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Healthcare leaders developing highly reliable organizations

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Healthcare leaders developing highly reliable organizations

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Content Healthcare Leaders Developing Highly Reliable Organizations
Kara A. Gormont
Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education
August 2024

© Copyright by Kara Gormont 2024
All Rights Reserved

1
The Committee for Kara Gormont certifies the approval of this Dissertation
Don Trahan, Jr
Todd Allen
Marsha Riggio, Committee Chair
Rossier School of Education
University of Southern California
2024

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Abstract
This study utilized a qualitative approach for learning from healthcare leaders with lived
experiences on becoming a highly reliable organization (HRO), further delving into their
challenges and recommendations for improvement. The study utilized a conceptual framework
that combined Weick and Sutcliff’s five guiding principles: preoccupation with failure,
reluctance to simplify, sensitivity to operations, commitment to resilience, and deference to
expertise (2015) with the theoretical framework of Burke-Litwin to structure the research,
literature review, best practice analysis, and thematic coding of research data (1992). The
conceptual framework also included the SCORE™ survey framework, an industry standard for
evaluating an organization’s readiness along its HRO journey (Vizient, 2023). There is no
agreed-upon industry model for implementing the cultural change necessary to become a highly
reliable organization. These frameworks, HRO principles, Burke-Litwin, and the SCORE
survey, were melded to form an implementation model. Further study is needed to evaluate how
beneficial this tool is as an industry standard for implementing a safety culture.
Keywords: high-reliability, highly reliable, HRO, Burke-Litwin, KMO, transformational
leadership, learning organizations

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Dedication
Dedicated to those harmed, silenced, or marginalized in organizations not yet highly reliable.

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Acknowledgments
To my family first and always, I love you and could not and would not have done this
without your inspiration. I love you, Kevin, Cesily, Sydney, Mom and Dad, my brothers, sisters
by choice (Gina and LaDonna), my godparents Jim and Gail, and Poppy; thank you for
inspiring me and allowing me to keep doing crazy things I never thought I would.
To everyone at the Queen’s Health System who helped me understand this critical topic
by constantly seeking to align with living the Queen Emma Way in service to our community,
thank you for restoring my faith in compassion and humanity and providing the healing that I
needed.
Kristen Fan, Veteran’s Affairs Separations Counselor, told me that I needed to apply for
a doctorate, relentlessly followed up until I did, and then eased the way to make the decision
simple. Also, thanks to Maryanne Garbowski, Jim Forrest, and Wayne Pritt, who are always
there for me and did not hesitate to write a letter of recommendation for my acceptance to the
program.
Shout out to Cohort-22, the magic of WhatsApp, Isaac for always reaching out, Zach’s
cataloging skills, Meredith’s witty, easy humor (huh?, LFG, & Doctor School). My friend,
Steve Atmiller, deserves a special shout-out; he is a mentor and friend, pulling me through a
formidable military-to-civilian transition. I also want to give a massive shoutout to all of you
other amazing, inspirational, and loving Cohort-22 friends. You made this journey fun and
consistently demonstrated how powerful a genuinely supportive group of exceptionally brilliant
people can change lives. Lastly, to our professors, this is what excellence looks like; you got us
through this rigorous journey with humility, compassion, and strength. Thank you!

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For the women who grew me and pushed me to be better than I thought I could be,
Kristen Beals, T Bailey, Ruth Bessinger, Felecia Burks, Darlena Chadwick, Emirza Gradiz,
Mary Hoekwater, Gail Kelley-Webb, Mary Krueger, Rachel Lefebvre, Denise Lew, Susan
Pietrykowski, and Judith Rogers, I love you all!
For my caring angels who got me through Covid when I would have literally died
without your support: Kasi Chu, Scott Filipino, Wendy Moreno, Elizabeth Beals, Beth Luna,
Angi Sheffield, Sherri Gevedon, Dr. Rocheleau, Dr. Vanichkachorn, Dr. Kim Fabyan, my
Wilford Hall Care Team, my remote ICU nurses, and most importantly, Terry Bailey. You all
know what you did for me and how hard you had to fight in a system that was so unreliable it
would have killed me without your interventions. I am so grateful for your grit and tenacity,
refusing to listen to the noise and centering my voice as a patient in need. You saved my life
when I didn’t even care if it was saved, and now, on the other side, I am so grateful for that.
To all of my dragons who gave me strength to fight when the stakes were the highest,
first my mom and my beautiful girls, Cesily and Sydney, and the rest of the dragon army: Heidi
McMinn, Rhoda Santos, Katie Salle, Jennifer Giovanetti, Jennifer Espiritu, Tiffany Andrews,
Shelley Izuno, Felecia Washington, Jackie Hall, Kristen Beals, Angelique Simpson, Leilani
Riley, Michael Hamilton, Tony Lawrence, Neesha Radford, Felecia Burks, Angel Vargas,
Jennifer Bein, Charlie Ruben, Sarah Monroe Whitson, Michele Milner, Angela Thompson,
Sandy Phillips, Stephanie China, Monica Botch, Teneshia DeAlba Ascencio, Allie Richards,
Candace Lucas, Jennifer Howell, and of course to Stephanie Proellochs, the fiercest fighting
dragon there ever was. Each of you enriches my journey.
Last, thank you to the Air Force Medical Service, who helped me learn the principles of
High Reliability Organizations over decades of service. The lessons I learned in the Military

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Health System (MHS) shaped my knowledge of what a healthy, robust culture of care, filled
with compassion and focused on safety, can be, even if, at the end of my career, it was the MHS
that also demonstrated to me what a long, long journey we still have; it was that knowing of
what it should be for others that brought me back. I am blessed, and feel destined, that those
lessons, as hard as they were, prepared me for the privilege I am now given to improve access at
Queen’s Health System for our community.
“Trust Takes Years To Build, Seconds To Break, and Forever To Repair”
__ Unknown

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Table of Contents
Abstract ........................................................................................................................................ iv
Dedication ..................................................................................................................................... v
Acknowledgments........................................................................................................................ vi
List of Tables.............................................................................................................................. xvi
List of Figures ........................................................................................................................... xvii
List of Abbreviations................................................................................................................ xviii
Chapter One: Introduction to the Study ........................................................................................ 1
Background of the Problem........................................................................................................... 2
HRO In Healthcare ................................................................................................................ 3
Preoccupation with Failure.................................................................................................... 5
Reluctance to Simplify .......................................................................................................... 5
Sensitivity to Operations ....................................................................................................... 6
Deference to Expertise .......................................................................................................... 7
Commitment to Resilience .................................................................................................... 7
Statement of the Problem .......................................................................................................... 8
Statement of the Problem: Preoccupation with Failure....................................................... 10
Statement of the Problem: Reluctance to Simplify ............................................................. 10
Statement of the Problem: Sensitivity to Operations .......................................................... 11
Statement of the Problem: Deference to Expertise.............................................................. 11

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Statement of the Problem: Commitment to Resilience ....................................................... 11
Purpose of the Study................................................................................................................ 12
Purpose of the Study: Preoccupation with Failure .............................................................. 12
Purpose of the Study: Reluctance to Simplify..................................................................... 13
Purpose of the Study: Sensitivity to Operations.................................................................. 13
Purpose of the Study: Deference to Expertise ..................................................................... 14
Purpose of the Study: Commitment to Resilience............................................................... 15
Research Questions ............................................................................................................. 15
Significance of the Study ........................................................................................................ 15
Definition of Terms................................................................................................................. 16
Assumptions, Limitations, Delimitations, and Positionality ................................................... 19
Assumptions........................................................................................................................ 19
Limitations........................................................................................................................... 19
Delimitations ....................................................................................................................... 20
Positionality......................................................................................................................... 20
Organization of the Study........................................................................................................ 22
Conclusion............................................................................................................................... 23
Chapter Two: Review of the Literature....................................................................................... 24
Search Description .................................................................................................................. 24
Conceptual Framework ........................................................................................................... 25

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Theoretical Framework ........................................................................................................... 30
Introduction to the Burke-Litwin Model ............................................................................. 30
Conclusion Burke Litwin Model......................................................................................... 37
Review of Research................................................................................................................. 38
Healthcare’s Need for High-Reliability................................................................................... 38
External Environment.......................................................................................................... 38
Transformational Factors .................................................................................................... 40
Transactional Factors .......................................................................................................... 45
Individual and Personal Factors .......................................................................................... 47
Individual and Organizational Performance........................................................................ 48
Conclusion: Need for HRO ..................................................................................................... 49
Introduction ......................................................................................................................... 50
External Environment.......................................................................................................... 51
Transformational Factors .................................................................................................... 52
Transactional Factors .......................................................................................................... 53
Individual and Personal Factors .......................................................................................... 61
Individual and Organizational Performance........................................................................ 65
Conclusion: Burke-Litwin Model ........................................................................................... 66
Recognized Best Practices....................................................................................................... 67
External Environment.......................................................................................................... 67

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Transformational Factors .................................................................................................... 69
Transactional Factors .......................................................................................................... 70
Organizational Effectiveness: Individual and Personal Factors.......................................... 73
Organizational Effectiveness: Individual and Organizational Performance ....................... 78
Conclusion: Best Practices.................................................................................................. 80
Conclusion: Literature Review................................................................................................ 81
Chapter Three: Methodology ...................................................................................................... 82
Research Design ...................................................................................................................... 82
Research Questions ................................................................................................................. 83
Research Setting .................................................................................................................. 83
Participants.............................................................................................................................. 84
Target and Accessible Population ....................................................................................... 84
Sample ................................................................................................................................. 84
Sampling Method ................................................................................................................ 85
Recruitment ......................................................................................................................... 85
Data Collection........................................................................................................................ 86
Demographic Survey ........................................................................................................... 86
Interview Protocol ............................................................................................................... 86
Procedures ........................................................................................................................... 88
Confidentiality Parameters.................................................................................................. 88

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Data Management................................................................................................................ 89
Dissemination of Findings................................................................................................... 89
Data Analysis .......................................................................................................................... 89
Descriptive Analysis............................................................................................................ 91
Thematic Analysis............................................................................................................... 93
Reliability ............................................................................................................................ 93
Validity ................................................................................................................................ 94
Conclusion............................................................................................................................... 96
Chapter Four: Presentation of Research ...................................................................................... 97
Statement of the Problem ........................................................................................................ 97
Participating Stakeholders................................................................................................... 97
Method of Coding ............................................................................................................... 98
Research Question 1: What are the lived experiences of healthcare leaders regarding HRO
principles? ............................................................................................................................... 98
Transformational Factors .................................................................................................. 100
Transactional Factors ........................................................................................................ 102
Interpersonal Factors......................................................................................................... 103
Conclusion Research Question One .................................................................................. 104
Research Question Two: What are the challenges faced by healthcare leaders regarding HRO
principles? ............................................................................................................................. 104

xiv
Transactional Factors ........................................................................................................ 106
Interpersonal Factors......................................................................................................... 107
Research Question Three: How can healthcare leaders implement HRO principles? .......... 108
Transformational Leadership............................................................................................. 109
Storytelling ........................................................................................................................ 110
Transformational Leadership............................................................................................. 111
Transactional ..................................................................................................................... 113
Learning Organization....................................................................................................... 113
KMO Knowledge Transfer Model .................................................................................... 114
Conclusion............................................................................................................................. 116
Chapter Five: Summary, Implications, Conclusions................................................................. 119
Summary of Research ........................................................................................................... 119
Discussion of Findings.......................................................................................................... 120
Recommendations for Practice.............................................................................................. 120
Recommendation 1: KMO ................................................................................................ 121
Recommendation 2: Transformational Leadership ........................................................... 122
Recommendation 3: Learning Organization ..................................................................... 122
Limitations and Delimitations............................................................................................... 125
Limitations......................................................................................................................... 125
Delimitations ..................................................................................................................... 125

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Recommendations for Future Research................................................................................. 126
Conclusion............................................................................................................................. 126
References ................................................................................................................................. 128
Bibliography .............................................................................................................................. 143
Protocols.................................................................................................................................... 144
Appendix A: Qualitative Interview Prompts............................................................................. 145
Appendix B: Code Book for Analysis....................................................................................... 150

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List of Tables
Table 1: Thematic Analysis Research Question One .................................................................. 99
Table 2: Thematic Analysis Research Question Two ............................................................... 106
Table 3: Thematic Analysis Research Question Three ............................................................. 109
Table 4: Thematic Analysis All Research Responses Coded to Burke Litwin Model.............. 117
Table 5: Thematic Analysis of All Research Responses to Best Practices............................... 118

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List of Figures
Figure 1: Highly Reliable Care Model .......................................................................................... 4
Figure 2: Five Principles of a Highly Reliable Organization ...................................................... 26
Figure 3: Burke Litwin HRO Theoretical Implementation Model.............................................. 29
Figure 4: Burke-Litwin Causal Model ........................................................................................ 31
Figure 5: Sentinel Events ............................................................................................................ 41
Figure 6: Leading Sentinel Event Types..................................................................................... 44
Figure 7: Safe and Reliable Culture Maturity Model.................................................................. 46
Figure 8: Leading a Culture of Safety: A Blueprint for Success................................................. 56
Figure 9: AF Trusted Care Model ............................................................................................... 57
Figure 10: Kirkpatrick Four Levels of Change Model................................................................ 59
Figure 11: IHI and Safe and Reliable Healthcare HRO Model................................................... 60
Figure 12: Transformational Leadership Model.......................................................................... 69
Figure 13: Maslow’s Hierarchy of Needs ................................................................................... 75
Figure 14: Burke Litwin HRO Theoretical Implementation Model.......................................... 124

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List of Abbreviations
AFMS: Air Force Medical Services
HRO: High(ly) Reliable Organization
KMO: Knowledge Management Overview
BLM: Burke-Litwin Model

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Chapter One: Introduction to the Study
In 1999, the Institute of Medicine published a report titled To Err is Human, which
estimated that between 44,000 to 98,000 people annually die in hospitals in the United States
(U.S.) due to preventable human medical errors (Kohn & Donaldson, 2000). The period after
this report is considered the Bronze Age of Safety in healthcare, with many gains in best
practices for improvement; however, implementation could be more consistent even after all this
time (Bates & Singh, 2018). Despite these gains in improvement, in 2022, The Joint Commission
reported that sentinel events (see Definition of Terms) rose 19% over previous years (Hollowell,
2023), demonstrating that a safety culture is still missing in healthcare. With transparency and
reporting of harmful healthcare errors at the forefront since the 1999 report, implementing
strategies to prevent harm has remained a priority for healthcare leaders. As strategy for change
varied, Weick and Suffclife (2015) introduce five organizing principles to help healthcare leaders
reduce sentinel events: preoccupation with failure, reluctance to simplify, sensitivity to
operations, commitment to resilience, and deference to expertise. This study examines lived
experiences and challenges that healthcare leaders face in implementing high(ly) reliable
organization (HRO) principles. It compares that information with the theoretical framework of
the Burke-Litwin organizational change model. This research presents a model using the BurkeLitwin theory, which demonstrates that organizational culture is changed by aligning essential
elements such as strategy, leadership, policy, and tactical actions, which must respond to external
influences (Burke & Litwin, 1992). In this study, the external influence forcing change is the
growing awareness of medical errors in healthcare and a call to action from healthcare leaders
and their patients.

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Background of the Problem
In the introduction, we learned that sentinel events, or events causing permanent harm or
loss of life, are on the rise within healthcare organizations; in fact, one study found that between
2021 and 2022, sentinel events rose 19% (Hollowell, 2023). In reviewing incidents across
reporting organizations, the Joint Commission’s team of experts found that most sentinel events
are failures in teamwork, communication, or inconsistent implementation of policies (2023).
With incidents on the rise and systematic failures identified as the root cause, healthcare leaders
benefit by studying the best practices of others to decrease these issues in their organizations.
With this growing awareness, the question was not whether healthcare delivery should
change but how. Healthcare leaders sought guidance by turning to other industries with a record
of high-risk operations. Despite complexity and challenges, industries such as aviation, nuclear
power plants, and the automobile sectors have found ways to provide consistently safe and
reliable service (Mahankali & Nair, 2019). Studying these industries proved a good place for
healthcare professionals to find solutions to their growing safety concerns.
After catastrophic events, industries such as aviation and nuclear power discovered that it
was necessary to identify early danger signals that could result in catastrophic failure (Hines et
al., 2008). As a response to failures, these industries studied challenges they had in common and
found seven underlying themes: hyper-complexity, the tight coupling of tasks across teams,
deferring decision-making to the most knowledgeable, not senior ranking, need for frequent and
immediate feedback, compressed time constraints, and high-stake accountability to evert severe
consequences, were all things these complex, high-risk industries had in common (Hines et al.,
2008). By looking at these challenges, the industries began to develop models of safety that they
implemented to prevent catastrophic events. Although there are exceptions to their success, now,

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after decades of focusing on safety, these industries operate daily with safe outcomes and are
considered high-reliable organizations (HROs; Coutu, 2003). By definition, an HRO is a
complex organization that operates without errors for extensive lengths of time (Mahankali &
Nair, 2019). The challenge healthcare professionals faced was how to take a model of HRO that
worked across these industries and adapt it to the healthcare setting. The key seemed to be in
Weick and Sutcliffe’s (2015) five operating principles: preoccupation with failure, reluctance to
simplify, sensitivity to operations, commitment to resilience, and deference to expertise.
HRO In Healthcare
It is possible to trace the first attempts to adapt HRO to the healthcare setting. In 1989,
Loma Linda adopted these HRO lessons from other industries to revitalize its pediatric intensive
care unit (Roberts, 2021). Loma Linda used HRO before Weick & Sutcliffe’s work on the five
principles released in 2001 (McKinnet, 2005). First attempts met many barriers to
implementation. Healthcare faces unique challenges in developing a safety climate; Hines et al.
(2008) discovered that healthcare has two additional complexities over other industries that
successfully adopted HRO. Those additional healthcare complexities are: first, the workforce is
highly mobile and extensively trained, and second, they care for humans, not machines (2008).
Peter Druker described the intricacy of healthcare as “the most complex human organization ever
devised” (as cited in Mahankali & Nair, 2019); this highlights some of the challenges of
implementing HRO principles across a healthcare system, which also may explain why it is
difficult, yet critical to pursue: the stakes are high.
Early attempts to translate success from other industries to healthcare worked from
various perspectives until 2001, when Weick and Sutcliff published their work on the framework
of HROs that outlined five activities organizations use to improve reliability (McKinnet, 2005).

