From HRO to HERO: Making Health Equity a Core System Capability : American Journal of Medical Quality

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From HRO to HERO

Making Health Equity a Core System Capability

Moy, Ernest MD1; Hausmann, Leslie R. M. PhD2; Clancy, Carolyn M. MD3

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American Journal of Medical Quality 37(1):p 81-83, January/February 2022. | DOI: 10.1097/JMQ.0000000000000020
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Health equity is an ideal state in which everyone has the fair and just opportunity to reach their best possible health.1 Deviations from this state manifest as disparities, that is, systematic failures that result in certain groups receiving poorer care or achieving poorer health than others. Although disparities in US health care quality2 and safety3 are well-established, coronavirus disease 2019 underscored their devastating impact on different groups of Americans. At the same time, many health systems have been working to become high-reliability organizations (HROs), where the perpetuation of such systemic failure is antithetical to the essential goal of “zero harm.” As a general observation, health equity has been largely absent from discussions about HRO principles. As the nation begins its recovery from coronavirus disease 2019, the time is right to infuse equity into the very marrow of US health care. We propose adding Equity to HROs in the most literal sense by designating it as a core component and achieving High Equity Reliability Organizations (HEROs).

Whereas the ultimate outcome of HROs is exceptionally safe, consistently high-quality care (Figure), the ultimate outcome of HEROs is the assurance of safe, high-quality care for all groups of patients. Further, where HROs improve care processes so that failure is rare and manageable, HEROs will improve processes so that failure is rare, manageable, and equitable for all groups. HEROs must not only eliminate disparities in processes but also support variations in care delivery that may be necessary to eliminate disparities in outcomes.

High Equity Reliability Organization framework. Adapted from Hines S, Luna K, Lofthus J, et al. Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. (Prepared by the Lewin Group under Contract No. 290-04-0011.) AHRQ Publication No. 08-0022. Agency for Healthcare Research and Quality. 2008. Authors’ additions bolded.

An early proponent of HROs, the Veterans Health Administration recently completed full-scale implementation of an HRO-guided framework at its Harry S. Truman Memorial Veterans’ Hospital. Following a study showing that the framework decreased mortality and complication rates,4 Veterans Health Administration is driving system-wide spread. With many other health care organizations doing the same, now is an opportune time to become a HERO.

The HRO philosophy enables organizations operating in complex, high-risk environments to minimize system failures and mitigate their effects. This outcome is achieved by adherence to the following 5 core concepts. Each should be expanded to include equity.

Sensitivity to Operations

In traditional HROs, leaders and staff prevent adverse outcomes by maintaining constant situational awareness of processes that place patients at risk. In HEROs, leaders and staff will broaden this awareness to include environmental factors, such as where patients live, work, and receive health care. For example, structural biases have led some groups to disproportionately live in under-resourced neighborhoods, which may impair adherence to clinical recommendations. In addition, firsthand experience with discrimination may cause some groups to distrust medical institutions. Therefore, attentiveness to these and other factors is critical to preventing the treatment failures that have disproportionately impacted historically marginalized groups.

Preoccupation With Failure

HROs view near misses as opportunities to improve patient care and to identify potential harms. HEROs, meanwhile, will utilize near misses in tandem with variation across populations, both in processes and adverse outcomes, to diagnose root causes. This approach will provide important insight into preventing failure among populations experiencing higher error rates and populations at average risk. Further, such an approach will mean those disparities affecting numerically small populations are worthy of investigation because of their potential to reveal broader risks that might otherwise go undetected.

Deference to Expertise

HRO leaders respond to observations by staff who interact with patients and have the most detailed understanding of work processes and risks. HEROs will recognize that patients often have the clearest vision about how they feel and what matters most to them using a “Whole Health” approach.5 Listening to patients, their families, and trusted community organizations can identify opportunities to mitigate risks affecting marginalized populations. Forming therapeutic partnerships with patients improves adherence to advice, especially outside acute care settings where patient self-efficacy and self-care are vital. In addition, diverse and inclusive work environments will empower all staff to speak up and reduce patient risk.


Whereas HRO leaders and staff are trained to detect and manage risk, prevent adverse outcomes, and respond to system failures generally, HERO leaders will know how to apply these skills to a diversity of patients. Additionally, these leaders will foster diverse and inclusive workforces that enhance their organization’s ability to adapt to new and unpredictable circumstances. Further, their sensitivity to systemic biases such as racism, sexism, ageism, and ablism will nurture safe spaces for holding difficult conversations and finding just solutions.

Reluctance to Simplify

HRO staff challenge simplistic explanations of failure and seek to understand the true reasons behind adverse outcomes. HEROs will not only recognize that the most complicated and variable part of patient care is “the patient” but also recognize that patient beliefs, preferences, and behaviors are shaped by myriad influences in and outside of healthcare settings. Appreciation and respect for these differences can lead to tailored solutions that minimize risk for all patients.

The HRO philosophy of zero harm already has enabled health care systems to reduce error and improve quality on many fronts. By recognizing disparities as systematic failures that require the same level of mindfulness as individual failures, the HERO framework will support the goal of delivering exceptionally safe, consistently high-quality whole-person care for all patients.

Conflicts of Interest

The authors have no conflicts of interest to disclose.


This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.


1. Braveman P, Gruskin S. Defining equity in health. J Epidemiol Community Health. 2003;57:254–258.
2. Agency for Healthcare Research and Quality. 2019 National Healthcare Quality and Disparities Report. 2021. Accessed August 30, 2021.
3. Agency for Healthcare Research and Quality. Chartbook on Patient Safety. 2021. Accessed August 30, 2021.
4. Sculli GL, Pendley-Louis R, Neily J, et al. A high-reliability organization framework for health care: a multiyear implementation strategy and associated outcomes. J Patient Saf. Published online October 8, 2020. doi:10.1097/PTS.0000000000000788.
5. Bokhour BG, Haun JN, Hyde J, et al. Transforming the Veterans affairs to a whole health system of care: Time for action and research Med Care. 2020;58:295–300.

disparities; equity; high reliability organization; patient safety; quality

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