the unit to identify the signs of stress in the staff. In this way we grew from a small eight-bed unit with no critically ill patients to the second largest Pediatric ICU in the state, and with half the patient mortality expected.




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Daved van Stralen, MD, FAAP, is Medical Director for the Riverside County EMS Agency and an Assistant Professor of Pediatrics, pediatric critical care, on staff at Loma Linda University Children’s Hospital and Children’s Subacute Center at Community Hospital of San Bernardino (California). He is also Adjunct Professor of Emergency Medical Service at Crafton Hills College, Yucaipa, California. He currently works with the San Bernardino City Unified School District to bring High Reliability methods to K-12 education. He developed and runs the International HRO Conferences and the HRO website www.High-Reliability.Org. He has previously served as medical director for American Medical Response, San Bernardino County and for San Bernardino County Fire Department.

Daved van Stralen worked as an ambulance person and fire department rescue ambulance driver for the Los Angeles City Fire Department in the 1970s with over 7,000 ambulance responses, mostly in South Los Angeles. He has a BA in Social Ecology and a BS in Biological Science from the University of California, Irvine; an MD degree from UC Irvine California College of Medicine where he completed his Pediatric Residency. By one review, he is the first career fire department paramedic to attend medical school. He completed a Pediatric Critical Care Fellowship at Children’s Medical Center and Parkland Memorial Hospital, Dallas, Texas.

At Loma Linda University he helped develop the Pediatric Intensive Care Unit, the pediatric critical care transport service, and the Emergency Medical Care bachelor’s degree, the first clinical academic degree in the US for paramedics. Using a fire service/EMS model with critical care principles he developed a subacute care model for profoundly handicapped children that allows them to play and develop despite dependency on mechanical ventilation for life.

Daved van Stralen collaborates with safety, risk, and reliability experts from wildland firefighting, business, and healthcare in the US and Europe to identify common approaches the individual uses to ensure safety and reliability. He connected the US Forest Service with the Bouches du Rhone Fire Service (France) for the joint US-France Wildland Firefighting project. He developed a website to share individual experiences in this field www.High-Reliability.Org and directs a series of international high reliability organizing conferences. He has traveled twice around the world.






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