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Figure One displays the five areas of HRO: preoccupation with failure, reluctance to simplify,
sensitivity to operations, commitment to resilience, and deference to expertise, with the first
three focusing on reducing incidents and the last two focusing on resilience (McKinnet, 2005).
One study suggests that of 18 organizations committed to implementing HRO, all agreed they
want to learn from each other on how they can apply lessons learned to improve quality and
safety for their patients (Hines et al., 2008). This study provides some of that ability to learn
from others. The following section introduces the concepts behind the preoccupation with
failure, reluctance to simplify, sensitivity to operations, commitment to resilience, and deference
to expertise in reviewing the five principles of HRO.
Figure 1
Highly Reliable Care Model

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Preoccupation with Failure
Healthcare organizations are complex and constantly changing. When issues arise, it is
easy for organizations to miss the clue that underlying issues may lead to more significant
problems. In the first concept of HRO, preoccupation with failure, the organization learns it must
constantly scan the internal environment for indications that there are flaws in its policies,
procedures, and care delivery models (Weick & Sutcliffe, 2015, p. 47). A failure to adopt a
mindset aligned with a preoccupation with failure leads to a tendency to not look for a root cause
that could prevent reoccurrences, to solve problems in secrecy, to have leaders solve problems
without bringing experts into the rooms, and then to keep those issues to themselves (Weick &
Sutcliffe, 2015). Over time, organizations develop habits that prevent a preoccupation with
failure due to organizational complexity, reactive problem-solving, fear of loss, lawsuits, shame,
retribution, or reputations (SHRM, 2022; Weick & Sutcliffe, 2015). These sorts of habits
develop in an organization for many reasons. However, Weick and Sutcliffe teach us that
organizations must adopt behaviors that help them become preoccupied with failure to become
highly reliable.
Reluctance to Simplify
Reluctance to simplify is the second HRO principle. Weick and Sutcliffe (2015)
developed this principle to address the problem of solving complex issues within healthcare.
Healthcare organizations are complex entities comprising thousands of employees that work in
different departments, often in various geographical locations, and have complex organizational
structures. These organizational complexities are frequently codified in hierarchical human
resource organizing but require matrixed care coordination across cost centers and organizational
chains of command to solve problems. Solving problems across the organization becomes

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difficult because issues often are not owned by any department or person; they are shared
problems and, therefore, need a shared governance structure to resolve them. This matrix of
responsibility can be complicated because determining who owns a problem and who is
responsible for driving the solution needs to be clarified. There is a reluctance to assume full
responsibility or to give ownership of a problem they share responsibility for with others for fear
of losing control of the outcome that may impact them. Weick and Sutcliffe offer the principle of
a reluctance to simplify to combat these concerns, stating that simplification risks obscuring
details and increasing the likelihood of unreliable outcomes of safe care (2015, p. 64). To resolve
problems, healthcare organizations find that it is not possible to simplify the solution if they want
to “hard-wire” the change. Adopting a mindset that allows the organization to review the
problems in totality helps build a reluctance to simplify the solutions.
Sensitivity to Operations
Healthcare organizations' complexity requires leaders to understand how processes,
systems, and workflows function to ensure safe and reliable care. Weick and Sutcliffe (2015) call
the principle that addresses this problem within healthcare sensitivity to operations. They state
complex issues have unlimited linkages (2015, p. 78). Processes across healthcare organizations
are interconnected, which means they have many leaders involved who may work to change a
particular aspect of a method, system, or workflow. This change impacts others, and there must
be a sensitivity to the operations to determine how those interdependencies connect (2015, p.
79). Poor alignment of strategy, priorities, responsibility, and accountability often results in
neglecting problems. Further, solutions to problems frequently fail to allow operations across the
organization to collaborate to solve the issue at hand, causing unanticipated consequences. One
concept in sensitivity to operations is that flexibility is needed as operations are happening

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constantly (2015, p. 80). This phenomenon highlights the importance of organizations
developing concepts of implementation and transformation that align with the HRO principle of
sensitivity to operations.
Deference to Expertise
Hierarchical organizations can lead to decision-making in a vacuum. Loosening the hold
of hierarchical structures on decision-making is a crucial aspect of deference to expertise (Weick
and Sutcliffe, 2015, p. 115). Failing to involve the process experts in favor of hierarchical
relationships may lead to resolutions that fail to understand the problem from where it matters
most: the frontline. Leaders may think they have the solution to the issues because they have
been in the organization or industry longer or perceive that their position requires them to solve
the problem in their manner. Leaders may provide a solution quickly, but without a complete
review and involving all stakeholders, the problem’s adjacencies may lead to problem-solving
that creates new ones (Weick & Sutcliffe, 2015). Leaders also may have an authoritarian
leadership style that does not value participation from frontline staff (Sarla, 2020). This
leadership style is unsuitable for problem-solving in a complex organization (2020). The
challenge of hierarchical and autocratic leadership in HRO is addressed further in Chapter 2
under best practices. Deference to expertise and bringing those experts to the table for problemsolving is critical in moving an organization toward solid HRO implementation.
Commitment to Resilience
When organizations are surprised, they can learn from those shocks to the system (Weick
and Sutcliffe, 2015, p. 94). In high reliability, the concept of commitment to resilience captures
this principle. Managing the unexpected allows leaders to react to this change in their
environment through the lens of a safety culture. Elasticity in an organization provides the

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opportunity to rework the system and adapt to the problem at hand (Weick & Sutcliffe, 2015, p
98). The impact of COVID-19 on healthcare operations is an excellent example of this resiliency
in action. Resilience occurs when independent people work interdependently to increase the
resources and knowledge to solve a problem (Weick & Sutcliffe, 2015, p. 107). Resiliency is
improved through psychological safety, accountability, teamwork, and communication (Weick &
Sutcliffe, 2015, pp. 94-111). Complex organizations must demonstrate a positive learning
culture, taking lessons from their failures and adopting change to improve and prevent future
harm (2015). As an organization adopts a safety culture through HRO principles, commitment to
resilience from adversity is critical to enhanced organizational reliability.
Statement of the Problem
Despite the five principles of HRO outlined by Weick and Sutcliffe, healthcare continued
to need help adopting a safety culture. Other industries where safety accidents are catastrophic
have successfully implemented HRO principles, while adaptation to healthcare remains
problematic (Veazie et al., 2019). Healthcare systems are complex and dynamic, with intricate
workflows across departments that rely on each other to deliver care (Edmondson, 2019) safely.
Furthermore, every patient is different, adding additional variables to an already complex system
of systems (Christensen, 2007). An urgency around patient safety must underscore further
research to determine best practices and lessons learned from healthcare leaders on how HRO
principles are adapted, adopted, and implemented effectively within the healthcare setting
(AHRQ, 2008). Researching healthcare adoption of HRO principles from other industries helps
leaders review previous successes and determine what techniques and models they want to
utilize as they embark on their HRO journey.

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Based on the problems mentioned above, the impact of needing a culture of safety in
healthcare is vast. The U.S. spends more per capita and per person than any other country, and
despite that, it cannot provide universal health insurance (McGee, 2019). Additionally, it has
worsening outcomes than any other well-developed nation (Gunja et al., 2023). The US
healthcare system design is not cohesive. It is siloed and, perhaps expectedly, is achieving the
result of a poorly designed system: skyrocketing costs, poor health outcomes, and increasing
patient safety incidents (McGee, 2019, pp. 10-28). “In 2021, the U.S. spent 17.8 percent of gross
domestic product on health care, nearly twice as much as the average OECD country” (Gunja et
al., 2023). Despite this heavy financial investment, life expectancy in the US in 2020 fell by 1.8
years, and although COVID-19 impacted that, it does not explain why the US saw more
significant declines in life expectancy than other countries during the pandemic (Otto Valdez,
2022). This disparity between the cost of healthcare and poor quality indicators is on top of everincreasing rises in sentinel events, up 19% in 2022 (Hollowell, 2023). This bleak picture
becomes the frontline battlefield of healthcare leaders who need to pivot their organization
towards high reliability; they do not have time, energy, or money to waste when the stakes of not
doing so are high.
The consequences of not studying lived experiences and the challenges healthcare leaders
experience in implementing HRO result in lower quality of life and even death. Healthcare
injuries can range from medication errors, pressure ulcers, and acquired infections to perhaps
more severe outcomes, such as surgeries that result in loss of life and ability (Cochrane, 2017).
The World Health Organization estimates that deaths related to unsafe care are one of the top ten
causes of death worldwide and that in developed countries, one in ten patients are harmed while
receiving care (WHO, 2019). The US has set up a system that cares for the sick but neglects the

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moral responsibility to care for the nation’s population trapped in systems of inequity, which
decreases the overall quality of life (Bailey et al., 2021); this inequity as patients enter the health
system cause even more significant safety challenges. With the consequences so high, it is
essential to provide healthcare leaders with insights from others who have found solutions to
these critical challenges.
Statement of the Problem: Preoccupation with Failure
When healthcare leaders fail to have a preoccupation with failure, they do not fix the gaps
that result in failures and hardwire solutions, so problems do not return. The impact of that is that
issues arise again and again. This inertia can disillusion staff, demotivating them from bringing
issues forward again. There is a sense that nothing will change, so why bother? Not being
preoccupied with failure can lead to a reactionary mindset versus a proactive one. An
organization would be inclined to wait until failure hits instead of working to root out failure
before harm occurs. If leadership is not infusing a preoccupation with failure, others avoid
making waves or causing problems. When employees are afraid to speak up, they are reluctant to
report errors and near misses. By adopting the principle of preoccupation with failure, everyone
gets invited to be part of the solution and is included on the journey towards developing safe and
reliable care.
Statement of the Problem: Reluctance to Simplify
Healthcare executives must solve problems across complex environments, and due to
those complexities, teaming and sharing of issues and solutions often need to be addressed. The
executive leadership sponsors issues aligned with strategic priorities, but thousands of lowerlevel problems need a champion to get resolution across departments. When challenges fail to
receive a champion from sponsoring a resolution in totality, the environment is reactive and not

11
prone to take on complex system re-engineering to ensure the problem does not reoccur. The
principle of reluctance to simplify helps an organization look across departments and involve the
views of others when they embark on their safe and reliable journey.
Statement of the Problem: Sensitivity to Operations
Failure to involve frontline staff in solving problems may harm patients. Understanding
the complexities across the organization can result in a better quality of care and better outcomes.
Sensitivity to operations can improve efficiency and effectiveness. Through sensitivity to
operations, the organization develops the mindset that problems are as complex as the
organization itself, and all stakeholders are invited to participate in solving them. The principle
of sensitivity to operations is where care delivery and safe and reliable outcomes happen.
Statement of the Problem: Deference to Expertise
Healthcare organizations that defer to expertise can succeed in solving problems, learn
best practices, and take advantage of evidence-based problem-solving approaches. When an
organization fails to involve the experts in shared decision-making, it can potentially increase
risk events. An organization must defer to the experts to learn from near-miss safety events.
Healthcare organizations that do not defer to expertise can make decisions and invest in solutions
that are ineffective in solving problems. Healthcare organizations can only use innovative
problem-solving by involving frontline experts in decision-making. This principle is critical in
transforming an organization to provide safe and reliable care.
Statement of the Problem: Commitment to Resilience
Disruptions across the organization can cause it to freeze. If employees do not have the
guidance that they are empowered to improvise and be resilient, they may not feel they can adapt
when problems arise. Healthcare organizations that are not resilient may not balance new

12
challenges while maintaining safe patient-care delivery, which can harm patients. Being illprepared to handle disruptions in normal operations may result in a negative reputation. A
commitment to resilience and continuous improvement is critical for an organization to
implement safe and reliable healthcare.
Purpose of the Study
This descriptive qualitative research, through a phenomenological case study, aims to
understand healthcare leaders' lived experiences and challenges and compare that information
with the Burke-Litwin theoretical framework, which outlines dimensions of organizational
culture for effective change to take place. Gaining this insight provides leaders with a model of
HRO implementation based on healthcare leaders' lived experiences against the Burke-Litwin
theoretical framework. This study focuses on understanding healthcare leaders’ personal
experiences, strategies, and the tools they embrace while implementing HRO in their
organizations.
Purpose of the Study: Preoccupation with Failure
This study aims to learn from healthcare leaders' lived experiences implementing HRO.
By assessing an organization's safety reporting culture and reporting systems, one may better
understand its commitment to the principle of preoccupation with failure. Reviewing these
systems and determining the methodology for reporting, trending, and identifying issues for
process improvement provides a glimpse into how concerned leaders are with preoccupation
with failure. Leaders can trend the frequency of reporting across units to get an idea of the
willingness of staff to report issues. They can further assess the staff's perception of the value of
reporting safety events. Evaluating the feedback loop for safety events reports by staff provides
insights into how reported events concluded. Further assessing an organization's attitudes toward

13
safety reporting and determining if employees feel a blame-free culture for reporting are
essential attributes in an organization's value on the preoccupation with failure. Employees'
comfort levels in reporting mistakes and near misses also provide insights into the commitment
to this principle. The research model proposed for this study utilizes the conceptual framework
of HRO, aligns potential areas of focus for using the Burke-Litwin model, and then evaluates the
organization's readiness for change through this phenomenology case study.
Purpose of the Study: Reluctance to Simplify
Through reviewing this organization's governance structure, this study provides a lens for
examining the importance placed on process improvement projects, audits of effectiveness, and
feedback loops from stakeholders. The SCORE™ survey allows a review of staff's perception
around shared decision-making and stakeholder engagement in solving problems, mainly when
there is a bottom-up problem identification, and how well those solutions involve others across
the organization to resolve the issue. This study provides a review of the perception of staff on
the effectiveness of organizational efforts to re-engineer problems to prevent reoccurrence;
particularly of interest might be how the organization utilizes and integrates technology to solve
problems. Through semi-structured interviews, this research's qualitative findings allow
comparison to and alignment with the Burke-Litwin model to offer solutions for implementing
the principle of reluctance to simplify across the organization.
Purpose of the Study: Sensitivity to Operations
Through reviewing the principle of sensitivity to operations, the research reviews many
factors that connect across the Burke-Litwin model, such as patient satisfaction scores, financial
performance, allocation of resources, and staff satisfaction scores. The survey also provides input
into how much joy and work-life balance employees feel in their roles. The principle of

14
sensitivity to operations is critical to pursuing highly reliable care. This principle indicates that
operations are often changing and that decision-making is best when allocated to the staff closest
to the problem. Having operations in the review process for changes to policies or workflows is
an example of how sensitivity to operations might be displayed. This study compares qualitative
research findings and determines alignment with the Burke-Litwin model of organizational
change.
Purpose of the Study: Deference to Expertise
The HRO principle of deference to expertise indicates that the true experts in solving
problems are those closest to them. The principle of deference to expertise demonstrates that an
organization should invite those closest to the problem to solve the problem. The principal
highlights that those who are doing the work are the ones who are best armed to provide safe and
reliable solutions. Understanding staff involvement in process improvement may be one
indicator of shared decision-making. To indeed have a shared decision-making model,
psychological safety must be present. This study may provide an opportunity to review
communication channels that allow frontline staff to share ideas with senior leadership. Another
potential area to determine deference to expertise is the organization's willingness to invest in
training opportunities for frontline staff, such as continuous education, safety culture, and
mentorship. This model of research provides the lens of the Burke-Litwin organizational change
model as the framework for the implementation of the principle of deference to expertise. This
scaffolding model allows the study to assess those areas identified for change based on the
factors of the Burke-Litwin model for organizational change.

15
Purpose of the Study: Commitment to Resilience
Healthcare organizations are complex and require a plan to implement the HRO principle
of commitment to resilience. Organizations can do this through contingency planning, command
incident reporting, preparedness training, leadership training, and employee knowledge of these
tools. This study provides insight into employees' perceptions of autonomy and ability to adapt to
emergencies. The study further analyzes how the employee feels the organization can handle
disruptions. This study provides a scaffolding model of organizational change in the BurkeLitwin model and compares that model to results from qualitative semi-structured interviews.
Those inputs are then compared to best practices supported in literature across all five of the
Burke-Litwin model. This review provides insights into how the participants perceive their lived
experiences and challenges and recommendations for HRO implementation.
Research Questions
● RQ1: What are the lived experiences of healthcare leaders regarding HRO principles?
● RQ2: What are the challenges faced by healthcare leaders regarding HRO principles?
● RQ3: How can healthcare leaders implement HRO principles?
Significance of the Study
Studying how leaders experience implementing HRO principles and changing a culture is
essential to better understanding the challenges of implementing wide-sweeping change across a
complex organization. Healthcare leaders face daunting challenges, many competing priorities,
and project fatigue internal to their organizations (Cochrane et al., 2017). The analysis of these
data provides a model of HRO implementation based on healthcare leaders' lived experiences
through the Burke-Litwin framework. These provide the framework and methodology to
improve HRO implementation.

16
There is a need to study the problem of practice of healthcare leaders' challenges in
dealing with these national safety outcomes as they face them daily in the crosshairs of their
internal organizations. Healthcare leaders must use innovation to balance safety, improve access,
and patient outcomes, while also sustaining their organization financially (Caldwell, 2022).
Healthcare executives face the challenge of moving away from the current model of care that
results in poor quality and safety outcomes by adopting innovative technology, delivering more
in-home care, focusing on improving health, and tackling racial disparities, all while maintaining
fiscal solvency (Harrison, 2021). Studying how others overcome these challenges is essential to
improve HRO adoption across healthcare.
The information gathered will contribute to the research by presenting a model based on
the lessons from leaders’ lived experiences with implementing HRO, comparing that information
to the SCORE survey, and aligning it within a model of implementation that follows the BurkeLitwin theory of organizational change. This model will inform healthcare leaders on how
healthcare organizations can be more reliable in ensuring a safe culture. This study provides
tangible concepts across the entire organization that may help implement HRO by changing
behaviors and actions that help transform their organizations into highly reliable care delivery
systems.
Definition of Terms
Agile Mindset
The term agile mindset became popular during the technical revolution. It began to mean
the opposite of a bureaucracy. A person with an agile mindset can constantly change to deliver
better value to the organization while interactively collaborating and forming teams to deliver
organizational change (Denning, 2019).

17
Culture of Safety
AHRQ states that a culture of safety is one in which healthcare professionals are not held
accountable for human mistakes and system errors but for unprofessional behaviors. This culture
would also identify errors before they occur, look for systems that prevent them from
reoccurring, and allow staff to learn from mistakes and near misses (ACHE & IHI, 2017).
Commitment to Resilience
Commitment to resilience acknowledges the need to continuously learn, adapt, and grow
from challenges (Weick & Sutcliffe, 2015).
Deference to Expertise
Deference to expertise makes organizations more successful at problem-solving when
they seek people with the highest experience and knowledge for solutions versus maintaining a
rigid hierarchy (Weick & Sutcliffe, 2015).
High(ly) Reliable Organization
HRO refers to a complex organization that operates without errors for extensive lengths
of time (Mahankali & Nair, 2019). In adapting these principles to healthcare, Weick and
Sutcliffe (2015) provide a model for healthcare leaders comprising five principles: preoccupation
with failure, reluctance to simplify, sensitivity to operations, commitment to resilience, and
deference to expertise.
Munchausen’s by Proxy
Munchausen by Proxy is the name of a mental health disorder where a person fictitiously
insists that another person has a medical illness and often will go to great lengths to have medical
providers believe that these symptoms are actual (Sousa Filho et al., 2017). This behavior is
usually to get attention.

18
Psychological Safety
Four attributes comprise a psychologically safe environment: anyone can ask questions,
anyone can ask for feedback, criticism with respect is encouraged, and innovative ideas are
considered helpful and not disruptive (Frankel et al., 2017). Further, Edmondson (2019) states
that immediate leadership influences psychological safety, and people in safe environments fear
holding back more than speaking out.
Preoccupation with Failure
Preoccupation with failure is a need to pay attention to the most minor anomalies that
could point to more significant underpinning problems (Weick & Sutcliffe, 2015)
Reluctance to Simplify
Reluctance to simplify is vital in healthcare as it acknowledges that healthcare
organizations are complex environments where underestimating the impact of challenges,
adjacencies, and dependencies leads to harm. (Hines et al., 2008).
Sensitivity to Operations
Sensitivity to operations is the awareness of interoperability between the guiding policies
and principles to which operations must respond. Operations change rapidly, requiring agility to
adapt (Hines et al., 2008).
Sentinel Event
A sentinel event is a medical harm that reaches the patient and results in permanent
damage or death (Hollowell, 2023).
Thematic Analysis
A thematic analysis looks for themes in narrative data collected during interviews
(Mortensen, 2023).

