Translating High-Reliability Principles to Public Health Outbreak Response
Improving Infectious Disease Response Through High Reliability Principles
Overview
The Center for Outbreak Response Innovation (CORI) is investigating how high-reliability organization (HRO) principles from industries like aviation and oil & gas and lessons from foodborne and emerging disease outbreak response can improve public health outbreak response systems.
The 5 HRO principles and Public Health
Why This Matters
Recent global health emergencies have exposed critical gaps in outbreak response capabilities:
- Coordination challenges across jurisdictions and agencies
- Information silos preventing effective data sharing for decision-making
- Reactive rather than proactive approaches to emerging threats
- Learning opportunities not implemented to improve response
Our research suggests that adopting proven high-reliability principles could address these challenges through systematic improvements to organizational structures, processes, and culture.
Our Approach
Through ongoing in-depth research with both industrial HROs and public health organizations, we're identifying:
- Transferable safety culture elements that strengthen detection and response
- Organizational structures that support high-reliability performance, including leadership active involvement
- Implementation strategies appropriate for resource-constrained public health settings
- Success metrics to evaluate improvement initiatives
Key Findings (Preliminary)
Our research reveals promising applications to outbreak response:
| HRO Principle | Industry Example | Public Health Application |
| System-Level Perspective | Incident analysis focuses on process failures, not employee blame | Focus on improving detection systems rather than individual performance |
| Reluctance to Simplify | Multiple data sources required before closing investigation | Maintaining multiple hypothesis during outbreak investigations |
| Sensitivity to Operations | Small anomalies treated as potential safety signals | Taking unusual case clusters seriously, even with small numbers |
| Commitment to Resilience | Continuous preparedness for rapid response to unexpected scenarios | Building adaptable surge capacity for investigation teams |
| Deference to Expertise | Junior crew empowered to voice safety concerns | Elevating insights from frontline investigators regardless of position |
Frequently Asked Questions (FAQs)
I. About High-Reliability Organizations
What is a "High-Reliability Organization"?
High-Reliability Organizations (HROs) are organizations that operate in complex, high-risk environments yet maintain exceptionally low rates of catastrophic failures. Classic examples include air traffic control systems, nuclear power plants, aircraft carriers and some healthcare organizations. These organizations have developed systematic approaches to managing risk, learning from experience, and maintaining performance under challenging conditions.
What are the five core principles of HROs?
- System-Level Perspective: Focus on understanding how systems fail rather than blaming individuals
- Reluctance to Simplify: Resist oversimplification and maintain healthy skepticism about initial explanations
- Sensitivity to Operations: Pay close attention to front-line operations and subtle warning signs
- Commitment to Resilience: Develop capabilities to detect, contain, and recover from unexpected events
- Deference to Expertise: Value knowledge and experience over hierarchical position in decision-making
To embed any or all of these principles, leadership full engagement is critical.
II. HRO Principles in Public Health
Why apply HRO principles to public health?
Public health, particularly outbreak response, shares many characteristics with traditional HROs: high stakes, complex systems, incomplete information, and severe consequences of failure. While public health has developed many effective practices, systematic application of HRO principles offers potential to further enhance reliability, particularly in coordinating complex multi-agency responses.
Is this approach proven to work in public health settings?
While HRO principles have been successfully applied in healthcare settings (particularly hospital safety), their systematic application to public health outbreak response represents new territory. Our research is designed to identify which principles transfer effectively and how they can be adapted to public health's unique context.
How can resource-constrained health departments implement these principles?
We recognize that public health often operates with limited resources. Part of our research focuses specifically on identifying high-impact, low-resource approaches and regional collaboration strategies that make HRO principles accessible to departments of all sizes.
III. Common STLT Implementation Questions
In order to incorporate HRO principles into our health department, do STLTs need to implement all five principles at once?
No. Our preliminary findings suggest that implementing even one principle with fidelity can yield meaningful improvements. Many organizations begin with a single principle that addresses their most pressing challenges, then expand over time.
Won't standardized protocols based on HRO core principles reduce our ability to respond to outbreaks flexibly?
This is a common misconception. HRO principles actually enhance adaptability by distinguishing between processes that should be standardized (routine operations) and those that require flexibility (complex problem-solving). The goal is appropriate standardization that creates a reliable foundation for innovation when needed.
