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HROs operate in complex, high‐hazard situations for extended periods without serious accidents or catastrophic failures. HROs relentlessly prioritize safety over other performance pressures. An example is a military aircraft carrier. The carrier operates under significant production pressures with aircrafts taking off and landing every 48–60 seconds; constantly changing conditions; and a hierarchical (military) organizational structure. However, personnel consistently prioritize safety and have both the authority and the responsibility to make real‐time operational adjustments to maintain safe operations as the top priority (AHRQ, 2018a, 2018b).

In the 1970s, research conducted by the National Aeronautics and Space Administration suggested that most commercial airplane crashes were caused by communication failures among pilots and crew, not by mechanical failures. In some cases, co‐pilots were aware that pilots were making unsafe decisions but did not verbalize their concerns because of authority gradient. Authority gradient refers to one's position within a group or profession. It was defined first in aviation when it was noted that pilots and copilots did not always communicate effectively in stressful situations if there was a significant difference in their perceived authority. Multiple aviation, aerospace, and industrial incidents have been attributed to authority gradients. This information was used to develop and implement the Crew Resource Management (CRM) training program. The training program focuses on interpersonal communication, leadership, and decision making in the cockpit, with the informal motto “see it, say it, fix it.” CRM is credited with the dramatic safety improvements in the airline industry (Helmreich, Merritt & Wilhelm, 1999) and has been adapted for use in health care and many other industries.

Similarly, the nuclear power industry has worked for many years to improve safety. The Institute of Nuclear Power Operations defines safety culture characteristics, some that are adaptable to the health care environment, and include: everyone is responsible for safety, leaders demonstrate commitment to safety, trust permeates the organization, decision making reflects safety first, a questioning attitude is cultivated, organizational learning is embraced and safety needs constant examination (Institute of Nuclear Power Operations, 2004). The American College of Healthcare Executives and Institute for Healthcare Improvement (IHI) published a blueprint for safety (2014) and is summarized in Table 4.2. These characteristics are essential for cultural transformation and are as applicable for all health care organizations.

Table 4.2 Safety Culture Characteristics

Establish a vision for safetyBuild trust, respect, and inclusionSelect, develop, and engage your BoardPrioritize safety in the selection and development of leadersLead and reward a just cultureEstablish organization behavior expectations

Source: Based on American College of Healthcare Executives and Institute for Healthcare Improvement. (2017). Leading a Culture of Safety: A Blueprint for Success. Retrieved from www.osha.gov/shpguidelines/docs/Leading_a_Culture_of_Safety-A_Blueprint_for_Success.pdf