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Triangulation
Triangulation is a study where two or three analysis points converge to improve emerging
findings (Merriam & Tisdale, 2018, p. 244).
Saturation
In qualitative interviews, one reaches the point of redundancy of information, and the
researcher begins to hear the same responses to the inquiry questions or observes similar
behaviors (Merriam & Tisdale, 2018, p. 100).
Assumptions, Limitations, Delimitations, and Positionality
Assumptions
Several assumptions in this study focus on healthcare leaders’ lived experiences of
implementing high-reliability organizational (HRO) principles. The first assumption is that these
leaders have actively engaged in HRO principles and will have an active working knowledge of
the five principles of HRO. The second assumption is that healthcare leaders will have diverse
thoughts and experiences reflecting on the challenges they have faced implementing HRO in
their organizations. The third assumption is that healthcare leaders understand and can share
thoughts about the complexity of healthcare delivery. The following assumption is that the size,
geography, and type of organizations (non-profit, for-profit, public health) will influence how
healthcare leaders have experienced the implementation of healthcare. The last assumption is
that exploring these many facets of the lived experience of the healthcare leader provides
valuable insights to those embarking on this journey.
Limitations
The review of limitations identifies potential areas of weakness for this study (Kornuta et
al., 2019). There are a few limitations of this research study that underpin the investigation. First,

20
this methodology is not a double-blinded, repeatable study with high validity and reliability. The
intention of this study is exploratory and qualitative. Secondly, this study setting is in a singular
extensive health system. It is purposefully unidirectional in the healthcare system that is studied.
This design decreases the sample size and diversity of the leaders' experience with HRO and the
implementation of those principles at other organizations. The selection process was intentional
so that the information reviewed might provide the most significant value to this organization as
it works to implement its HRO program. Third, this study is being conducted in a limited
timeframe and does not provide a longitudinal study on how leader perceptions and lived
experiences may change over time. Moreover, the study duration and type results in limited
triangulation, limiting the robustness of the study conclusions (Creswell & Creswell, 2018, p.
200). These limitations are essential for others to consider when reviewing the study results.
Delimitations
Delimitations are how the study will be limited and narrowed in scope (Kornuta et al.,
2019). Many aspects of this study ensure appropriate delimitation of the research. The first is
time. This study spans a four-month timeframe. Secondly, the study will be in one health system
in one state. Third, the qualitative research will concentrate on the demographic of three
organizational layers: senior leaders in the position of Vice President or higher, managers, and
frontline workers. Last, the study is qualitative, with semi-structured interviews.
Positionality
A researcher brings their positionality to a study. I have been a nurse for thirty-one years
and have worked as a healthcare leader for most of that time. The study's participants are senior
leaders in the position of Vice President or higher. Although the participants were selected for
convenience, they could be included in the study if others were recommended. A relationship

21
may need to be formed to get enough participants and mitigate potential bias from already
established relationships.
One challenge for me is that they bring the bias that transformational leadership is
necessary to change a sizable, complex health system. When one has worked as a senior
executive, they have great privilege. Although they may realize there are struggles of inequity, it
is hard to honestly know what it is like for those without the same positionality. Another aspect
of positionality to consider is the relationship with the participants. Johnson and Christensen
(2014) suggest that it is essential to establish trust in the encounter when interviewing. However,
the interviewer must simultaneously maintain neutrality to the participants' answers. Evolving
science also requires a profound concern for privacy, respect, and dignity (Lincoln, 1995) while
conducting interviews. These concepts will be necessary for a researcher’s frame of mind in any
interview session.
With this research centered in Hawaii, Tuhiwai Smith (1999), cited in Glesne (2011),
brings up an important ethical consideration: cultural consideration when designing a research
study. Smith states that research in New Zealand demonstrated that core principles of
collaborative research should center on respect, being present, being generous and cautious,
respecting the mana (land), and not being a “know it.” Centering oneself in this manner is
imperative in Hawaii. The Māori people of New Zealand that Smith (1999) mentions in their
study have closely linked lineage to Native Hawaiians, and the culture found across the Pacific
Islands is part of the legacy of our health systems. Further, Hawaii is a great melting pot of
diverse cultures, and many are not on the dominant side of Morgan’s (2018) power axis. As a
newcomer, research efforts must not come off as pushy and all-knowing, just as Smith cautions
against above. However, by looking at this problem through the lens of a transformative mindset,

22
there is real meaning aligned with the purpose of the study and the need to improve healthcare in
the community, especially for Native Hawaiians and other Pacific Islanders. People here
understand there is a critical need to find solutions to the problems of health inequities.
This study serves other healthcare leaders interested in addressing the pressing problem
of implementing HRO in the problem of practice. Although the leaders stand to benefit from the
growing body of research on healthcare leadership, if it proves helpful, entire organizations and
communities could benefit from the actions of those who adopt lessons learned effectively. If
one fails to protect the interviewee’s interest, this potentially harms the subject. The implications
of that are that the work is from a singular view and, before being adopted, would need to be
compared to other scholarly findings and will benefit from the view of others. Participation in the
interview process will be voluntary. There would need to be agreement and consent to the
interview process. Confidentiality will be maintained by blinding the names of the participants
and protecting the notes from the interviews from public discovery. The study results will be
published online after allowing the participants to review their contributions and providing time
for feedback and changes.
Organization of the Study
This dissertation is a traditional five-chapter model. Chapter One includes an introduction
to the problem of practice, context, and background of high-reliability organizations and models
of implementation as it relates to healthcare. This chapter also introduces the purpose and
importance of the study, the research questions, and definitions for key terms. The first chapter
outlines the theoretical framework and fundamental concepts influencing transformational
leadership. Chapter Two reviews the literature on HRO, transformational leadership, and
psychological safety. Chapter Three outlines the qualitative research methodology and

23
triangulation with existing data from surveys and interviews. Chapter Four is an analysis of the
findings from the qualitative research. Chapter Five reviews outcomes, recommendations, and
future research opportunities.
Conclusion
This research study uses a qualitative design to learn from healthcare leaders’ lived
experiences implementing high-reliability organizational (HRO) principles. The qualitative
portion utilizes interviews in a healthcare setting and compares that data to the Burke-Litwin
organizational change model. Examining the lived experiences of healthcare leaders through the
lens of the five principles of HRO; preoccupation with failure, reluctance to simplify, sensitivity
to operations, commitment to resilience, and deference to expertise, helps us learn how they view
these principles and the challenges they see in aligning cultural and organizational change to
implement them.
Further, this study attempts to contextualize the HRO framework and the leaders’ lived
experiences by integrating Burke-Liman’s framework for organizational change. The framework
allows a cascading of layers that organizations can use to engage the principles of HRO across
the strategic, cultural, and human dimensions of the change process. As healthcare leaders
continue to strive towards implementing HRO in their organizations, this study aims to assist in
finding ways that the lived experience of healthcare leaders can utilize the overlaying of BurkeLitman’s framework for change management to infuse the organization with HRO principles.
Through studying the lived experience of healthcare leaders, the five HRO principles, and how
they relate to Burke-Liman, this study hopes to find additional insights for leaders to use to
improve success.

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Chapter Two: Review of the Literature
This literature review examines HRO principles and the Burke-Litwin Model, exploring
intersections and implications around an organization's effectiveness in implementing a highreliability safety model. Reviewing existing research aims to understand how HRO principles
integrate with the Burke-Litwin framework, enabling resilience, change management, and
improved performance. The search for information contained a combination of terms such as
high reliability, HRO, highly reliable organizations, or other combinations of highly reliable
principles. HRO combinations included a further search by adding terms such as healthcare,
healthcare organizations, healthcare systems, the Burke Litwin model, SCORE™ survey, and
safe and reliable healthcare.
The literature review examines the HRO principles as they pertain to the conceptual
framework for this study. The five HRO principles of the conceptual framework in this literature
review are preoccupation with failure, reluctance to simplify, sensitivity to operations,
commitment to resilience, and deference to expertise (Weick and Sutcliffe, 1996). The
conceptual framework draws upon its relation to the organization's readiness for change,
analyzed through the SCORE™ survey. The purpose of the study is covered later in the literature
review. The literature review examines the importance of the Burke-Litwin model in evaluating
the participant comments against the theoretical framework, which informs the study.
Search Description
In the search for literature on the theoretical framework and HRO implementation, the
Burke-Litwin model of organizational change focused on 1999-2023. Older articles were
relevant to study the history and early stages of adopting HRO in healthcare. Recent articles
between 2018-2023 helped determine the effectiveness of adoption interventions; however, with

25
the impact of COVID between 2020-2023, literature and adoption of HRO slowed down as
healthcare turned to pandemic management. The primary source of articles came from the USC
online library, and Google Scholar provided a broader range of open-access articles. The
following search terms aid in locating articles for the study of these topics and concepts: high
reliability, highly reliable organizations, highly reliable healthcare organizations, healthcare
HRO, safe and reliable healthcare, Burke-Litwin, and Safe and Reliable Healthcare.
Conceptual Framework
The conceptual framework for this study arises from a survey of the problem of practice:
improving the safety culture in healthcare. This study utilizes three main frameworks to
conceptualize change: the principles of HRO, the SCORE™ Survey, which measures
organizational readiness for culture change, and the Burke-Litwin model for organizational
performance and change. The following three paragraphs will individually review the
development of a safety culture, the need to measure cultural change, and the Burke-Litwin
model of organizational change.
The literature indicates that the conceptualization methodology that healthcare
organizations use to improve safety is that of becoming a highly reliable organization (AHRQ,
2008). AHRQ reveals this terminology after studying other industries, such as the nuclear power
and aircraft industries, which adopted a safety mindset to improve reliability and safety and
decrease harm. Weick and Sutcliffe studied these industries and formulated their five principles
of HRO: preoccupation with failure, reluctance to simplify, sensitivity to operations,
commitment to resilience, and deference to expertise (Chassin & Loeb, 2013).

26
Figure 2
Five Principles of a Highly Reliable Organization
There are five fundamental concepts of HRO: preoccupation with failure, reluctance to
simplify, sensitivity to operations, commitment to resilience, and deference to expertise, with the
first three focusing on reducing incidents and the last two focusing on resilience (McKinnet,
2005) the definitions of these are provided (see Figure 2). They further describe this model of
five principles as a state of mindfulness that an organization centers around to improve its safety
culture (AHRQ, 2008) purposefully. The literature also reveals that although there is no
singularly approved adoption model, these five HRO principles are foundational to an
organization's work to improve its safety culture (Veazie et al., 2019). With a model of adoption,
it is easier for healthcare leaders to know how to change their organizational culture to improve
safety, even if they agree that change is imperative and that the five guiding principles of HRO

27
are the foundation of that change. Even with the alignment of the call to action to change and the
guiding principles, the fundamental question remains: How?
The safety culture must align with this vision to lead an organization toward becoming
highly reliable. Healthcare systems are known to be some of the most complex organizations
across all industries (Magee, 2019). Complex organizations are self-creating systems where silos
are formed and not required to interconnect for effectiveness (Rouse & Serban, 2014, p. 15).
This complexity of healthcare that essentially operates as silos of systems within an organization
makes it difficult to improve safety, let alone to consistently practice as an HRO. Cultural change
is difficult; transforming healthcare organizations' alignment of behaviors to outcomes is
imperative. Frankle and Leonard (2018) describe the ability of an organization to align with
cultural values as a maturity model discussed later in Figure 4. This model helps healthcare
organizations review where they are in the ability to adopt cultural change. Chassin and Loeb
(2013) provide a model for assessing an organization’s maturity and readiness for change.
Another methodology suggested for assessing cultural readiness for change is the SCORE™.
This survey is the maturity model used in this study. This survey allows the organization to
review if its organizational culture and behaviors align with HRO principles. Further, the survey
provides recommendations for actions leaders can take to improve behaviors, aligning cultural
adoption to HRO safety principles. This survey is presented later in this chapter as a best
practice.
The third conceptual theory framing this study is the Burke-Litwin theory of change. The
Burke-Litwin model of organizational performance and change demonstrates a framework that
leaders use to drive strategy adoption and, finally, is measured in organizational performance.
Burke-Litwin’s underlying premise is that external factors such as regulatory, economic, or

28
public opinion will force organizations to adopt change (Burke & Litwin, 1992). Those external
pressures have a cause-and-effect relationship to force change in the internal environment
(Spangenberg & Theron, 2013). Organizations must invest considerable collective effort,
competence, and commitment to embark on the HRO journey (Weick & Sutcliffe, 2015, p. vii).
Cultural change does not happen quickly; it is only through alignment of the vision of the change
and a steady commitment to resilience along the HRO journey that an organization improves.
The Burke-Litwin model describes the three main aspects of organizational change as an
alignment between leadership, mission and strategy, and organizational culture (2013). With the
external pressures forcing alignment of the three drivers of change, the organization begins the
transformation. In this situation, the cultural driver of change is improving the safety culture.
Burke-Litwin’s theory of change is constructive within the complexity of a healthcare
organization, as it demonstrates that change is most challenging in these types of environments.
Burke and Litwin state that increased variables, the magnitude of the journey, and the complexity
of human systems all contribute to the difficulty of change that makes the journey almost
impossible to control (Burke & Litwin, 1992). This understanding of the complexity of change is
instrumental in implementing HRO in a healthcare setting.
For the conceptual model, these three principles—HRO, the SCORE™ Survey, which
measures organizational readiness for culture change—and the Burke-Litwin theory of
organizational performance and change combine to form this study's conceptual framework (see
Figure 3). HRO is the external environmental pressure that the Burke-Litwin model recognizes
as the catalyst for change. The literature review will demonstrate how healthcare leaders
experience HRO from external pressures, which they must adopt and add to their organization’s
internal pressure for change. This conceptual model shows the need for alignment across the

29
healthcare system for effective internal adoption to this external pressure. This model
demonstrates the layers of change needed for a healthcare leader to effect change. Finally, at the
bottom of this visual depiction of the conceptual theory is the SCORE™ Survey, which
measures the organization’s effectiveness in adopting the HRO principles. Studying the survey
results can help the organization determine where they are not effectively implementing change
along the Burke-Litwin model. The intertwining of these three change dimensions is explained
more in the theoretical framework section. This alignment of the three principles structures the
Figure 3
Burke Litwin HRO Theoretical Implementation Model

30
study and provides the conceptual framework to study the problem of practice: improving the
safety culture in healthcare.
Theoretical Framework
Introduction to the Burke-Litwin Model
The Burke-Litwin model of organizational performance and change incorporates many
other change models into one organizing theory (Burke & Litwin, 1992). The model is
multidimensional and complex, as seen in Figure 4 (HiSlide, 2024), which may not appeal to
those who want to simplify an organization but is representative of the reality most large
organizations face in changing culture and behavior (1992). To begin with, however, Burke and
Litwin (1992) feel the impetus for change results from an external driver, and the outer sphere of
the model demonstrates that phenomenon. These external phenomena can be market competitors,
laws and regulations, economic, or consumer-driven (Exeter, 2023). The model has 12 variables
outlined which bucket actions organizations need to consider when implementing change (1992).
The variables are layered on top of each other to depict the hierarchical nature of the
organization, with the top layer beginning with leadership direction, the middle layer indicating
transactional practices, and the lower level indicating personal and organizational performance in
achieving the change (Mind Tools, 2023). One beneficial outcome of this model of change is that
it provides discernment between transformational and transactional leadership, outlining where
those attributes are essential in an organization to achieve change (Spangenberg & Theron,
2013). This layered, complex model of change is constructive in a healthcare organization.

31
Figure 4
Burke-Litwin Causal Model
External Environment
The impact of the external environment on an organization is often the impetus for
change, and leaders must continuously scan their social environment for indicators that change is
necessary (Exeter, 2023). The next step is understanding how those changes may impact the
organization and what drives the need for change (Mind Tools, 2023). The Burke-Litwin model
is important because it uses the resource dependency theoretical framework constructed by
Pfeffer and Salancik (1978). It incorporates that into its model by recognizing the importance of
the external environment in driving the necessity for organizational change. Weick (1996) states
that Salancik compares the demand from the external environment and the need for
organizational change to a contest. Weick (1996) shows that Salancik compares organizational

32
contests for change as those competing over scarce resources, uncertainty, interdependencies,
long-existing institutional frameworks, and internal domination of power dynamics across the
organization.
Transformational Factors.
Burke-Litwin aligns transformational leadership theory into three significant variables of
their model: mission and strategy, leadership, and organizational culture (Spangenberg &
Theron, 2013). Burns (as found in Northouse, p. 190, 2022) states that transformational
leadership motivates employees to do more than they usually would by raising their
understanding of the importance of an organizational goal, which inspires employees to put their
interests aside to address an aspirational goal.
Mission and Strategy
Mission and strategy align as transformational factors when the leaders of an organization
can help their employees understand the organization's central purpose (Burke & Litwin, 1992).
They say strategy forms around how the organization intends to achieve that purpose.
Strategy is formulated by leadership behavior that is scanning the environment,
anticipating changes in the actions of their competitors, and determining threats and
opportunities (Spangberger & Theron, 2013). Mission and strategy development in the BurkeLitwin model is crucial to how the organization will drive change to mitigate those external
inputs.
Leadership
Bass & Avolio (as found in Northouse, p. 191, 2022) state that transformational
leadership tends to improve and develop employees to their highest capabilities. By aligning
high-functioning employees with the mission and strategy, the Burke-Litwin model begins to

33
take shape. Leaders must chart the future of their organizations (Spangberger & Theron, 2013).
Commitment from the organization’s top leadership demonstrates the organization’s intention for
change, and without that precise alignment, employees will perceive this as another initiative that
will disappear in six months (Exeter, 2023). Executives are the role models for change, and
followers’ perceptions will influence the effectiveness of the leaders in implementing change
(Burke & Litwin, 1992).
Organization Culture
Organizational culture is the collection of overt and covert ways of doing things in an
organization with enduring guiding principles (Burke & Litwin, 1992). An organization’s culture
is its ability to bring together a sufficient number of people to sustain an effort over time, and its
approach and outlook enable it to solve problems (Weick and Sutcliffe, p. 130, 2015). Gray,
Densten, and Sarros (2003) found in Spangberg and Theron (2013) that culture defines an
organization's functioning through values, assumptions, and approaches to problem-solving.
Culture motivates performance and problem-solving and aligns the employees to an
organization’s strategy.
Transactional Factors
Transactional leadership theories study the necessary exchange between leaders and
followers (Northouse, 2022, p. 186). Transactional leadership is pervasive and displayed across
all organizational levels (2022). Burke-Litwin aligns transactional leadership theory with three
significant variables in their model: structure, management and practices, and system and
policies (Burke & Litwin, 1992). These operational, transactional factors move the organization
incrementally through the change process (1992).
Structure

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An organization's structure aligns with its strategy and mission by aligning areas of
responsibility, decision-making authority, and resource allocation to achieve the organizational
goal (Burke & Litwin, 1992). A plan may often result in realigning organizational structure to
achieve the goals (Exeter, 2023). Senior and middle managers have the most impact on
implementing an organizational change strategy (Spangberger & Theron, 2013).
Management and Practices
Management practices refer to how managers take actions to influence the human capital
and material resources at their disposal to implement the organization’s strategy (Burke &
Litwin, 1992). Managing human capital and resources effectively allows managers to establish a
positive workplace culture (Spangenberg & Theron, 2013). The department’s culture is the
perception of cohesion, collective vision and values, and their orientation and commitment to
achieving organizational objectives (2013).
Systems and Policies
Systems and policies are simply the processes and procedures to improve an
organization’s ability to achieve a desired outcome (Mind Tools, 2023). This part of the model
covers many organizational methods for achieving the desired results (Burke & Litwin, 1992).
Leaders must align systems and policies to influence behaviors that drive organizational
outcomes, pivoting to change. Burke and Litwin (1992) state that this level of the model is tied to
control systems such as performance appraisals to drive accountability and change that the
organization desires.
Individual and Personal Factors
This tier of the Burke-Litwin model benefits from the cascading inputs from the
transformational and transactional layers (Spangenberg & Theron, 2013). The individual and

35
personal factor layers are meaningful interactions where the transformational and transactional
layers meet the individual employee. This level is imperative to influencing change and aligning
behavior with the organization’s strategy and implementation goals. Weick (1996) argues that
individuals will align to values and champion them until the institution and the individual
become intertwined and interconnected.
Work Unit Climate
Employees' immediate work environment shapes their perceptions of the organization
(Exeter, 2023). The literature review demonstrates that climate, environment, and culture are
used interchangeably (Bohlman & Deal, 2021; Burke & Litwin, 1992; Exeter, 2023; Weick &
Sutcliffe, 2015). There is debate about the role of leadership in shaping climate and the link
between culture and results (Bohlman & Deal, 2021, p. 272). Burke and Litwin turned to earlier
research by James and Jones (1992) in developing their framework. Organizational climate is
considered different than psychological climate in that organizational climate is the attributes of
an organization, but psychological climate is how employees perceive those attributes (James &
Jones, 1974). Weick and Sutcliffe (2015, p. 132) discuss a fragmented view of organizational
climate that accepts ambiguity in determining a workplace climate. In other words, workplace
climate is highly personal, and a unit’s direct leadership often influences individual perceptions
of the climate. The impact of leadership on individual perception of the climate becomes
important later when we discuss the effects of psychological safety in developing an
organization's high-reliability culture.
Task and Individual Skills
Tasks and individual skills are assigned to accomplish the outcomes that align with the
organization’s strategy for change. To change behavior, the organization must train employees

36
on the new tasks and develop the knowledge, skills, and abilities of the employees to adopt those
new behaviors (Burke & Litwin, 1992). To effect change across the organization requires skills
the team must have to carry out the work (Exeter, 2023). A manager aligning their workforce
towards change objectives must assess if the knowledge, skills, and abilities are present in their
employees (Exeter, 2023). If not, the manager may need to look outside the organization to help
develop those skills (Exeter, 2023).
Motivation
Motivation is the energy the employees and the organization demonstrate to attain an
objective (Burke & Litwin, 1992). An individual's needs and motivation are considered
interpersonal (Spangenberg & Theron, 2013), but an organization can influence the individual
through the transformational, transactional, and individual layers of the Burke-Litwin model.
Aligning the organizational change model to influence personal behavior influences outcomes.
Individual Needs and Values
Psychological factors influence individuals' desire to engage in their work environment
and align their actions and thoughts with the organization (Burke & Litwin, 1992). There is a
link between leadership style and an employee’s mental health (Grewal, 2023). Burns (1978, as
cited in Northouse, 2022, p. 186) establishes that transformational leadership is inseparable from
employees’ needs. Understanding employees' needs and values becomes increasingly important
as our workforce diversifies (1992). Understanding the link between leadership and the needs
and values of employees is critical to ensuring an effective organizational change.
Individual and Organizational Performance
Individual employee behaviors significantly influence the effectiveness of an
organization (Spangenberg & Theron, 2013). The Safe and Reliable SCORE™ survey is a tool

37
that measures the effectiveness of an organization in implementing HRO principles. Combined
with the Burke-Litwin model, this tool provides insight into how effectively an organization uses
all layers to influence change. The Burke-Litwin model offers that to impact an organization’s
climate and performance, the following factors must align: a sense of direction, effective
structure, standards, a commitment to change, reinforcement, a focus on excellence, alignment
with the needs of the customer, and strength to disregard the internal pressures to maintain the
status quo (Burke & Litwin, 1992). As healthcare leaders work to implement their safety culture,
they must consider how they will measure the impact of their efforts. The SCORE™ survey is
one tool for that measurement.
Conclusion Burke Litwin Model
The Burke-Litwin theoretical framework provides an opportunity to structure this
research and evaluate participants' comments against a model for organizational change. This
offers the chance to review lived experiences, challenges, and recommendations, based on the
model and determine if themes emerge. As the model aligns with best practices, the framework
further allows an analysis of the emerging data and how that crosswalks with recommended best
practices.