How do we measure success in becoming a high-reliability organization?
We're developing measurement frameworks tailored to public health applications. Initial metrics include:
- Time to detect and respond to outbreaks
- Quality and comprehensiveness of after-action learning
- Staff perceptions of safety culture and empowerment
- Systematic implementation of improvements based on lessons learned
The 7-1-7 model is an exciting framework to look at for considering metrics in Outbreak response.
Will this approach require significant organizational restructuring?
Not necessarily. Many HRO principles can be implemented through cultural and process changes rather than structural reorganization. The approach emphasizes working within existing systems to enhance reliability through targeted improvements. Active leadership engagement is critical for the success of this approach.
IV. CORI’s Research on HRO Principles in Public Health
What research is being conducted by CORI on HRO principles and public health?
CORI is currently carrying out two complementary studies. This ongoing research examines how HRO principles can improve outbreak response capabilities on one hand, and examines best practices and lessons learned from foodborne and emerging disease outbreak management on the other.
What methods are you using in these studies?
Our mixed-methods approach includes:
- Key informant interviews with leaders from aviation, oil & gas, and public health sectors. So far we’ve had Interviews with 25+ leaders from HRO (Aviation, Oil & Gas, Nuclear, Healthcare) and public health sectors (CDC, FDA, State, County Health departments)
- Comparative analysis of organizational structures and processes
- Case studies of outbreak responses
- Limited observational studies of response activities
How does the HRO project fit with CORI's broader mission of implementing modeling and analytics solutions?
The HRO project represents a foundational element of CORI's broader mission. While CORI helps STLTS to implement advanced analytics and modeling tools like RedCap for outbreak response, we recognize that these tools can only reach their full potential when implemented within systems designed for continuous learning and improvement.
High-reliability principles provide the organizational framework necessary for analytics tools to drive meaningful changes:
- Tools as Means, Not Ends: Solutions like RedCap are means of improvement, not ends in themselves. HRO principles ensure organizations can fully leverage these tools not just for streamlining current work, but as data sources for identifying systemic barriers in outbreak response.
- Creating Learning Systems: By implementing HRO principles, health departments develop the culture and processes necessary to transform data insights into actionable improvements.
- Enabling Data-Driven Decision Making: High-reliability organizations excel at using data to drive decisions. Our HRO work builds the foundation for health departments to effectively implement and act upon analytics solutions.
Throughout our research, we're documenting how these foundational capacities and reliability-focused infrastructure enable public health leaders to maximize the value of analytics innovations. The HRO project isn't separate from our analytics mission—it's what makes those analytics truly transformative.
V. Getting Involved
How can my health department participate in this research?
We're actively seeking partner organizations interested in:
- Contributing to case studies to our near miss tracking system
- Piloting HRO-based approaches and testing implementation frameworks through our Outbreak Response Innovation-Network (ORI-Net)
- Participating in learning communities through our CORI Community of Practice (CoP)
Contact us at CORI@jh.edu to discuss collaboration opportunities
Subscribe to CORI Digest to receive alerts on new opportunities
Where can I learn more about HRO principles?
We are currently building a resource library of articles, case studies, and implementation guides tailored to public health applications introducing HRO concepts specifically for public health professionals.(coming soon)
A few helpful reads to learn more about HRO principles include:
- Morrow, R. (2016). Leading High-Reliability Organizations in Healthcare (1st ed.). Productivity Press. https://doi.org/10.1201/b19529
- Weick KE, Sutcliffe KM. (2015). Managing the Unexpected: Sustained Performance in a Complex World (3rd ed.). San Francisco, CA: Jossey-Bass; 2015. ISBN-13: 9781118862414.
Is funding available to support implementation projects?
CORI does not provide direct funding. If you are interested in carrying out implementation projects, we invite you to join our ORI-Net network
Project Team
- Denise Cardo, MD - Senior Consultant
- Fatima Ameaka, PharmD, MPH – Senior Analyst
- Sarah S. Firestone, MSW– Research Program Manager
- Alex Zhu, MSPH – Analyst
- Ivy Marilyn Acquaye, PharmD – Student Intern