Applying HRO principles to Safety II in healthcare

By David Varnes, Principal, Press Ganey Consulting, and Dr. Tejal Gandhi, Chief Safety and Transformation Officer, Press Ganey.

Modern healthcare operates in a reality defined by constant change, tight timelines, competing priorities, and little margin for error. For decades, safety improvement efforts were largely guided by what is now referred to as Safety I—an approach that defines safety as the absence of harm and focuses on identifying the causes when things go wrong While Safety I has led to important progress, it’s not enough on its own to manage the complexity and variability of real-world care delivery.

Safety II complements this approach by redefining safety as a system’s ability to succeed (deliver safe care) under a wide range of conditions. Rather than focusing on what goes wrong, Safety II emphasizes understanding how everyday clinical work usually goes right, even in the face of resource constraints, interruptions, and uncertainty. Within this paradigm, the principles of High Reliability Organizations (HROs) offer a practical framework for strengthening safety by enhancing resilience, learning, and adaptive capacity across healthcare systems.

Safety as a product of resilient systems

Traditional Safety I approaches are grounded in linear cause-and-effect models and treat deviations from the standard as problems to fix. Safety II, on the other hand, recognizes that variability is unavoidable—and it’s even often essential for delivering effective care to diverse patients. Safety depends on how people, technology, workflows, and organizational conditions work together. Therefore, clinicians and staff aren’t the source of most errors—they’re essential to preventing them, using their ability to anticipate, adapt, and respond.

Preoccupation with failure: Learning from near misses and recoveries

High reliability in healthcare requires a preoccupation with failure—not to assign blame, but to catch early signs of risk. Near misses, delays, workarounds, and recovered errors provide critical insight into where systems are vulnerable and how clinicians successfully compensate. Actively learning from these signals helps healthcare organizations identify emerging threats and intervene before patient harm occurs.

Reluctance to simplify: Respecting clinical complexity

Healthcare delivery is complex, shaped by interactions between patients, clinicians, technologies, and organizational pressures. A reluctance to simplify interpretations helps organizations avoid overly reductive explanations for safety events. Rather than seeking a single root cause, Safety II focuses on factors like workload, cognitive demands, staffing, information flow, and competing goals and how these real-world pressures shape clinical performance. Understanding these dynamics more deeply leads to improvements that are more likely to be effective and sustainable.

Sensitivity to operations: Understanding work as done

Sensitivity to operations means staying closely connected to what’s happening on the front lines, in real time. It means understanding how work actually gets done, not just how it is documented or designed. Practices like safety huddles, leader rounding focused on conditions of work, and front-line storytelling help illuminate the operational realities of the job and give organizations to make adjustments before risks escalate.

Commitment to resilience: Managing the unexpected

A commitment to resilience is central to both Safety II and high reliability. Healthcare systems must be able to absorb surges in demand, adapt to interruptions, and recover from unexpected events, all while continuing to deliver safe care. Resilience emerges through skilled clinical judgment, teamwork, and flexible use of resources. Investing in nontechnical skills, surge capacity, and in- situ simulation make teams better able to manage the unexpected.

Deference to expertise: Letting clinical knowledge lead

In dynamic and high-risk clinical situations, decisions should be made by those who have the most relevant expertise, regardless of where they rank in the organizational hierarchy. This principle helps teams recognize problems sooner and act faster. It also depends on psychological safety and a just culture, where clinicians feel empowered to speak up, question decisions, and act in the interest of patient safety.

Integrating Safety I and Safety II

High reliability healthcare systems recognize the need for both Safety I and Safety II. Standardization, protocols, and technology help manage expected risks, while Safety II and HRO principles strengthen the system’s capacity to adapt when reality diverges from the plan. Together, these approaches enable healthcare organizations to achieve safety that is both reliable and resilient.

Healthcare strategies for implementing Safety II using HRO principles

HRO principle	Safety II intent in healthcare	Healthcare-specific strategies	Impact on care delivery
Preoccupation with failure	Learn from near misses and recoveries	Discuss near misses and intercepted errors in huddles and M&M conferences; ask what made care safer today	Earlier identification of emerging risks
Reluctance to simplify interpretations	Understand complexity of care delivery	Examine workload, staffing, cognitive load, and trade-offs during event reviews	More accurate understanding of system vulnerabilities
Sensitivity to operations	Real-time awareness of front-line care	Leader rounding focused on conditions of work; daily safety huddles	Faster response to operational threats
Commitment to resilience	Support adaptation under pressure	Train nontechnical skills; maintain surge capacity; use in situ simulation	Sustained safety during disruptions
Deference to expertise	Mobilize clinical knowledge	Empower staff to speak up; use structured communication; reinforce just culture	Earlier intervention and harm prevention
Learning orientation	Study how safe care is achieved	Analyze clinical successes and recoveries; share adaptive performance stories	Continuous improvement grounded in real work

To learn more and to discuss these principles further, get in touch with an expert on Press Ganey’s safety and high reliability team.