38
Review of Research
Healthcare’s Need for High-Reliability
Healthcare professionals take an oath to not harm (Reed et al., 2023), but despite that
oath, in a focus group of 525 Black and Hispanic individuals, 55% said that they lost trust in
their provider after a negative interaction, and 36% say they forgo further medical treatment due
to perceived poor interpersonal interactions. After decades of enjoying prestige as one of the
most respected professions, healthcare providers and systems now face declining respect,
leading to poor healthcare outcomes, disrespectful interactions between healthcare professionals
and patients, and growing burnout (Sweeney, 2018). These phenomena accelerate when patients
hear of some of the horrific malpractice and unintentional harm events in the news. Despite the
attention to improving quality and safety in healthcare over the past three decades after the
release of To Err is Human (1999), medical errors remain a concern. Although medical errors
account for significant harm, rigorous efforts to quantify that harm remain elusive (Toker et al.,
2023). Further challenging, multiple studies have cited medical errors as the third leading cause
of death in the United States. Jaklevic (2023) cautions that we must question studies that are not
scientifically sound. Regardless of the uncertainty of exact numbers, what is certain is that
historically, medical errors were considered rare, but we now know they are much more
common (Carver et al., 2023). The need for change is apparent.
External Environment
Healthcare leaders face unprecedented dynamics in their environments, leading to
increasing pressure to adopt HRO principles. The external environment significantly impacts
healthcare and is the environmental factor causing pressure for change, which the Burke-Litwin

39
model states is the beginning of all change (1992). This section will outline the impact of
legislation and social media that are the impetus for adopting HRO.
Legislation
The 1999 report To Err is Human recommended a balance of external recommendations
spanning legislation, economic, professional, moral, and other incentives to encourage
healthcare professionals to adopt a safety culture inside their organizations (Kohn & Donaldson,
2000). In response to the recommendations, Congress enacted many changes to pressure
healthcare leaders to improve safety, such as the Patient Safety and Quality Improvement Act of
2005 (Klein, 2005) and the Nursing Staffing Standards Act of 2017 (Schakowsky & Brown,
2017), to name a few. Reimbursement also changed, placing significant pressure on healthcare
leaders of Accountable Care Organizations to meet quality and safety goals established under
the Affordable Care Act (Kachalia et al., 2016). These legislative requirements provided a need
for healthcare organizations to respond to these changing legislative influences. Nevertheless,
legislation is only one area where healthcare organizations feel pressure to change. Social media
is also changing the healthcare landscape around HRO.
Social Media
Social media provides instant access and spreads virally when harmful events impact
patients and their families. Patients now have global reach when they feel their needs or
treatment by healthcare workers is not safe, they can reach out to others who have similar
experiences and ask for validation or advice. This global awareness that medical providers are
not omnipotent is shifting the patient-physician relationship from one where physicians make
decisions and patients follow to one of patient empowerment and healthcare partnership in
decision-making (Saraykar et al., 2022). This growing awareness is shifting trust. In 1966, 73

40
percent of patients said they trusted their providers. However, in 2012, this number decreased to
34 percent; in 2017, 87 percent of providers felt trust was continuing to decline. Growing
awareness of medical harm events continues to increase mistrust and the need for healthcare
organizations to improve transparency, reliability, and safety.
Transformational Factors
Recent news and social media’s role in changing the patient/provider dynamic allows
patients to voice their concerns and increase exposure to significant harmful events. These
external environmental factors underscore the need for a leader to implement HRO principles
and align the organizational efforts through the transformational factors of the Burke-Litwin
model: mission, leadership, and organizational culture. This section outlines the need for HRO
that healthcare leaders face in the transformational factor level of the Burke-Litwin model of
sentinel events and will discuss the transformational imperative of determining the
inclusiveness of types of injuries, structure of harm, and the appropriate documentation of those
issues when developing HRO.

41
Sentinel Events
Safety errors that cause
significant harm or death are
called sentinel events (see
definition of terms).
Figure 5
Sentinel Events
Despite focusing on HRO
implementation, events continue to
rise (see Figure 5).
The Joint Commission (TJC, 2023) reviewed the leading causes of sentinel events
(Figure 6) to consistently categorize falls, delays in treatment, retained foreign objects, wrong
surgery, and suicide. Figure 6 demonstrates that these are consistently the leading categories for
sentinel events for the last five years. However, when considering HRO, healthcare leaders need
to look further at all areas of reliability where they may fail to capture sentinel events.
Depending on how we define terminology around harm and HRO is imperative when
considering the scope of the problem. Carver et al. (2023) state that medical error, previously
defined as disability or death unintended due to medical mismanagement, is also harmful.
Carver et al. (2023) argue that there is a flaw in the definition of a harmful event because it
requires that a negative outcome reaches the patient before the event is considered harmful.
They argue that harm occurs when the process fails, even if the failure does not reach the patient

42
and results in harm. An argument might be that process failure is when a healthcare
organization becomes unreliable to the patient, whether there is immediate harm or not.
Healthcare organizations must not fail to uphold their commitment to the Hippocratic Oath
(Luxford, 2016). Successful implementation of HRO principles in an organization helps
maintain that commitment. Some examples of other categories to focus on are failure of
healthcare infrastructure, healthcare-acquired infections, and misdiagnosis. In one such event in
2003, an elevator decapitated a doctor when it malfunctioned. Earlier that year, in a second
hospital, an elevator caused serious harm to twelve patients when the cord failed and dropped
several floors (Hipplayer, 2003). An infrastructure failure such as this is a good example of how
harmful events may result from process issues across the organization, and healthcare leaders
must take a holistic approach to consider the definition of harm when implementing an HRO
culture in their organizations. Healthcare-acquired infections (HAI) are another type of
healthcare harm event Goldhill (2009) says we cannot overlook. His article documents how his
eighty-three-year-old father, who was still working the day he went to the hospital, acquired
additional infections that eventually cost him his life, becoming just a statistic, one of the over
100,000 documented HAIs that occur annually. A 2022 study by Leapfrog (Dall, 2022)
demonstrates that the impact of Covid on hospital resources to prevent infections is suffering
with a rise in catheter-associated UTIs (CAUTI) up by 60%, and 18 of 50 states showing a
significant increase in the rates of methicillin-resistant Staphylococcus Aureus (MRSA). Central
line-associated bloodstream infections (CLABSIs), CAUTIs, and MRSA (Dall, 2022) are all
trackable HAIs. COVID-19 is now another HAI one has to worry about catching when admitted
to the hospital. Airborne droplets transmit COVID-19, and it is, therefore, more difficult to
determine the association and origination of infection; however, one study demonstrated in a

43
cohort of 288 hospitals and 171,564 hospitalizations, 4.4% of patients caught COVID while
inpatient and in another 3.8% were undetermined (Hatfield et al., 2023). Catching COVID
while hospitalized is not insignificant. The Centers for Disease Control attributes COVID-19
infections as the third leading cause of death in America, right behind heart disease and cancer
(CDC, 2023). An example of misdiagnosis currently in the media is the case of Maya Kowalski.
Taking Care of Maya is the name of a Netflix documentary (Keating, 2023) that chronicles the
horrific family battle to get appropriate treatment for their daughter Maya. Maya has chronic
regional pain syndrome (CRPS), but medical providers blamed her mother for the child’s
condition and labeled her as having Munchausen’s by Proxy (See Definition of Terms). Maya
was eventually diagnosed and treated for CRPS, but not before her mother killed herself from
the stress of the allegations of abuse. Keating says (Batey, 2023) that after this documentary,
dozens of families were coming forward to claim they have suffered similarly from
misdiagnosis at the hands of healthcare organizations whose responsibility is to protect and care
for children. Unfortunately, however, they have experienced the opposite. Infrastructure
failures, HAI, and misdiagnosis are a few additional harm categories not indicated in the TJC
(2023) report. Toker et al. (2023) demonstrated through a cross-sectional database of 21.5
million U.S. healthcare discharges that an estimated 795,000 Americans become permanently
disabled or die due to missed diagnosis. Missed diagnosis is an example of a harmful event that
is often not considered in the calculation when a healthcare system is implementing HRO. More
concrete harm events are usually the focus, but a misdiagnosis resulting in permanent disability
is arguably as important as medical negligence resulting in harm or death. This lack of clarity
on the actual volume and terms around harm events exemplifies why Jaklevic (2023) cautions

44
Figure 6
Leading Sentinel Event Types
that scientific rigor is imperative when calculating harm. However, through the growing reach
of social media, the public is responding to these events, and the totality is an impact healthcare
organizations face. In the Burke-Litwin model, this background provides an understanding of
the environment causing pressure for healthcare organizations to adopt HRO principles.
The viral transparency and public awareness of sentinel events inflame the growing
distrust of healthcare organizations and providers. Social media continues to fuel those concerns

45
as patients validate their experiences globally. This level of social transparency and validation
only came into existence within the last decade. The external pressures of legislation, social
media, and sentinel event reporting are all growing environmental pressures requiring
healthcare leaders to enact HRO principles. However, society is placing increasing expectations
that events outside of what healthcare typically addresses as safety events are included and
improved. These pressures are environmental factors that incentivize healthcare leaders to act.
Although To Err is Human (1999) began the era of HRO implementation in healthcare, this new
era of public pressure indicates that healthcare leaders need to scan the environment to regain
trust in the provider/patient relationship. These issues shape the environment, which pressures
healthcare organizations to take action to embark on the transformational change that is outlined
in the Burke-Litwin model.
Transactional Factors
Although transformational alignment to change is critically important, Burke-Litwin
(1992) also recognizes a need for transactional factors to align with change. Transactional
factors are those that influence structure, policies, and processes. This section will outline some
of the needs for HRO healthcare leaders to see in the transactional factors.
In addition to external pressures and HRO models that are not easily transferable to
healthcare, leaders also face additional challenging internal pressures to implement a culture of
safety, which in part goes back to one of the principles that define an organization that should
consider HRO: hyper-complexity (AHRQ, 2008). Interrelatedness means the components of a
system that influence each other, and this complexity increases with the number of components
and unique relationships (Kannampallil et al., 2011). The hypercomplexity of a healthcare
organization can be demonstrated by following one patient through the system and considering

46
the number of people who will influence their care from the many physicians, nurses,
technicians, nutritionists, billing, pharmacy, medical equipment maintenance, medical records,
and housekeeping staff to name a few (Hines et al., 2008). To implement HRO for this patient’s
experience, the healthcare leader must influence all of the departments that the patient
encounters to encourage each participant to see their work through the lens of a highly reliable
organization. Culture refers to the shared assumptions and behaviors individuals use to solve
problems that those in the organization identify with enough to train new members to solve the
issues and behave based on this culture (Schein, 1992, as cited in Kuscu et al., 2015).
Organizational culture must have adequate and aligned leadership focused on zero harm, a
safety culture, and an agile learning environment (Frankel & Leonard, 2018) to move their
existing culture to one of zero patient harm through HRO principles. Frankel & Leonard (2018)
offer a model of cultural maturity to measure these three components to determine the readiness
of the organization to implement the cultural change that is necessary on the journey to high
reliability (Frankel & Leonard, 2018, Fig 7).
Figure 7
Safe and Reliable Culture Maturity Model
“Evidence suggests that change in complex organizations is often more dynamic and potentially

47
more problematic because of interdependent relationships among stakeholders, the political
context of change, and the nature of organizational structures'' (Lewis, 2019, p. 49). Research
shows that leadership that is strongly aligned to HRO, and effective has the potential for
successful culture change (Hines et al., 2008; Frankel & Leonard, 2018). The internal culture
review demonstrates the complexity of organizational change and the challenges that healthcare
leaders face in changing existing culture to implement the principles of HRO. When a
healthcare leader embarks on the HRO journey, they can consider accommodations for this
hypercomplexity in the transactional actions of the Burke-Litwin model.
Individual and Personal Factors
Healthcare leaders face unprecedented dynamics in their internal and external
environments. These pressures significantly impact individuals who work in healthcare. In the
Burke-Litwin model, the impact of these pressures appears at the individual and personal factors
level. The model has four areas of individual and personal factors where healthcare leaders can
influence HRO adoption by their healthcare workforce: work unit climate, tasks and particular
skills, motivation, and individual needs and values. This section is where burnout's impact on
healthcare workers is found.
Work unit climate is one area of the individual and personal factors level of the BurkeLitwin model. Healthcare leaders feel the need to change the current work unit climate through
the increasing impact felt by healthcare professionals' expression of an increase in burnout.
Burnout is felt significantly by helping professionals and demonstrated through a decrease in
self-efficacy, depersonalization, emotional numbness, and exhaustion (Gregory et al., 2018). In
one study, physician burnout measurably increased after the pandemic, with emotional
exhaustion rated by 39% and depersonalization growing by 61% to pre-pandemic numbers

48
already at 40 and 50%, respectively (Shin et al., 2023). Although the correlation of healthcare
worker burnout and patient safety has not been well correlated, studies are beginning to
demonstrate that high levels of employee burnout result in suboptimal care, such as one study
that found higher mortality rates in an ICU even after other factors had been standardized such
as workload (Montgomery et al., 2019). Burnout theory centers around the employee and their
workplace; however, efforts to decrease burnout center around the employees' ability to regulate
their behavior response to their environment (Gregory et al., 2018). Employee acceptance of
change is imperative for success and requires engagement (Leiter & Harvie, 1998). As
healthcare leaders consider the external environmental pressure to become a highly reliable
organization by adopting HRO principles, Burke-Litwin's individual and personal factors offer
one area to consider when reviewing the need for change.
Individual and Organizational Performance
Healthcare leaders feel the impact of these internal and external environments on the
outcomes and effectiveness of their employees and the organization overall. Individual
effectiveness correlates to unit effectiveness. The Burke-Litwin model measures this impact at
the Individual and Organizational Performance Factors level. The model needs to clarify how to
measure efficacy; this chapter provides a section of best practices that outline options for
measuring the effectiveness of organizations in adopting HRO principles. This section will
outline the need for HRO healthcare leaders to consider social inequity as a need for adopting
HRO principles.
Inequity
Specifically, although not uniquely to the organization of this study, there is a need to
review the implementation of HRO through the lens of marginalized communities and how they

49
experience psychological and cultural safety when seeking care. This organization, central to this
study, has a mission to care for an indigenous population and others in the community. As with
other indigenous communities, Native Hawaiians, and other Pacific Islanders (NHOPI) suffer a
disproportionate burden of health diseases and higher barriers to access to services (Morisako et
al., 2017). Social determinants of health, such as education, food security, language barriers,
economic equity, and societal influences impact the health of the patients seeking care even
before they enter the health system (McGee & Crane, p. 9). This organization's mission is to
develop strategies that prevent barriers to care, improve access, and ensure safe and reliable care
delivery. Studying the implementation of an HRO model through this lens may help determine
available solutions. The Burke-Litwin model demonstrates a need for individual and
organizational performance. This organization’s mission demonstrates how adopting HRO
principles across all areas of the Burke-Litwin model helps an organization consider the impact
of those principles on meeting core mission functions for the community.
Conclusion: Need for HRO
The literature review demonstrates the need for healthcare organizations and their
leaders to adopt HRO principles and begin their journey toward high reliability. The Burke
Litwin has three factors healthcare leaders can leverage as they scan their environment for the
need to embark on their safe and reliable journey. The three layers are transformational,
transactional, and individual and organizational (Burke-Litwin, 1992). A needs assessment
reviewed the pressures from the external environment that healthcare organizations and their
leaders face when deciding to embark on the journey to highly reliable healthcare. The change
required to move an organization through a heavy cultural change is complicated. However, the
need for healthcare organizations to change is significant. Leaders can review the Burke-Litwin

50
model from the view of a needs assessment to determine if their organization is feeling similar
pressures externally and internally, as outlined in this literature review. Once the individual
organization reviews their needs assessment through the Burke-Litwin organizational change
model, the healthcare leader has the information needed to consider how they use this
knowledge to implement change. The following section will outline challenges leaders may face
when considering their HRO journey.
Healthcare Leaders’ Challenges
Introduction
Healthcare leaders have many challenges when considering their journey toward highly
reliable care. In adapting HRO principles to healthcare, Weick and Sutcliffe (2015) provide a
model for healthcare leaders comprising five principles: preoccupation with failure, reluctance
to simplify, sensitivity to operations, commitment to resilience, and deference to expertise. They
define preoccupation with failure as a need to pay attention to minor anomalies that could point
to more significant underpinning problems. Reluctance to simplify is essential in healthcare as it
acknowledges that healthcare organizations are complex environments, and the impact of
challenges resulting from these complexities indicates that organizations must focus on a
questioning environment to prevent failures. Adjacencies and dependencies are proximate in a
complex organization and are factors to consider when solving complex problems to avoid harm
(Hines et al., 2008). Sensitivity to operations is the awareness that there is interoperability
between the guiding policies and principles to which operations need to respond, and those can
change rapidly, requiring agility to adapt (Hines et al., 2008). Commitment to resilience
acknowledges the need to continuously learn, adapt, and grow from challenges (Weick &
Sutcliffe, 2015). Deference to expertise makes organizations more successful at problem-

51
solving when they seek people with the highest experience and knowledge for solutions versus
maintaining a rigid hierarchy (Weick & Sutcliffe, 2015). They further demonstrate that this last
principle results in frontline workers being invited to participate in solutions instead of retaining
senior leadership-level decision-making. When success is required one hundred percent of the
time, organizations must continually reinvent themselves (Roberts, 2021). HRO principles
provide healthcare leaders with a model to consider how they may continuously learn and
evolve their safety culture. These HRO principles are essential for healthcare leaders to adopt
when working towards highly reliable, zero-harm care delivery.
External Environment
The Burke-Litwin model shows the importance of tying the environmental pressure to
the transformational change (Burke-Litwin, 1992) to mission and strategy. In healthcare, this
becomes difficult because the message of high reliability has to survive the reality of internal
environmental pressures. Healthcare organizations are largely for-profit and influenced by a
network of corporations termed the medical industry complex (Geyman, 2022). This for-profit
economic reality is also challenging for nonprofit organizations that must maintain solvency.
Healthcare leaders have a challenge in helping their organizations balance HRO implementation
with the actual financial pressures they experience by aligning the importance of providing safe
and reliable healthcare to remain competitive in their market. That alignment may help people
make decisions. For example, do you spend $100,000 a year on transportation for patients with
conscious sedation to decrease fall risks, or do you save money to demonstrate a profit margin?
This example represents just one of the thousands of decisions healthcare organizations must
make when balancing HRO implementation against fiscal realities. A leader who saves money
at the risk of patient safety without adding other safeguards must demonstrate the

52
transformational linkage that the Burke-Litwin model requires in their organizational change
model.
Furthermore, healthcare leaders have responded to rapid external pressure changes
across social policy reform and economic changes in the past few decades. They also face the
added challenge that, unlike other advanced industrialized countries, healthcare in the US is not
a uniform health system but composed of thousands of distinct organizations (Kadrie, 2017).
These external complexities add to healthcare organizations' difficulty when implementing
HRO models from other industries to improve safety. The following section outlines the
challenges leaders face in transformational factors when implementing HRO.
Transformational Factors
The expectation of shared decision-making when implementing HRO is another
challenge for healthcare leaders as they implement change. Before 1970, physicians made
decisions, and patients followed their advice. However, patients now have more information
and want to be involved in their care planning (Saraykar et al., 2022). There is a continuum of
shared decision-making that, at one end, has this older model of paternalistic one-sided views,
and the other gives the authority for decision-making to the patient (Christianson et al., 2011). A
healthy balance is somewhere in the middle. However, shared decision-making is an evolving
concept that requires specific knowledge, skills, and abilities for effective incorporation of the
views of others (2011). Another changing aspect of physician-shared decision-making is the
relationship between physicians and healthcare administrators. Due to the evolution of the
medical industrial complex, growing healthcare legislation, and focus on for-profit healthcare,
administrators in healthcare have grown 3500% in the past five decades (Cantlupe, 2017).
Physicians previously led most organizations and drove decisions, so this administrative bloat

53
changes healthcare decision-making dynamics (2011). For example, before a surgeon enters the
operating room, there are administrative decisions regarding instruments, medication, staffing
ratios, and equipment (Shortell, 1983). As a leader works to set the transformational factors
around HRO required in the Burke-Litwin model, shared decision-making is a factor in leading
effective change.
Another transformational factor challenge for healthcare leaders implementing HRO is
the need for an agile mindset (see Definition of Terms section). An agile mindset allows an
organization to adapt to change. Unfortunately, in a recent study, only 18% of people feel they
are change agile, and only 35% of change initiatives stick over time (Denning, 2019). This selfacknowledged lack of agility is problematic in transformational factors. At an enterprise level,
organizational cultural change requires that strategy, structure, human resources, and technology
align toward the new operating model (Jurisic, 2020). The organization hardwires change by
developing a backbone of stable teams that steer the work (2020). Rewiring an entire
organization towards a new care delivery model takes collaboration; a leader needs to assess the
challenges they face when moving through this level of change while most of the organization
is, by their report, of a different mindset. Leaders who wish to transform their organization to
one that is highly reliable use this knowledge of a lack of agile mindset and organizational
flexibility to align their initiative throughout the Burke-Litwin change model transformation
factors by setting vision, strategy, leadership, and organizational culture that supports this
journey (Burke-Litwin, 1992).
Transactional Factors
The Burke-Litwin model reminds us that strategy alone cannot move an organization
forward through change. After a leader has worked through transformational challenges, they

54
must also consider the challenges they face in transactional factors. Structure, policy, and
process are all transactional factors outlined in the Burke-Litwin model (1992). This section
outlines some challenges healthcare leaders face in transactional factors as they adopt a change
strategy for HRO implementation.
Structure
HRO principles were first used in healthcare in 1989 (Roberts, 2021), and the pivotal
report To Err is Human was released in 1999 (Kohn & Donaldson, 2000). Hence, the adoption
of HRO principles across healthcare organizations began. Bates and Singh (2018) consider this
a “watershed moment for the US healthcare system.” However, industry models for aircraft and
nuclear energy are not readily transferable, and healthcare has not adopted a single agreed-upon
HRO model; even so, many healthcare organizations have made great strides in improving a
culture of safety (Cochrane et al., 2017). Chassin and Loeb (2013) offer three techniques to
improve the safety culture incrementally to enhance the adoption of external healthcare models.
Their three principles are 1.) leadership commitment to zero harm, 2.) a robust and mature
safety culture across the organization, and 3.) a widespread and fully adopted model for process
improvement (Chassin & Loeb, 2013). These principles can be seen as tools for implementation
and should not be considered additions to the five HRO principles outlined above. However,
leaders may struggle with the exact processes that the Burke-Litwin model highlights in the
transactional factors. How does a leader adopt this recommendation through the transactional
factors: structure, management practice, and policies? The following section on best practices
provides recommendations from four recognized experts in this discussion.
Lack of Single Model for Success

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Another challenge for healthcare leaders considering implementing the five highreliability principles: preoccupation with failure, reluctance to simplify, sensitivity to
operations, commitment to resilience, and deference to expertise (Weick & Sutcliffe, 2015), is
the need for a single model for organizational implementation of these five principles. Many
organizations have attempted to capture their change model, and others have developed models
to frame the problem and provide options for healthcare leaders to adopt. However, despite
these efforts, there has yet to be a consensus on a model that works to embark on culture change
that leads to zero harm in healthcare as effectively as other industries such as airline and nuclear
have adopted. Adopting these principles enables hospitals to reach zero harm safety compared
to other sectors (Chassin & Loeb, 2013). The problem remains: How does one align the
organization toward that change? This section reviews four models: the Agency for Healthcare
Research and Quality (AHRQ), the American College of Healthcare Executives (ACHE), the
Air Force (AF) Trusted Care, and the Institute for Healthcare Improvement (IHI). IHI partners
with Vizient and Safe and Reliable Healthcare for their model and evaluation of the model
(Frankel et al., 2017). Reviewing these models provides healthcare leaders options for
addressing the challenges they face when considering the framework they need for
implementing HRO in their organizations.
AHRQ HRO Model
The first model for review is the AHRQ white paper titled “Operational Advice for
Hospital Leaders” (AHRQ, 2008). This model aligns nicely with the Burke-Litwin model and
recommends that healthcare leaders scan their environment for the need for change. They also
recommend scanning internal environmental barriers to change and planning for standardization
across the health system. They also align with Burke-Litwin by addressing transformational

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factors, such as leadership support and strategy. They then jump into a need to link staff
behavior to outcomes, that interventions must align to policy, and that owners for actions of
implementation are critical. They also outline a need for leaders to improve quality and safety
through process improvement through aligning processes, people, and resources. The last
portions of their model are titled doing the work and measuring outcomes. This paper does
provide some good advice for healthcare leaders, but it appears lacking in a structured
implementation process. The other challenge with this white paper that leaders must consider is
a lack of tie into existing organizational change frameworks used and tested through various
research studies.
American College of Healthcare Executives (ACHE) HRO Model
The next model to consider is from ACHE. Their model is titled “Leading a Culture of
Safety: A Blueprint for Success” (ACHE, 2016). Figure 8 is a depiction of the ACHE model
titled Leading for Safety.
Figure 8
Leading a Culture of Safety:
A Blueprint for Success
Like the AHRQ model, the model starts with a
vision and aligns with the Burke Litwin Transformational Factors. However, this model
develops other previously unseen concepts, such as a Just Culture, Trust, Respect, Inclusion,
and Behavior Expectations. These areas of the ACHE model align with the individual and

57
personal factors of the Burke-Litwin model. Another linkage that the ACHE model includes is
board engagement. Engaging the hospital’s Board of Directors is an essential factor not
discussed in previous models or the literature in this paper. However, it is a critical step to
healthcare leadership success in change management. The last pillar of the ACHE model is the
development of leadership. Board engagement becomes important across all other areas of
adoption, and the ACHE model provides a good deal of foundational, tactical, and sustaining
options for the healthcare leader to consider. This model is not tied to a theoretical framework
but does provide an opportunity for healthcare leaders to self-assess their organization's
effectiveness in implementing a safety culture. The tie to effectiveness brings us back to the
Burke-Litwin model of organizational change. It is also worth noting that ACHE partnered with
IHI to develop its model.
Air Force Medical Service (AFMS) HRO Model
The next model reviewed is the AF Trusted Care Concept of Operations (AFMS, 2015). An
immediate strength noted in this concept is that the pathway to move to Zero Harm is not
another process improvement but a complete behavioral change of the system. Figure 9 displays
the AF Trusted Care model.
Figure 9
AF Trusted Care Model
This model rests on the foundation of the
AF Core Values. The following cultural
change principles are respect for people,
the duty to speak up, and commitment to

58
resilience. The next level is the continuous process improvement level that outlines a need to
focus on the frontline and every Airman daily, solving problems. The next level is enterprise
alignment, which outlines the need for a constancy of purpose and systems thinking. The last is
the results, which drive towards zero harm and maximizing the value of the patient. The AF
takes these values and drives behavior change by adopting a month's theme. They take the
abovementioned principles of HRO and send monthly messages to remind the leadership and
employees of these principles and their commitment to change. They also adopt the leadership
process by walking around to reinforce the change they want to see in the organization. The AF
model is also the first model that aligns a theoretical framework using the Kirkpatrick Four
Levels of Change model displayed in Figure 10 below.
The Kirkpatrick Theory organizes four aspects of learning: knowledge, motivation, and
organization (KMO) (Kirkpatrick & Kirkpatrick, 2016). Various research studies have
extensively validated this theory's effectiveness in evaluating training programs. The AF
Trusted Care concept utilized this knowledge transfer model to determine the effectiveness of
their HRO training programs. The KMO model demonstrates that individuals go through four
levels of knowledge transfer: reaction, learning, behavior, and results.

59
Figure 10
Kirkpatrick Four Levels of Change Model
Although initially developed for evaluating traditional classes, the KMO theory
effectively evaluates all interventions and change management (Kirkpatrick & Kirkpatrick,
2016, p. 85). For an organization to achieve its desired effectiveness, participants must move
through all four stages to transition knowledge into behavior (AFMS, 2015, p. 33). The AF
indicates that even the most effective training does not lead to organizational change without
deliberate and persistent follow-up. Previous research shows that even when an organization
aligns 85% of its resources to a new initiative requiring training, only 24% of participants
transfer this training into effective results (Peterson, 2004; Almeida, 2009; as found in AFMS,
2015). This framing of the complexity of knowledge transfer provides a helpful consideration
Level 4: Results To what degree do targeted outcomes occur
due to the learning event(s) and subsequent
reinforcement?
Level 3: Behavior To what degree do participants apply what
they learned during training when they return
to the job?
Level 2: Learning To what degree do participants acquire the
intended knowledge, skills, and attitudes based
on their participation in the learning event?
Level 1: Reaction To what degree do participants react favorably
to the learning event?

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for healthcare leaders in understanding the complexity of changing culture and employee
behaviors when adopting new programs.
The last model of HRO reviewed in this section is from a fifteen-year collaboration
efforts of the Institute for Healthcare Improvement (IHI), Vizient, and Safe and Reliable
Healthcare (Frankel et al., 2017). The premise of the framework is that there are two interacting
domains: culture and a system of learning (2017). They explain that the learning system is
influenced by the values, beliefs, behaviors, and abilities that make up the culture. Figure 11
demonstrates the Safe and Reliable Healthcare framework for high-reliability healthcare
(Frankel et al., 2017, p. 8).
Figure 11:
IHI and Safe and Reliable Healthcare HRO Model
.
The center focuses on the efforts of the care team and the patient. The next inner circle
depicts the culture and learning system enhanced by leadership and knowledge. The outer wheel

61
demonstrates management systems that interact to influence the culture and learning system
through twelve concepts. Personal accountability, teamwork and collaboration, a healthy
environment, and connection and alignments influence culture. They say this is where a sense of
community, respect, and trust allows team members to feel a part of something bigger.
Transparency and data assessment provide knowledge of the program. This level enables
leaders to have transparency in data so they can adjust and learn. They are learning and
designing, improving and deploying, and implementing and sustaining the influence of the
learning system. The learning system allows information from the culture and knowledge
domains to enable continuous learning to zero harm and safe and reliable care. Last, leadership
skills, activities, accountabilities, and behaviors influence leadership outcomes. Leaders are
pivotal in determining the organization’s success in achieving zero harm by supporting the Safe
and Reliable Healthcare framework and HRO adoption model.
These four models provide a challenge for leaders who are implementing HRO. The
healthcare leader may scan the environment and understand the transformational vision for a
call to action around safe and reliable care, but without a single implementation model, how
does a leader start changing the transactional areas Burke-Litwin list: structure, management
practices, and system and policies? There needs to be a how-to book on HRO implementation.
The challenge leaders face is that all these models provide essential considerations, and not one
model aligns all aspects into a structure that offers a cookbook for success. Another factor that
leaders need to consider is the Burke-Litwin individual and personal factors.
Individual and Personal Factors
The individual and personal factors level of the Burke-Litwin model receives inputs
from the strategic and management levels. Also, it provides outputs to these levels through

62
improved human resource proficiencies and effectiveness (Spangenberg & Theron, 2013).
There are four factors at the individual and personal level of the Burke Litwin model: work unit
climate, task, particular skills, motivation, and individual skills and needs (Burke Litwin, 1992).
The model is one of causality and expresses that leaders experience challenges at this level
when their employees face realities that prevent them from excelling (1992). In other words,
issues that detract from human performance cause a decrease in organizational effectiveness.
This section outlines a few challenges healthcare leaders face within the four individual and
personal factors as they work to adopt cultural change that benefits HRO implementation.
Work Unit Climate
One area of the individual and personal factors that impact HRO in healthcare is the
climate within employees' work units. Work unit climate can be considered the morale, how
people get along, and how they resolve conflict (MindTools, 2023). The unit climate is the
collection of the members’ feelings, perceptions, and beliefs about one another, other units, and
supervisors (Burke Litwin, 1992). Burke Litwin (1992) argues that the distinction between
climate and culture is that the climate is a day-to-day sense of direction derived from the
strategic clarity of mission, individual roles, and responsibility as aligned from an effective
structure, personal standards, and commitments resulting from managerial certainty, and
separate views of fairness related to the application of systems and organizational practices. The
climate is the day-to-day reality of the strategy and managerial sections of the organization.
Healthcare unit climates are impacted by individual elements of an organization that influence
the productivity, effectiveness, quality, and safety of care delivered to patients (Carlucci &
Schiuma, 2014). The following paragraph will discuss some of the unique features of healthcare
units that challenge leaders when implementing HRO.

63
The healthcare unit climate is unique by the nature of the care delivery model. Unit
climate may consist of an “unhealthy” environment that is physically fatiguing due to harsh
lighting, close spaces, many people, and noise fatigue from alarms (Alameddine et al., 2009).
They further state (cite author, 2009) that alarm fatigue contributes to hypersensitivity to this as
a work unit stressor. Further, the healthcare unit climate is emotionally charged and full of lifeand-death decisions moment by moment (cite author, 2009). Another unique attribute of unit
climate in healthcare organizations is how healthcare workers perceive personal risk through
exposure to needle sticks and infectious diseases and their perceptions of healthcare leadership’s
role in protecting them from these workplace hazards (Wagner et al., 2019). Interpersonal
relationships influence the healthcare climate and directly impact the quality of care provided
(Kosydar-Bochenek, 2022). Andre & Sjovold (2017) demonstrate that unit climate influences
the ability to change, making this Burke Litwin (1992) factor of considerable importance during
the change process. These are some of the unique healthcare influences on workplace unit
climate that require leaders' consideration when implementing HRO.
Individual Needs, Motivation, and Values
A second area of Burke Litwin's individual and personal factors that impact HRO in
healthcare is the impact of personal needs and values in their work. They state (1992) that
individual needs and values are the psychological perceptions that the person’s contribution to
their work provides worth and desires that influence their perceptions of their job. This
perception of worth leads to improved motivation at work (Hackman & Oldham, 1980, as cited
in Burke Litwin, 1992). Personal needs and values contribute to an employee's ability to be
personally and professionally successful (Spangberger & Theron, 2013). This outlines why
meeting individual needs and values is vital for leaders engaging in change. Moral injury is one

64
area where the needs and values of individual healthcare workers cause a significant challenge
for healthcare leaders.
For decades, when a healthcare worker was experiencing work-related stress symptoms,
the term used to describe this phenomenon was burnout (Dean et al., 2019). Moral injury more
aptly describes the experience healthcare professionals describe they face when they
continuously observe and are unable to prevent actions that go against their deeply held moral
beliefs (2019). Moral injury is further defined as having to choose between conflicting options
that still lead to negative consequences, committing acts that go against your belief, failing to
take action despite your belief that you should, bearing witness to these activities, and being
betrayed by others (or systems) that you once trusted (Watson et al., 2020). Healthcare
professionals take an oath to put others' needs first, and when they cannot do so due to the
systems of care they work in, this causes moral injury (2019). Post the COVID-19 pandemic,
34% of healthcare workers studied responded with statistically significant moral injury scores
(Rushton et al., 2022). A review of twelve research studies confirms the linkage between moral
injury suicides and suicidal ideation (Jamieson et al., 2023). Recently, Tristan Kate Smith, a
nurse from Ohio, left a suicide note titled “A Note to My Abuser” (TheNurseErica on TikTok,
2023). One may immediately read that title and conclude that this young nurse was talking
about her significant other, but that would be incorrect. The abuser this nurse identifies is the
healthcare system she worked in, and she calls out abusive behavior such as not listening to
their cries for help, placating staff with pizza parties and thank yous, and asking staff what they
had done when patients had turned violent against them (TheNurseErica on TikTok, 2023). One
could also review this as the singular experience of an individual nurse. However, the review of
the comment section alerts you to the implications that many in the healthcare system

65
understand this level of moral injury. The significance and widespread nature of reported moral
injury is a genuine concern and challenge healthcare leaders face when working towards a
highly reliable organization.
Task Requirements, Individual Skills, and Abilities
In this level of the Burke-Litwin Model (1998), they demonstrate that individuals need
to have the knowledge, skills, and abilities (KSA) and understand what is required of them to be
effective. It is important to realize that KSAs are essential for every individual at every level of
the organization; the levels of the Burke-Litwin Model are not to be confused with a
hierarchical structure. Individuals need to know how to accomplish a task (Burke & Litwin,
1998). Behavioral scientists find, in general, that facilitating alignment for an individual's
values, roles and responsibilities, clarity of mission, and structure, results in organizational
change and outlined intended outcomes. In developing an organizational change model, it is
vital at this step that the workforce is given specific tools, techniques, job aides, and
expectations of how their behaviors can change to align with organizational goals.
Individual and Organizational Performance
Organizational effectiveness is recognized as the ability to meet one's mission and
survive year after year (Yukl, 2008, as cited in Spagneberg & Theron, 2013). Humans often
resist change, and the magnitude of the environmental changes influences the outcome of
human performance in meeting changing demands (Burke Litwin, 1992). The various
challenges that leaders face when pursuing change in the organization affect the success or
failure of their initiatives. Burke Litwin (1992) recommends that organizations consider two
lines in changing their performance: how the organization functions and how to pursue a change
to that functioning deliberately. If the challenges outlined in this section are true, when outlining

66
an HRO implementation model, one must consider how they will work to change that
experience. For example, if the organization’s healthcare workers report alarm fatigue as a
significant workplace unit stressor, one level of change in HRO implementation must work to
eliminate this as a barrier to performance in the workforce. Overall organizational performance
is the result of these combined efforts (1992).
Conclusion: Burke-Litwin Model
Pursuing HRO in healthcare is considerably challenging. This section outlined only a
few considerations of those challenges. The framework provided in this review aligned with the
Burke-Litwin model of organizational change (1992). Considering that one challenge is that
there is no singularly agreed-upon model of HRO implementation, this research allows a review
of the challenges healthcare leaders experience and provides a framework for healthcare leaders
to consider when developing their model for implementing HRO. The later sections review the
best practices of the various models presented here and a few recognized best practices in the
three levels of the Burke-Litwin model: transformational factors, transactional factors, and
individual and personal factors. Although the complexity of healthcare makes implementing
HRO challenging, the journey toward zero harm is worth the effort.

67
Recognized Best Practices
Although there are many challenges healthcare leaders face as they embark on their
journey towards high reliability, there are also many best practices to consider. Weick and
Sutcliffe (2015) provide five principles: preoccupation with failure, reluctance to simplify,
sensitivity to operations, commitment to resilience, and deference to expertise, and the
healthcare leader must consider those principles across the entire continuum of the
implementation model. The healthcare leader should consider what the literature supports as
best practices in organizing change throughout their implementation strategy. Marrying the
HRO conceptual framework to the Burke-Litwin model of change that starts with scanning the
environment, outlining transformational strategies, establishing transactional managerial
processes, and influencing individual motivation and performance are all important to
ultimately influence organizational change and effectiveness of the change initiative (Burke &
Litwin, 1992). This section reviews the literature supporting the implementation of change
management across the Burke-Litwin factors that support adopting HRO principles. This
linkage is essential when working towards highly reliable, zero-harm care delivery.
External Environment
The Burke-Litwin change model (1992) recommends that leaders begin the change
process by scanning the environment. Healthcare leaders are most aware of the environmental
challenges that call them to enact change (AHRQ, 2008). Despite this need for change, project
fatigue is a phenomenon that decreases health systems’ ability to sustain high reliability. A
healthcare leader effectively translates what they see in the environment into action within their
organization through storytelling.

68
Best Practice One: Storytelling
In a study conducted exploring 40 organizations' projects with sizeable economic impact
initiated by senior leaders, 58% failed to meet their target, 20% captured only a third of the
expected return on investment; however, 42% of the successful companies not only achieved
their results but, in some cases, exceeded expectations by 200-300% (Denning, p. 36, 2011).
The single thing these successful organizations had in common was storytelling. Storytelling is
emerging as a core leadership competency, with a chapter devoted to the art appearing in many
leadership books in the past decade (p. ix, 2011). Change occurs when you can unfold
communication across and among the many stakeholders in an organization (Lewis, p. 13,
2019). With over sixty-four million views, Simon Sinek is known for his viral video titled “How
Great Leaders Inspire Action” (Sinek, 2009), where he encourages all of us to tie our strategic
vision to the “why” that matters to those we lead. Denning (p. 63-64, 2011) recommends a
springboard story to inspire others to act toward change. The springboard story (2011)
communicates the change idea, includes actual examples, is told from the perspective of a single
protagonist typical of the audience, provides dates and times, makes it clear what the outcome is
without the change, provides succinct details, is positive and authentic and provides a happy
ending, and ties back to the call for action in the change (Sinek, 2009) provides a more
straightforward pathway for a storyteller: to describe what we do, how we do it, and why.
Communication is a significant part of the change initiative as it is demonstrated to play an
essential role in the change process (Lewis, p. 56, 2019). The importance of storytelling in a
leadership journey toward high reliability must be carefully thought out. This best practice is an
integral part of how the leader translates the need for change they observe in the environment to
the actions the organization needs to take to address those challenges.

69
Transformational Factors
Best Practice Two: Transformational Leadership
The theory demonstrates that transformational leaders stimulate followers to achieve
extraordinary outcomes while maximizing their potential (Johnson, 2007). Aligning strategy to
goals and enabling an entire health system to work towards those goals is vital in addressing the
severe problems facing healthcare today.
Transformational leaders align strategic goals with objectives and empower those who
work for them to transform an organization (Johnson, 2007). As the Burke-Litwin model (Burke
& Litwin, 1992) demonstrates, the transformational factors, mission, strategy, leadership, and
organizational culture are the impetus for organizational change. This type of visionary
leadership for change is necessary for healthcare organizations if the existing paradigms are to
change, allowing the organization to achieve the goals of zero harm.
Figure 12
Transformational Leadership Model

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The theory of Burke-Litwin organizational change model (1992) creates a conceptual
model of how transformational leadership theory (Bolman & Deal, p. 351, 2021) supports their
assertion that a leader who practices these behaviors helps drive change. The conceptual model
(see Figure 12, Transformational Leadership Model) centers on the relationship between the
leader and the follower. This theory supposes that the bidirectional interaction of leader and
follower raises the morality and performance of both leaders (Denning, 2011, p. 292;
Northouse, 2022, p. 186). Northouse (2022) further states that this relationship forms through
shared vision, transparent communication, trust, encouraging creative problem-solving, and
recognizing accomplishments. Specifically, the thread that connects a transformational leader to
the desired change is the narrative for change that threads across their behavior, actions, and
communication (Denning, 2011, p. 293). This type of transformational leadership is necessary
for change in complex healthcare systems. Even with the best intentions, due to the complexity
of the environment, without this type of visionary and dynamic leadership principles, it
becomes increasingly difficult for change to occur. This view is supported by transformational
leadership theory (Northouse, 2022) and the Burke-Litwin organizational change model (1992).
A significant benefit of the Burke-Litwin model is the linkage between transformational
leadership and organizational performance and the ability to distinguish between transactional
and transformational leadership (Spangenberg & Theron, 2013).
Transactional Factors
Transactional factors of the Burke-Litwin model (Burke & Litwin, 1998) are consistent
with managerial functions. Transactional leadership is counter to transformational leadership in
that the relationship between the manager and the employee is based on an exchange of
behavior for rewards (Northouse, 2022, p. 194). In the Burke-Litwin model, transactional

71
portions are part of the transformational leader's method for organizational change (Burke &
Litwin, 1992). Traditional transactions are required even with a transformational leadership
approach to organizational change (Burke and Litwin, 1992). The transformational leader still
inspires the morale and performance of the individual to meet these transactional factors. The
following paragraph demonstrates a model of change managers use to align strategy to behavior
change.
This level of change in the organization where management practice must influence
employee behavior change is supported by a second model called evidence-based leadership
(EBL), a model researched across a growing number of Studer Group’s partner organizations
(Cochrane, 2017). EBL is a model that aligns accountability and management functions, stating
that aligning these activities is crucial to an organization’s successful change adoption. The
model is adaptable, applied across the organization, and scalable (Cochrane, 2017). The model
further demonstrates that organizational change is supported when managers align organization
goals to behaviors and processes. The following section outlines how transformational
leadership utilizes transactional tools to align organizational goals to behavior change that
transforms an organization.
Best Practice Three: Developing a Learning Organization
Traditional transactional managerial practices within the Burke-Litwin Model align
strategic priorities with the actions that help the rest of the organization adopt the changes the
senior leadership envisions (Coruzzi, 2020). Organizations must learn and adapt as customer
expectations pressure them (Edmondson, 2012, pp. 21-22). One way health care learns is
through teaming to improve its safety culture (Edmondson, 2012, p. 162). Organizational
learning uses teaming as the engine that fuels the process (Edmondson, 2012, p. 14). Safety

72
culture is improved when it is visible and prioritized throughout the organization in everyday
actions through diverse groups and information sharing (TJC, 2017). One methodology to
enhance information sharing across teams is through a performance management system, which
includes adopting information technology, management systems, and clinical operations
framework and governance (AF CONOPS, 2015). Developing ways to accelerate technology
adoption in HRO practices and continuous improvement aid in program success (Coruzzi,
2020). Weick (as found in Edmondson, p. 162, 2012) states that teaming is “heedful
interrelating.” Through adopting technology and sharing information, daily behavior begins to
change. Culture culminates in an organization's daily activities (TJC, 2017). Keeping HRO
principles visible and enfolding them into everyday behaviors helps shift the organization's
culture to align with the new safety model.
Organizations have successfully improved HRO adoption by moving the principles into
daily actions. Organizations must find ways to adopt thoughtful leadership to adapt and learn or
risk that spontaneous managers may inadvertently ambush the connection between strategy and
change (Edmondson, 2012, p. 23). One option is to utilize a Learning and Engagement System
(LENS™) board that allows a department to electronically and visibly display the activities they
are engaging in (Vizient, 2023). This LENS™ system is a visual display that allows all team
members to have a voice in change, closes the loop in communication, decreases fragmentation
of information, aligns work across disciplines, and provides an opportunity for mindfulness in
planning work (Edmondson, 2012). LENS™ is an electronic platform that leaders can see from
their desktops. However, it is also a visual display, usually with a larger monitor in a prominent
department area. This tool serves as a single source of information to guide work and focus on
safety concerns.

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Transparency is another tool leaders use to improve safety. Chassin and Loeb (2013)
identify five components of a safety culture: trust, accountability, identification, strengthening,
and assessment. Managers reinforce these five areas of a safety culture through transparency by
sharing safety-event stories, celebrating reporting, and encouraging those who speak up (TJC,
2017). Other tools managers use to influence transactional change in the behavior of employees
include rounding for outcomes and staff huddles (Cochrane et al., 2017). Rounding for
outcomes, led by culture and safety teams, provides expert guidance for employees in modeling
the organizational change managers and leaders want to see (Cochrane et al., 2017). Leadership
rounds decrease burnout when leaders use their hierarchical position to improve individual work
settings based on information learned during rounding (Sexton et al., 2018). Through active
engagement and transparency, leaders determine their employees' needs and, through that
insight, adopt interventions that help drive actions (Coruzzi, 2020). Transparency between
leader and follower helps the discovery process that aids the organization’s change.
Organizational Effectiveness: Individual and Personal Factors
The Burke-Litwin model demonstrates three main factors that influence organizational
change: strategy, culture, and the utilization of the talent of the people in the organization
(Spangenberg & Theron, 2013). Individual and personal factors are critical determinants of
success in achieving organizational change. The first two approaches of outlining strategy and
establishing culture influence individuals' ability to contribute to the change process
(Spangenberg & Theron, 2013). Individuals attribute their desire and worth to the organizational
change process and become influenced by these attributes (Burke & Noumair, 2015). Aligning
the transformational and transactional portions of the Burke-Litwin model results in the
organization's and its personnel's effectiveness (Burke & Noumair, 2015). When personnel are

74
motivated by transformational vision and leadership, it elicits behavior that helps an
organization move towards goals and take action, and as a result of the alignment of vision and
action, personal performance and satisfaction are attained (Burke & Noumair, 2015). An
organization must align transformational goals with the individual and personal factors that
enhance employee performance and well-being. This is particularly important in an organization
that is reaching to achieve accelerated growth and transformation. The following section will
discuss the best practices for establishing psychological safety in the workplace and teams
across the organization.
Best Practice Four: Psychological Safety
Psychological safety is vital in obtaining those goals in an organization focused on
growth, development, and organizational change. To lay the foundation for defining
psychological safety, one can start with Maslow’s hierarchy of needs. Maslow demonstrated
that individual motivation is based on a hierarchy of needs being met (As cited in Barnes,
2000).

75
Figure 13
Maslow’s Hierarchy of Needs
Figure 13 (Dorr, 2016) outlines the five levels of Maslow’s hierarchy. By adopting the BurkeLitwin model, an organization may help its personnel achieve their basic needs (Burke &
Litwin, 1992). The Burke-Litwin model and the Maslow model demonstrate that a person must
meet basic safety and security needs before they can begin to feel they belong, can achieve, and
can actualize their ability for personal growth and fulfillment. This acknowledgment of the
fundamental base of needs is as essential in a person’s journey to self-actualization as it is for an
organization on a journey towards cultural self-actualization as a highly reliable organization.
Given Burke & Litwin's belief that individual performance is tied to organizational
performance and Maslow’s outline of basic needs, the question turns to how an organization

76
helps align organizational and individual goals and motivations. One method is to establish safe
spaces for talking about complex issues.
An example of this is Crew Resource Management (CRM) training. One study found
that 70% of all aircraft accidents occurred due to human error (APA, 2014). Soon after, CRM
training was implemented across aviation. CRM is a training that includes training in
knowledge, skills, and abilities across areas such as communication, working together as a
team, teaming for problem-solving, and gaining a broader understanding of the situation
(Skybrary, 2024). In one situation before implementing CRM, a short conversation shows how
the co-pilot explains the situation; the pilot says, “Nah, I do not think so,” and then the co-pilot
agrees and then the pilot turns around and says, “I am not sure” (APA, 2014). This failure of
communication and problem-solving resulted in the death of all individuals on the aircraft.
Later, this study demonstrated that crews who had CRM training had 31 communications per
minute and up to one per second at the peak of the escalation, and the team even recruited
another pilot riding on the plan to come help with the situation. This training and change in
behavior resulted in a different scenario that saved many lives. Healthcare organizations have
similarly complex interdependent processes that require teaming and coordination in a
psychologically safe space to achieve the best outcomes. Looking to the airline industry and the
implementation of CRM training may be a place to start in developing a psychologically safe
environment.
Establishing psychological safety is not as easy as one might think. The role of a
person’s job in a capitalistic or neoliberal economy represents the fundamental needs that
people need to survive (Mate, Year, pp. 277-280). Mate further states that an actual or perceived
loss of work threatens our survival with the potential loss of healthcare, food, and shelter. The

77
exact needs indicated in Maslow’s model, and biological and physical safety are fundamental to
human survival. When an employee does choose to speak up, that does not make them immune
from the consequences of that bravery (Edmundsson, 2019, p. xv). One can argue that this
reality makes it difficult for healthcare leaders to build an environment of psychological safety
where people should speak up when they see the organization has safety concerns. In their
meta-analysis, Frasier et al. (2016) identify that psychological safety is fundamental in the
unfreezing process
necessary for
change and
organizational
learning. The
organization's goal
is to create a
culture of safety
where the
individual feels their security to the extent that they fear not speaking up for the organization
more than they fear for their safety (Author, 2019). Frankel and Leonard’s (2018) Safe and
Reliable Culture Maturity Model demonstrates that psychological safety is crucial to an
organization’s maturity development, leading to an organization of high reliability. The need for
psychological safety in the organization is a fundamental building block towards high reliability
and a key area for organizational focus when beginning this journey.

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Best Practice Five: Kirkpatrick’s Training Evaluation Model
Earlier in Chapter Two, we learned that the Air Force model of implementation of highreliability principles utilized Kirkpatrick and Kirkpatrick’s (2016) knowledge transfer model
known as KMO. This should be considered a best practice for the Burke-Litwin model
regarding needs, values, motivation, tasks, individual knowledge, skills, and abilities. Selfdetermination theory (ST) demonstrates that competence at work is a critical factor in
decreasing burnout (Leiter & Maslach, as cited in Elliott et al., 2017). Helping individuals learn
the skills that the organization expects in developing a culture of high reliability helps
individuals find these new competencies. Transferring learning to behavior adoption is where
the Kirkpatrick Model of learning is most effective (Kirkpatrick & Kirkpatrick, 2016, p. 6). This
model recommends that organizations evaluate their training programs to determine
effectiveness and return on investment. It outlines that knowledge transfer to intended
behavioral change is the hardest part of organizational change. Changing behavior is a critical
element of developing a highly reliable learning organization, which makes evaluating the
effectiveness of training tools a crucial best practice for leaders to consider when embarking on
this journey.
Organizational Effectiveness: Individual and Organizational Performance
The last step of the Burke-Litwin theory is that the model's other cascading attributes
influence organizational and individual effectiveness. The interrelated parts of the overall
Burke-Litwin change model can lead to the success or failure of any organizational change it
endeavors to achieve (MTCT, 2016). An organizational culture emphasizing teamwork and
harmony directly influences employee effectiveness Spangenberg& Theron, 2013). The needs
of the individual are intrapersonal drivers and motivation that influence success (2013).

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Individual performance influences organizational performance through outcomes such as
quality, safety, productivity, customer satisfaction, and financial stability (Burke & Noumair,
2015). In other words, the performance of individuals directly affects the organization's
performance. Organizational development leaders see the direct relationship between individual
and organizational goals (2015). Leaders who want to develop a safety culture through highreliability principles must determine a tool for measuring individual and organizational
performance, safety, and success. The following section reviews a few tools that are available
for HRO leaders.
Best Practice Six: Measuring Success
As healthcare leaders embark on the journey of high reliability, they should consider
their measurement of success. A few tools offer healthcare leaders options for this review. First,
the Oro™ 2.0 High-Reliability Assessment Tool addresses measurements for five areas of HRO
implementation: leadership, culture of safety, data systems, training, and process improvement
(Veazie et al., 2019). This tool assesses a maturity model of beginning, developing, advancing,
and approaching that measures 14 components. Veazie et al. (2019) also found that this tool has
advanced testing validity and high reliability. A second tool of measurement is the American
College of Healthcare Executive’s (ACHE) Culture of Safety Organizational Self-Assessment
Tool. However, this tool lacks an assessment of the organization’s training and learning and
process improvement initiatives, nor does it have any published data on reliability and validity
(2019). A third tool is from Vizient called Safe and Reliable SCORE™ Survey. This survey
reviews five cultural dimensions and six engagement domains (Safe and Reliable, 2018). The
domains of the BLM and the three domains, preoccupation with failure, reluctance to simplify,
and deference to expertise, are not as easily measured through this tool. The strengths and

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weaknesses of these tools are essential to consider as a healthcare leader begins this
transformational change necessary to move an organization toward HRO. Ensuring that the tool
one uses tells the story of the organization's journey compared to the implementation model is a
crucial indicator of successful implementation.
Conclusion: Best Practices
Through the lens of the Burke-Litwin model, this section reflected on best practices for
healthcare leaders to consider when implementing HRO. Without a standardized and agreedupon implementation model, leaders need to develop a pathway of implementation that helps
them design a framework that enables their success. One best practice for leaders to consider is
storytelling, which addresses the external influence a leader responds to. The external influence
in the Burke-Litwin model is the impetus for changes that a leader responds to when deciding
on organizational change. The second best practice is designed to influence the transformational
aspect of the Burke-Litwin model. It is aptly designed to ensure transformational leadership
principles to influence organizational and cultural change. The next best practice aligns with
Burke Litwin’s transactional level and demonstrates the need for an organizational structure to
become a learning organization. Additionally, a best practice that measures individual and
organizational performance is psychological safety. This domain is critical to the organization's
ability to implement a safety culture. Without personal safety, organizational effectiveness is at
risk. Next, an organization must develop a best practice of evaluating their organizational
learning programs. Changing behavior is a critical step to developing a safety culture. Ensuring
the knowledge, skills, and abilities the organization desires are trained and adopted by their
employees is a critical step of knowledge transfer. Lastly, the best practice of measuring
organizational and personal success is essential for a healthcare leader to understand if they

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have achieved their goal. The difficulty for a leader is that the tools for measurement vary in
effectiveness and provide potential gaps in a leader’s understanding of how they measure their
effectiveness and where they are on their journey. Nevertheless, developing a measurement of
effectiveness is an essential aspect of the HRO journey, as well as understanding the
organization’s progress in meeting the goals it set out for itself.
Conclusion: Literature Review
The literature review demonstrates a need for HRO implementation across healthcare
organizations. It also indicates that there is no solid pathway for implementation, a challenge
that disadvantages leaders who want to embark on this path of cultural change for their
organization. Due to the lack of a standardized model, this chapter introduces the organizational
change model that Burke Litwin outlines for successful change, which provides perspectives
that cascade across the organization. Lastly, the literature review offers perspectives on five best
practices in implementing HRO: storytelling, transformational leadership, developing a learning
organization, establishing psychological safety, and measuring outcomes. These best practices
are offered at each of the levels of the Burke-Litwin model so that the leader can determine how
those concepts may influence their overall implementation plan. Further, the concept of an
organizational maturity model that might allow an organization to compare its development to
Maslow’s hierarchy of needs is introduced. Leaders need to understand that the journey towards
HRO is a cultural change endeavor and not a simple program to implement. This literature
review further informs the study when exploring a leader’s lived experience, challenges, and
tools for implementing HRO, which will be further introduced in the study methodology.

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Chapter Three: Methodology
This descriptive qualitative research study aims to gain insight into healthcare leaders’
lived experiences and challenges in implementing highly reliable organizational principles.
Those lived experiences, challenges, and recommendations are compared to the Burke-Litwin
model for organizational change. The model of HRO implementation aligns with the BurkeLitwin framework to improve an organization's safety culture. Both models recognize a need for
change. Ultimately, a continuous process of monitoring how the organization is doing on its
cultural change journey is necessary, and this study utilizes SCORE™ as a best practice for
monitoring cultural change. This chapter outlines the qualitative research methodology and
study design. Appendix A lists the semi-structured qualitative research questions used. This
chapter includes the sample selections for the qualitative interviews, the methods for analyzing
the data, safeguarding those data, and tools for protecting the participants. This chapter also
includes background on the research and the ethical approach used.
Research Design
The methodology used in this study is a phenomenology case study of a bounded system
(Merriam &Tisdale, 2016, p. 24). The research will consist of qualitative interviews of eight
healthcare leaders who have experience implementing HROs. This choice allowed the use of
qualitative interviews to delve deeper into the lived experiences of healthcare leaders who have
experience implementing HRO. Qualitative research enables exploring the participants'
experiences with a particular event (Author, 2016, p.24). The interviews were coded for
experience themes, compared to the five factors of the Burke-Litwin model, and then to the six
best practices outlined in Chapter Two. Cross-referencing the thematic experiences allowed a

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deeper understanding of the organizational culture and which participants' lived experiences
might improve HRO implementation.
The qualitative research methodology used aligns with the phenomenology case study
design. A case study is when research studies one or more entities or programs in a bounded
timeframe through various collection methods (Creswell & Creswell, 2018). This research is a
phenomenology case study because it evaluates the HRO safety culture and lived experiences of
implementing that program in one healthcare system. This case study focuses on one hospital by
studying the lived experiences of healthcare leaders employed by that system in implementing
their HRO program. The case study type is phenomenological, aiming to get to the heart of the
subjects' lived experiences (Merriam & Tisdale, 2016, p 113) in implementing the HRO
program in their organization.
Research Questions
● RQ1: What are the lived experiences of healthcare leaders regarding HRO principles?
● RQ2: What are the challenges faced by healthcare leaders regarding HRO principles?
● RQ3: How can healthcare leaders implement HRO principles?
Research Setting
Microsoft Teams was used for the semi-structured interviews. Interviews were
scheduled with leaders from the organization studied in this case. Consent was requested during
the initial onset of the appointment by going over the study, describing the methodology, and
the process for the participant to revoke consent at any time before publishing without any
retribution. Permission from the subject was sought to record and transcribe the interviews with
the understanding that the recording was for the sole purpose of transcribing notes, that no
statements would be attributed to the participant, and that all information used in the study

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would be de-coded to protect anonymity. These recordings were used to go back to the
interviews during the thematic analysis. Once the transcripts were coded using thematic
analysis, the participants were allowed to review and make edits. They were reminded that they
could decline to participate any time before the paper was published.
Participants
This qualitative research case study in one healthcare system reviewed the lived
experiences of eight healthcare leaders who had experience implementing HRO. These
participants' stories provided rich insight into the challenges healthcare professionals face on the
frontline when changing a complex organization’s culture to enhance reliability and safety. This
perspective offers the opportunity to deconstruct their personal experiences by analyzing the
themes of other leaders in the same setting and the challenges they face. Through thematic
analysis, areas of opportunity emerge for consideration by the healthcare leadership team.
Target and Accessible Population
The target population is healthcare leaders in the U.S. The accessible population for the
qualitative research is healthcare leaders in Hawaii. Eight healthcare leaders from one hospital
system in Hawaii were the sample for the qualitative study.
Sample
The sample population for the qualitative analysis was senior healthcare leaders at a
tertiary care health system who have familiarity with, or who have taken, training on highreliability organizational principles and who have shown an interest in understanding the
SCORE™ survey results from Safe and Reliable Healthcare (2023) as well as implementing a
safety culture. The sample consisted of eight healthcare leaders. Although it is impossible to
know when saturation (see Definition of Terms) may occur, one methodology recommended

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(Merriam & Tisdale, 2018, p. 100) is that analysis continues simultaneously with the research
interviews. At the saturation point, there is little value in continuing the qualitative inquiry.
Saturation was reached with this study with the eight participants; if it had not, there was an
opportunity to continue recruiting.
Sampling Method
The participant selection used a nonprobability methodology for this qualitative study.
This methodology of participant selection is an appropriate approach when researchers are
trying to discover what is occurring and the implications of those actions (Merriam & Tisdale,
2016, p. 96). The sampling method used for Hawaii was convenience. Due to time, money,
location, and availability, a convenience sampling method can be appropriate for qualitative
research (Merriam & Tisdale, 2016, p. 98). This same methodology was attributed to site
selection when selecting the hospital participating in this research study. Because this study
aims to evaluate healthcare leaders who have experience with HRO in a large healthcare setting,
conducting this research at a singular local organization was convenient and helpful. Studying
participants in the same health system decreases variables such as communication, training, and
leadership style so their experiences can be better compared. The interview sample selection
methodology focused on direct employees of the healthcare setting that is studied.
Recruitment
To recruit participants for this qualitative phenomenology case study, participants were
requested from the HRO Steering Committee for the organization, and from there, referrals to
others who were interested in participating were obtained. In approaching the prospective
participants, the concept of the study, and how their contributions are perceived to add value,
were discussed with each participant in a one-on-one conversation before scheduling the

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interview. If questions about their ability to add value came up, it was explained how they were
perceived as a good candidate and ensured they could say no, if uncomfortable. All of those
asked to participate agreed.
Data Collection
In this qualitative phenomenology case study, interviews were selected as the primary
methodology for data collection. This methodology allowed the direct collection of information
from the participants on their lived experiences in implementing HRO in their organization.
Through an open-ended interview, the framework of semi-structured questions during the
interview provided an exploration of the participants' lived experiences and recommendations to
improve HRO implementation. Through open-ended conversations, the participants shared their
experiences, illuminating the stories that quantitative research does not fully explore.
Demographic Survey
The participants were asked to provide data regarding their demographics for the
qualitative research study. The demographic data provides a snapshot of the leaders'
backgrounds, experiences, and characteristics which provided insights into their lived
experiences. This demographic information is a small sampling and provides an opportunity for
future research on how the demographics of a population may influence lived experiences. That
is not the intent of this study or the purpose of collecting this information. Due to the small
sample size and the case study methodology, demographic data are not included in the research
findings in Chapter Four to protect the confidentiality of the participants.
Interview Protocol
The research protocol used for this study is a qualitative semi-structured interview
process. Qualitative research allows a broad understanding of holistic systems through a natural

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information collection with few cases (Morgan, 2014). The goal is to learn about the subjects'
lived experience with the HRO principles and barriers to implementation. This research
structure allows the subjects to tell their story in their own words and allows the conversation to
evolve naturally (Bogdan & Bilken, 2007). A set of questions will guide the conversation but
can also develop naturally as the person tells their story.
The qualitative interview structure consisted of 26 open-ended questions. Ten questions
relate to RQ1 and the critical conceptual theory of lived experience. Eight questions relate to
RQ1 and the critical conceptual theory of motivation. Eight questions align with RQ2 and the
conceptual framework of barriers to implementing HRO. Eight additional questions align with
RQ3. These 26 questions guide the initial interviews. However, the semi-structured approach
allows for a combination approach that opens the opportunity to delve further into other subjects
as the interview evolves (Patton, 2002). A semi-structured approach offers flexibility while
allowing for a more formal portion of the interview. Hence, there is consistency across
participants while allowing the participant to tell their stories in a manner that is most valuable
to them.
A recording of the data for the qualitative research interviews preserves the conversation
for future analysis. A transcription of the interview is available as well. As well as notes taken
during the interview to compare thoughts during the interview with the interview recording
later. Simultaneous to the ongoing interviews, data from interviews is analyzed immediately
after the interview to prevent delays that could cause a failure to remember the interaction
context. This data is further categorized and analyzed for themes.

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Procedures
A script guided the introduction and conclusion in preparation for the qualitative
interviews. Although the script does not need to be read word for word, it serves as a helpful
tool to provide structure for the researcher and participant (Castillo-Montoya, 2016). The
interviews were scheduled via Microsoft Teams and recorded after explaining that the purpose
of the recording was to go back and take notes and that confidentiality would be maintained.
The interviews took approximately one hour each. The review of the purpose and basic
structure of the interview occurred at the beginning of the interview. Once consent to proceed
with the interview and to record were granted, the interview began, and once those items of
business concluded, the interviewer started the recording. The interview consisted of thinking
and feeling questions (Kruger & Casey, 2009), which helped pull out analytical thoughts and
emotional responses to the topic. As the interview concluded, the final question was to ask if
there was anything else they wanted to go over. After that question, the interview concluded,
and the recorder was turned off. Once the recording ended, the conversation turned to a more
personal one-on-one dialogue, with the participants lingering to discuss perceptions or
additional thoughts they did not want recorded.
Confidentiality Parameters
The findings were analyzed, kept confidential, de-identified, and used to compare the
lived experience of senior healthcare leaders. The qualitative interviews were conducted via
Teams and transcribed using that system. The data will not be shared and is now deidentified.
The final data and analysis report includes coded thematic analysis (see Definition of Terms),
and any direct quotes utilized in the final report do not include information that may reveal a
particular respondent's position or identity. Every deidentified quote was given to the

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participants for their review. Some subjects covered were very sensitive and needed this step to
ensure anonymity.
Data Management
The data for the qualitative interviews is maintained and collected via a personal Teams
account on a personal computer. It is deidentified and confidential. This thematic coding matrix
in Appendix B provides the methodology for analyzing and attributing the data across the
thematic domains of the three research questions, Burke-Litwin Model, and best practices.
Encryption
The data for the qualitative research interviews collected on Teams is password
encrypted. The user is invited to participate in the interview and has a code to enter the room.
This data is unavailable without permission, and a password is only available to program
participants.
Dissemination of Findings
Qualitative data findings are deidentified and analyzed. To ensure the integrity of the
study and overall findings, the distribution of the data and its analysis is authorized only to
those inside the academic process. After passing an International Review Board approval and
final defense, the final paper will be posted in the USC library for further use by others studying
similar topics.
Data Analysis
The qualitative data analysis for this study occurs throughout the interview process.
After each interview, the interviews were transcribed and thematically coded. This was first
done by hand and later organized using a Google Sheets document that proved very helpful in
sorting and analyzing the data. A review of the transcribed notes happened in conjunction with

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the audio recordings to account for any information that could cause identification of the
subject. This process was conducted a second time later in the analysis to ensure the subject’s
information is kept confidential. A copy of the finalized notes was provided to the interviewee
for review to ensure that the information collected reflected what the interviewee intended to
say. This process of interviewing, transcribing, reviewing, and checking the information was
ongoing and cyclical to ensure appropriate data collection. With the data validity ensured, it was
then organized for analysis and reviewed for coding around themes, and the generation of
concepts of interest begins (Creswell & Creswell, p. 194, 2018). These steps were necessary to
prepare for cross-reference with the research questions, the Burke-Litwin model, and the best
practices outlined in Chapter Two.
Variables of interest in implementing HRO align with Weick and Sutcliffe (1999), and
those variables align with organizational safety and readiness cultural scores. The SCORE™
survey is a tool that is used at over 700 healthcare organizations to measure the dimensions of
organizational culture that “integrates safety and teamwork culture, local leadership, learning
systems, resilience/burnout, and work-life balance,” as well as employee engagement (Safe &
Reliable, 2023, p. #). The information correlates with HRO implementation and is a tool
healthcare leaders use to engage workers to improve safety (Adair et al., 2022). This tool guides
healthcare leaders in reviewing and developing strategies to accelerate their HRO journey. This
study incorporates the conceptual framework of HRO and the Burke-Litwin theoretical
framework for organizational change to further study the thematic analysis (see Definitions of
Terms section) of the qualitative interviews for opportunities to enhance the implementation of
HRO in the phenomenology case study setting. The organization can then use the results of their
SCORE™ survey to further analyze the data from the participants to the results of their survey

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to look for trends. Layering the three standalone points of information, HRO implementation,
Burke-Litwin, and organizational change, and the qualitative interviews into a thematic review
provides an opportunity to infer correlations between the concepts and lived experiences of the
participants. Once those thematic reviews emerge through the convergent analysis, they allow
alignment to the Burke-Litwin model for a more complete implementation of HRO in a
complex organization.
Descriptive Analysis
The study uses an experimental design that is an explanatory sequential core design. The
matrix (see Appendix B) provides a methodology for analyzing the semi-structured interview
data (see Appendix A) through the thematic content analysis (see Definitions of Terms section).
This mapping of research data to the Burke-Litwin model and the best practice themes provides
the areas of improvement for implementing HRO for the organization studied in the
phenomenology case study. The qualitative interviews' triangulated thematic analysis (see
Definitions of Terms section) compares the Burke Litwin model with the participants' lived
experiences to match the best practices in HRO implementation. The Safe and Reliable
Healthcare organization analyzes the SCORE™ survey, a tool this organization uses to measure
readiness for change. This study did not compare SCORE™ results with the thematic coding of
the participant data. This is an excellent next step for the organization to consider when
implementing change. This study uses descriptive and inferential statistics to analyze all data
sets to answer the following research questions:
RQ1: What are the lived experiences of healthcare leaders regarding HRO principles?
RQ2: What are the challenges faced by healthcare leaders regarding HRO principles?
RQ3: How can healthcare leaders implement HRO principles?

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Data was analyzed through descriptive statistics, looking for similarities in the
demographics or characteristics of participants and their experiences. Descriptive statistical
analysis allows the study of cultural and social norms (Merriam & Tisdale, 2016, p. 229). In a
case study, this helps to look at similarities of experiences. Descriptive statistics allows a review
of the frequency of a variable occurring by measuring the theme's mean, median, and mode
(Mishra et al., 2022). The type of descriptive statistics used to calculate the frequency of the
thematic code is central tendency, variation, and standard deviation (Mishra et al., 2022).
Numerical counting measures the frequency of variables. A range of data will be used to
measure variation.
Demographic Data
The qualitative semi-structured interview questions include a few demographic data
collection questions. Demographic data for a study is often collected and provided in a table in a
research study (Connelly, 2013). Demographic data allows the reader to understand the sample
size and the type of people who participated in the study. For this interview, the analysis
includes questions on the number of years in healthcare leadership, the level of education, and
the occupation of the respondents. The sample size for this qualitative study is small. With a
small sample size, demographic questions can compromise the data and make the participants
uncomfortable (Robinson & Leonard, 2019, p. 141). Due to the nature of this study, the
limitations of the small sample size, the case study setting, and the narrow focus of HRO
committee members, demographic data analysis is withheld in Chapter Four to protect
anonymity.

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Thematic Analysis
The interviews are analyzed using a thematic analytical approach (see Definitions of
Terms section). A thematic analysis looks for themes in narrative data collected during
interviews (Mortensen, 2023). Mortensen (2023) goes further, saying that thematic analysis
allows respect for the data by letting it speak for itself developing themes that can be compared
across interviews and analyzed for patterns. He provides six steps in thematic analysis:
familiarize oneself with the data, assign codes, look for patterns, review themes, define those
themes, and produce the data report. This methodology is the approach taken for the thematic
analysis.
Reliability
Reliability is maintained in the qualitative study by documenting the steps and
methodology across all participants. To enhance the integrity of themes, Creswell and Creswell
(2018, p. 202) recommend that a checklist or database helps outline the research methodology
to prevent errors in reliability, such as a shift in the definitions of themes and data coding. By
following these steps, the integrity of this process improves the reliability and validity of this
study. The inclusion and exclusion criteria for thematic analysis are provided (see Appendix B).
Dependability
To determine the dependability of this research study, one must consider the extent to
which the findings are reliable and consistent (Moon et al., 2016). This study provides the
ability to export the methodology to other organizations to determine if these results are
dependable and consistent. Moon et al. (2016) find that dependability is critical when
considering policy recommendations. Dependability is essential in this study as it seeks to
influence policy and programs around HRO implementation in healthcare. The success or

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failure of implementation of HRO might result in outcomes as severe as harm or death. Hence,
it is essential to consider the dependability of these results and how they connect to the BurkeLitwin model for organizational change and relate to the HRO implementation before changing
policy or programs in one’s organization.
Confirmability
Confirmability is the degree to which the research results from the research conditions
are not a product of the researcher's bias (Moon et al., 2016). This study allows others to
confirm results by transparently sharing the tools used. Confirmability improves by using tools
to align the findings with the conclusions and recommendations in a way that can be repeated
(Moon et al., 2016). Others may consider replicating this analysis to determine confirmability
by utilizing the tools provided and the analysis model. This further research strengthens claims
and analyzes potential unintended bias in the model.
Validity
In qualitative research, it is essential to protect the validity of the research through
training, preparation, and intellectual rigor (Merriam & Tisdale, 2016, p. 260). Triangulation
allows various data collection methods to improve the study's validity (Merriam & Tisdale, p.
2016, 259,). Creswell & Creswell (2018, p.194) recommend that data be organized and coded
for themes such as leadership, education, and psychological safety, among others, to help
validate the data's accuracy. Coding allows for a review of raw comments along themes and
attributes found across interviews. The more one reviews the information, a framework with
inclusion and exclusion criteria helps build a foundation for sorting information. Another
methodology used in this study is member checking (Author, 2018, p. 200) to allow the
participants to review the themes and data analysis to ensure that the information evaluated was

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consistent with what they were trying to convey in the interview. This is an example of why
member checking is essential. One participant was given her quotes for review, and she
corrected this one, “Are we giving the [managers and directors] the tools to solve the problems
and know what these processes look like?” When she returned it, she added the word “should.”
The quote now reads, “Are we giving the [managers and directors] the tools to solve the
problems and know what these processes ‘should’ look like?” This is an essential distinction
because she was trying to convey that we don’t currently have these processes outlined, so how
can the staff know if we don’t? This is an excellent example of why member checking is
essential in the coding and validation.
Credibility
In research, it is crucial to consistently build credibility through the many processes used
to analyze data (Zohrabi, 2013). The researcher can do this by consistently explaining the
methods for every step in the research, collecting data from various sources such as interviews
and surveys, and leaving an obvious audit trail so that others can review the data and
methodologies (Zohrabi, 2013). This study attempted to do this by providing detailed
information in the appendices and confirming information with participants.
Transferability
This study aims to allow other researchers to validate this research by utilizing the
qualitative semi-structured interview questions (see Appendix A) and the thematic coding
matrix (see Appendix B) to transfer this to their organization to determine if this analysis
methodology is helpful to them. Utilizing the tools provided gives others the transparency
necessary to adopt this to their organization. Once they have conducted similar qualitative
interviews, they can analyze those themes and crosswalk them to the Burke-Litwin HRO

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implementation model provided. This model of implementation, the Burke-Litwin model of
HRO implementation, allows the model to be transferable to other organizations. This model
merges the conceptual framework, the five HRO principles, with the theoretical framework, the
Burke-Litwin model, for a fully informed organizational cultural change model addressing HRO
implementation. That transfer enables different organizations to develop actionable tools to
improve their safety culture.
Conclusion
This study aims to analyze and compare the qualitative results of healthcare leaders’
lived experiences with the implementation of HRO and the reality of the organization’s climate
on the journey of cultural change toward becoming a safe and reliable healthcare organization.
The themes from these qualitative experiences allow a framework for the comparison with the
Burke-Litwin model and how those compare to best practices outlined in the literature review.
The organization uses the SCORE™ survey to measure culture, which has proven reliable and
valid and demonstrates that when leaders target interventions based on feedback from this
survey, they can continue to improve their journey toward highly reliable care (Sexton et al.,
2023). This study provided an approach to determine what behaviors and lived experiences may
influence an implementation model that uses Burke Litwin’s framework of organizational
change to improve and accelerate the organization along the journey of safe and reliable
healthcare

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Chapter Four: Presentation of Research
Statement of the Problem
Healthcare organizations face vast external pressures to improve their safety culture to
decrease safety events and improve the quality of care. The High-Reliability framework
provides five core principles outlined by Weick and Sutcliffe (2015). They recommend that
organizations embarking on a high-reliability culture follow guiding principles adopted
successfully in industries such as nuclear and aviation to decrease safety failure events. These
five principles comprise this study's conceptual framework: preoccupation with failure,
reluctance to simplify, sensitivity to operations, commitment to resilience, and deference to
expertise. The healthcare industry has developed these five guiding principles as the path to a
zero-harm environment; however, no implementation model thoroughly guides healthcare
organizations. There are many tools, and even more vendors, healthcare organizations look to
for implementation processes, but learning from an organization’s leading experts is an
opportunity for leaders to learn what is and is not going well. This study utilizes the lived
experiences of healthcare leaders in a single system to learn about their challenges and
recommendations for implementing HRO.
Participating Stakeholders
This study is a phenomenological case study of one healthcare system. Qualitative
interviews were conducted with eight participants. These participants were all in various
leadership roles within the organization. All of the participants were well-educated on the HRO
practices at this organization. They all were members of the HRO Implementation Committee.
The participants represented a variety of career fields, including three nurses, two physicians,
and three administrative roles. The administrative roles and additional identifying information

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are not included in this report to retain the anonymity of the participants. Many participants
wanted to ensure confidentiality in this process as they did not want to appear too critical if
comments were taken out of context, and the underlying theme was that the organization was
still early on its journey to becoming an HRO.
Method of Coding
The qualitative interviews were hand-coded to correlate with the three layers of this
study. The first layer was aligned with a research question. Once completed, they were aligned
to a factor in the Burke-Litwin Model of Organizational Change. As that was completed, the
coding aligned each comment with one of the best practices presented in the literature review in
Chapter Two. The codes used are included in Appendix B, which outlines the inclusion and
exclusion criteria for each code and an example quote.
Research Question 1: What are the lived experiences of healthcare leaders regarding HRO
principles?
The interview participants provided 243 comments directly attributed to the BurkeLitwin Model of organizational change. Of those comments, thematic coding revealed that 78 of
the comments aligned with Research Question One. These 78 comments were further broken
down into alignment with best practices presented in Chapter Two, visually represented in a
table (see Table 1). For Research Question One, there were a total of eight responses that
aligned with the best practice of storytelling. Of these eight, two responses aligned with the
Environmental Factors and six with Transformational Factors. Seventeen responses aligned
with transformational leadership. Of these 17 responses, one aligned with environmental
factors, 14 with transformational, one with transactional, and one with interpersonal. Another 17
responses aligned with the best practice of learning organizations. Of those, the majority of

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responses, 15, aligned with transactional factors on the Burke-Litwin model. Interpersonal and
organizational factors also have one alignment under learning organization. The best practice of
psychological safety also received 17 responses. Transformational factors aligned with 10 lived
experiences and seven interpersonal factors. The best practice of the KMO Knowledge Transfer
Model received the most response alignment with 18 responses. The Burke-Litwin
disbursement of these 18 responses was more widely attributed to one environmental factor, six
transactional, and nine interpersonal, and two of the responses were attributed across the board
with all factors in the Burke-Litwin model. Lastly, one response aligned with the best practice
of measuring success, and that response was attributed to the transformational factor in the
Burke-Litwin model.
Table 1
Thematic Analysis Research Question One

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This review demonstrates that leaders implementing HRO have vast perspectives on the
impacts of the safety journey across their organization. Although these leaders were in senior
leadership positions, they understood the importance across the entire breadth of the BurkeLitwin model’s five layers of organizational change. However, these leaders also focused less
on external pressures or measuring outcomes. Most of their focus was on transformational,
transactional, and interpersonal factors of change, the middle tiers of the Burke-Litwin model. A
total of 71 of 78 of their responses were in these three dimensions. Further, their focus on best
practices was relatively evenly distributed, with 17 reactions on transformational leadership,
becoming a learning organization, and developing psychological safety. Focusing on KMO and
knowledge exchange was slightly higher, with just one more response totaling 18.
Transformational Factors
The Burke-Litwin level of Transformational factors focuses on mission, strategy,
leadership, and organizational change. Respondents felt it was important for the organization to
demonstrate transformational leadership by committing to the journey of high reliability with
surety. They felt the organization was “fighting fires every day and that we are focused on
sustainability, but that sustainability and reliability were the same things.” A second leader
echoed this by stating, “finance and quality should be the same; they are different sides of the
same coin.” They agreed that quality and safety are not separate from financial stability. One
respondent felt the organization would benefit from “connecting what resonates with the staff
with what resonates with leadership.” Another thought is that it is essential to “understand the
interconnectedness” of what the organization's leadership wants and what the frontline needs to
succeed. As a leader and an HRO committee member, this leader felt that even they had
difficulty connecting the HRO principles with what the frontline is expected to do daily. A

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different leader commented that the expected behavioral change was confusing, saying, “you
cannot do HRO halfway, thinking you are going to pull people along.” Four leaders stated that
they felt the journey to high reliability was a cultural change. One noted that “we are not there
yet,” while another said, “there is no psychological safety” in the organization at a level needed
for transparency in solving problems. One leader had worked in another organization further
along on their safety culture, and they felt that “transparent debriefs [of safety issues] is how
you build trust.” These threads help us understand the importance of transformational aspects of
the Burke-Litwin change model.
Another aspect of the transformational factor is that of psychological safety. These
participants attributed 10 comments to the best practice of psychological safety. One leader
stated that it takes time to build trust, which is truly important in creating an environment where
people can bring forward controversy. Another leader mentioned that during COVID-19, one of
the organization’s senior leaders established a town hall meeting where they listened to the
voice of the frontline, establishing trust and vulnerability during a tough time. They felt that was
very helpful in building trust. A participant shared a story that they felt eroded psychological
safety when a provider, in a very public way, let it be known that they did not think the nursing
staff were able to care for a patient. This type of detrimental problem-solving erodes trust,
stating that “once you lose psychological safety, it is harder to rebuild trust.” This group
demonstrated that psychological safety was a key consideration in transformational factors and
that this concept was crucial for an organization to become highly reliable.
One of the most poignant comments regarding the transformational factor of the BurkeLitwin model was an opportunity for the organization to tie the organization’s mission to the
need to transform into a highly reliable organizational safety culture. This leader stated that if

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we do not do HRO well “and fail to take care of disparate populations in Hawaii, where there
are health inequities, health disparities, we are no better than the system and the policies, the
social policies and public policies and leadership that caused the indigenous people of Hawaii
not to be able to recover from colonization.” This is an excellent example of the importance of
an organization considering the transformational factor of organizational change while
implementing HRO. Tying it all together became a theme that was important to many of the
participants. The journey to high reliability is not easy. Realizing that the investment aligns with
the mission and financial stability can strengthen the organization's resolve to achieve a highreliability journey.
Transactional Factors
For Research Question One, 22 responses aligned with transactional factors. In the
Burke-Litwin model, this level aligns with structure, policies, implementation, and items that
blueprint how the organization manages change. Of these 22 transactional factors, the majority
(15) focused on becoming a learning organization. At this level, there were concerns that the
organization was “not set up for success.” There was concern that this would become just
another “program of the month” or a “buzzword” without any intent to stick to the cultural
change necessary. One leader showed concern, worrying that “they [the frontline] have been
telling us for years they are burnt out, but what have we done about it?” Another leader stated
that in our current state,
we do not always do a root cause analysis, and even though we admittedly identify some
of the causes, we do not track it down, we do not actually change it [the root cause] and
then reevaluate, whereas in a highly reliable organization, not only do you do a root

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cause analysis, you do a performance improvement plan to get at some of the key
causes.
Becoming a learning organization that listens to the frontline, implements change, and
feeds back results appears to be an essential aspect of this group of leaders' lived experiences in
implementing HRO. This consideration aligns well with the five HRO principles outlined in the
conceptual framework.
Interpersonal Factors
This level of the Burke-Litwin organizational change model is the daily working
environment that one finds oneself in. This is separate from a hierarchical model, as every
employee has a work setting where they must have the knowledge, skills, and abilities and
know what is expected of them, no matter what level in the organization they may work. The
Burke-Litwin Model also shows that the work setting must have a climate that fosters the
employees' needs, values, and motivations. This study attributed 18 responses to this level
(Burke & Litwin, 1992).
At this level, psychological safety again becomes essential. There were seven responses
attributed to interpersonal psychological safety. One leader stated that “psychological safety” is
the backbone of HRO. Another leader indicated that they felt that “they were not safe,”
recounting an event where a leader told them in front of everyone that they were wrong.
Another comment was that “we are not there yet,” meaning psychologically safe at the
individual unit level. There was also an acknowledgment that calling someone out at the
moment to say, “hey, that is not cool, and it makes me uncomfortable,” is asking much of
someone. These thoughts demonstrate why carefully building skills to open conversations in a
psychologically safe manner is an essential cornerstone of HRO.

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Another aspect of interpersonal factors is the importance of teaching new behaviors,
which was identified by the participants nine times and attributed to the best practice of the
KMO Knowledge Transfer Model. The participants felt that people were exhausted, so to
change behaviors, you must “make a connection with the concepts,” “thoroughly explain what
the benefit is,” and you should tie the concepts to “saving lives” or “making a significant
difference in the outcomes.” One participant stated they “think people want to do the right
thing, but they are so busy that it has to be something that is making their job a little bit easier.”
The theme here was helping the front line connect to HRO concepts and how their behavior in
adopting them will improve safety outcomes. The lived experience of these participants
demonstrated that the ability to tie these principles to behavioral change is difficult.
Conclusion Research Question One
In conclusion, 78 responses were attributed to Research Question One. Recapping the
majority, 31 were transformational factors, 22 were transactional, and 18 were interpersonal. Of
these, there was equal spreading between the best practices of transformational leadership,
learning organization, psychological safety, and KMO knowledge transfer, with the latter
getting one more attributed comment than the other three. The participants' lived experiences
highlighted that psychological safety, transformational leadership, and becoming a learning
organization, both collectively and individually, are all crucial to the success of implementing
HRO.
Research Question Two: What are the challenges faced by healthcare leaders regarding
HRO principles?
The interview participants provided 243 comments directly attributed to the BurkeLitwin Model of organizational change. Of those comments, thematic coding revealed that 62

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comments aligned with Research Question Two, and a visual depiction is provided of this
coding (see Table 2). These 62 comments were further broken down into alignment with best
practices presented in Chapter Two. For Research Question Two, there were a total of five
responses that aligned with the Burke-Litwin model and best practice of storytelling. Of these
five, two responses aligned with environmental, two with transformational, and one with
interpersonal factors. Ten responses aligned with transformational leadership. Of these ten
responses, four aligned with environmental factors, four with transformational, and two with
interpersonal. Of all of the responses, twenty-three responses aligned with transactional factors,
12 aligned with the best practice of a learning organization, and 11 with the best practice of the
KMO knowledge transfer model. An additional 22 responses aligned with interpersonal factors:
one with storytelling, two with transformational leadership, 11 with psychological safety, and
eight with KMO knowledge transfer best practices. Lastly, three responses aligned with the
organizational factor of the Burke-Litwin model, another one with the best practice of becoming
a learning organization, and two additional ones aligned with the best practice of measuring
success. Research Question Two focuses on the challenges of implementing HRO.

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Table 2
Thematic Analysis Research Question Two
Transactional Factors
The Burke-Litwin model describes the transactional level of the organization as where
structure, management practices, and system policies and procedures are implemented (Burke &
Litwin, 1992). For organizational change, these issues are essential for the successful evolution
from the current to the desired state. Participants' responses mainly were coded towards learning
organizational skills and knowledge transfer as best practices for this factor. Participants felt
that the organization was not “focused on implementation to fruition” or that “we needed better
processes” and even stated that “we were losing in some critical areas.” One respondent stated
that we have a propensity for “making our processes really complex and then customizing them
further.” There was also a feeling that there was “inertia” in the organization and that to be
successful with HRO, “we simply must do something” when referring to the feedback the
organization receives in the SCORE™ survey. These are challenges that the leaders felt they

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faced when trying to solve complex problems that impact their ability to implement the change
needed for HRO.
Interpersonal Factors
The interpersonal factor level of the Burke-Litwin model is at the individual work
setting level. At this level, the climate and the individual level of knowledge, skills, and abilities
influence their motivation, needs, and values in implementing the change the organization
desires. At this level, the respondents correlated 22 responses, with the majority in
psychological safety (11) and eight more in KMO knowledge transfer. At this level, the
respondents felt that “sometimes the VP level is unable to hear from the bottom” and that
“sometimes people at the top do not want to hear.” In contrast, one respondent gave some grace
to these leaders by saying we should consider “the bandwidth and support that those leaders get
to be able to support and nurture on top of everything else they need to do.” Additionally, a
factor in psychological safety the respondents considered was how one “gets people to feel
comfortable to talk openly about a problem.” One respondent felt that “we have psychological
safety in pockets, but it is not everywhere, and right now, I think it is based on the leaders in
those spaces,” demonstrating the importance of transformational leadership in creating
psychological safety. Another barrier to psychological safety is the fear that one participant
feels, which results from healthcare workers fearing being legally held liable and potentially
losing their license or being heavily fined. Lastly, one participant stated, “we are not ready for a
Just Culture algorithm; we are struggling with the basics.” Concerning the eight comments that
aligned with the KMO knowledge transfer difficulties in this space, the participants made
comments such as: “We need to focus on closed-loop communication,” “The organization needs
to be action-oriented,” or “Why would I share my concerns if nothing is done about it?” This

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demonstrates that the organization cannot work towards a culture of alignment of motivation,
needs, and value alignment without addressing these issues that the participants feel are barriers
and challenges to successfully implementing HRO practices.
Research Question Three: How can healthcare leaders implement HRO principles?
Of the 243 comments the participants provided, the majority (103) of those comments
aligned with Research Question Three. The participants had many good ideas about how the
organization could better support the implementation of HRO principles, which could result in
an improved safety culture. The following analysis further breaks down the comments attributed
across the Burke-Litwin organizational change model.
Of those 103 comments, 35 aligned with transformational factors, and 42 aligned with
transactional factors along the Burke-Litwin model. Of the 35 transformational factors, 21
aligned with the best practice of storytelling, and another 10 aligned with transformational
leadership practices. Of the 42 comments aligning to transactional factors in the Burke-Litwin
model, 31 of those responses attributed to the KMO Knowledge Transfer model, and 10 aligned
to becoming a Learning Organization. The last of the 42 items in the transactional factors
aligned with storytelling. For a visual representation of the overall coding for question three see
Table 3. Although they had ideas that spanned the entire Burke-Litwin organizational change
model, this analysis will concentrate on the two areas with the most significant impact:
transformational and transactional factors.

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Table 3
Thematic Analysis Research Question Three
Transformational Leadership
The participants had 11 comments aligned with transformational leadership, one at the
environmental level. This participant reminds us, "a highly reliable organization helps us have
the discipline from inpatient to outpatient to population health where you are in the community;
it is the only way you are going to make the changes that we need to reach our aspirational
goals.” They further discussed how our community's social and environmental aspects impact
our HRO journey, and it takes a transformational leader to balance both the external pressures
and the internal need to address those pressures. Another participant demonstrated that
transformational leadership looked like leaders building trust daily by “doing what they say,
saying what they do, and with that, you cannot go wrong.” Another participant demonstrated
this by stating, “it is really about what we do as leaders every day with our teams to build them
up so that they bring their voice to the table because we cannot do this [HRO] without them.”

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Others felt that having a clear roadmap was part of the bigger picture of a transformational
leader, stating, “what is our strategic road map? We aren't sustainable if we don’t have a bigger
role.” This view of transformational leadership often intersects with storytelling; it is through
tying in the actions of the leaders with the bigger story that one participant says, “helps us
showcase how we are different.” Transformational leadership is a crucial component that the
participants feel is necessary to show how and why HRO is essential, how it makes a difference,
and how the organization will organize toward the journey of high reliability.
Storytelling
Another thread was the importance of storytelling. Participants felt that the organization
should consider strengthening the ability to tell the story about why the organizational change of
HRO was needed, how it fits in with other initiatives, why it matters, and how the individual fits
into the larger picture. One participant stated, “leaders need to share that this is a three–five-year
journey, and we are unlocking little pieces over time. They must be transparent about where we
are and the pieces we are unlocking.” The participants felt that the organization should look for
help in telling this story by looking into the organization to “get the influencers and the opinion
shapers” to tell the story and shape opinion. One leader thought it was essential for us to
recognize that as leaders, we are vulnerable, “we all want to think if you are in a leadership role
that things happen because you want them to. The reality is that some people will either sink or
cause a project to flourish. It is truly a cultural change in an organization.” The commenter
further states that aligning this journey with our heritage provides an opportunity; they express
this when saying, “ideally, HRO will be a cultural change, grounded in who we are at Queen's,
grounding it in our founders, what we stand for, our identity.” There was a strength for this
organization to tell the story of HRO by having a “very direct and intentional conversations

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around centering Native Hawaiian values and HRO, and visioning what an integration would
look like.” Leaders felt that if we were successful in doing that the result would be to “integrate
DEIJ and HRO principles,” which in the end they felt that “would be the best care, right?” This
storytelling, if successful, could help motivate our organization and people to, “eliminate health
inequities, we would be thoughtful about where we put our resources, time, people, and
money.” The participants wove together a theme that HRO and the highest quality of care for all
Hawaiians was “what the King and Queen wanted for us,” they felt that “the outcomes could be
transformational, patients would feel heard and valued to get care like that, and it would feel
right.” One participant commented that we often “focus on the technical skills and checklists.
However, it is the stuff we do not pay as much attention to that matters, and it is the feelings
behind the principles that matter.” We need to concentrate on when telling the story of why
HRO matters. One participant ended the session by saying, “I'm curious though, what is the
vision of HRO longer term? What is this thing, and how do we tie it all together,” with our other
priorities? This last statement opens an opportunity for leaders to consider how they are telling
the story of HRO, why it is essential, and how to relay that to the frontline and their senior
leaders leading change and coaching throughout the organization. This critical step is one that
the study participants encourage the leadership to help them with.
Transformational Leadership
Similar to storytelling, the theme of transformational leadership was also crucial to the
study participants regarding what is needed to implement a safety culture around highly reliable
principles fully. Although some of the themes between storytelling and transformational
leadership are similar, storytelling differs in telling the why; for this study, when coding for
transformational leadership, the focus was on telling how the organization was strategically

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pursuing this journey. Participants' comments in this category demonstrated the importance of
leaders “doing what they say and saying what they do” consistently. One participant stated, “it
is really about what we do as leaders every day with our teams to build them up so that they
bring their voice to the table because we cannot do this without them.” They wanted to connect
the mission with this new program that puts safety at the forefront. Comments include, “our
mission is to bring the highest quality healthcare services to Native Hawaiians and all other
people of Hawaii. A highly reliable organization is how we will know we are doing that.” Still,
they wanted help in behaviors that help them lead at that transformational level. This indicates
that the story of our mission needs to relate to the actuality of the organization, which is walking
through the journey of cultural transformation with a safety mindset. Participants also wanted to
see how the HRO strategic journey was broken down into concrete steps, “What is our strategic
road map? We aren't sustainable if we don't have a bigger role.” Some even wanted more details
than just a strategic roadmap. There were comments like, “if we do it in chunks, we can tell
people we are gonna focus on this right now.” Participants stated they needed this breakdown of
information to support the strategic roadmap; they felt it was vital for them to know where they
and their people were on the path to training and the rollout of tools and behavior changes. They
felt that without that, their ability to be a transformational leader was hampered. Participants
also shared that they did not want to pour energy into this effort without a strategic road map to
sustain the work. They indicated that a cultural change takes accountability by saying, “you
have to have strategic discipline if you are going to make the changes that you need to make in
the time frame that you have set and with the budget you have set.” Overall transformational
leadership and storytelling are tied together. The participants are looking to the organization to
help connect the mission, the why for HRO, and the five Weick and Sutcliffe principles

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meaningfully. They also want the tools to be the transformational leaders needed in this cultural
change journey.
Transactional
In the Burke-Litwin Model, transactional factors correlate to the structure, management
practices, systems, policies, and procedures in place to implement organizational change. For
coding purposes, the exclusion criteria included transactional factors at or below the
management level of behavioral change. Inclusion factors focused on those transactional factors
that were put into place to aid the organization’s leadership team in implementing the
organization’s strategic vision. Of the 103 comments associated with Research Question Three,
42 aligned to transactional factors and ten aligned with the best practice of becoming a learning
organization, while 31 aligned with the need to develop a knowledge management structure that
aided behavioral change and knowledge transfer.
Learning Organization
In the journey to high reliability, organizations learn to prioritize daily lessons that help
grow them towards the safety culture they want to become. Amy Edmondson (2012, pp. 30-31)
states a model of execution where learning is integrated, small-scale, and almost unremarkable
as it becomes constant and habit-forming. Participants shared how important this was by
saying, “there needs to be massive changes; we can’t tinker here and there.” This mindset
allows for a continuous learning model that ensures it is a journey, not an achievement.
Edmondson (2012) also shares the importance of establishing a culture where the organization
can learn from its staff. Participants shared that it is essential to nurture a culture where one can
put oneself “out there, coming from a non-punitive way, not pointing fingers, being supportive.”
They also needed to organize a structure around sharing what we are learning. When an

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employee shares feedback and needs change, “what's the communication loop back to
staff...here's how we are going to make these changes that will improve the process.” They
stated that the feedback loop doesn’t work well now, “we make decisions, but we forget to go
back and check. We don't do the check and adjust very well.” They also stated that the structure
of continuous improvement “is important, we need to be transparent with where we are as an
organization” and that “we need to focus on PDCA cycles, we got improvement to do.”
Participants also shared that they need the organization to define their role in this change for
employees: “people need to know what their role is; as a system, we are on a journey, and there
is a methodical way of rolling this out.” Further stating that they need a repository of tools and
information to help lead that change, “one thing [that would be helpful] is to go on the intranet
and show these are the steps for [HRO] a repository, a guide, of what it looks like and the ideal
state and end goal.” Leaders also wanted to see timelines with milestones, stating, “calendar
segmentations so you know when leaders round” is helpful. Others stated that “I like timelines
on it [HRO Implementation], too.” This theme of becoming a learning organization outlines
why the Burke-Litwin model recommends that the transactional factors of organizational
change are essential in lending the structure and methodologies behind the behavioral change
that the organization wants to see.
KMO Knowledge Transfer Model
When coding the qualitative study, the information gathered after coding for the
research question and the appropriate level on the Burke-Litwin Organizational change model,
the next step was to code for best practices. For the best practice utilizing the KMO Knowledge
Transfer Model, 31 of the 103 BLM transactional factor codes aligned to KMO. Additionally,
another eight comments aligned with the best practice of KMO but at different levels of the

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organization model. The total codes aligning with BLM from question three were 39 of one
103, or 38% of all Research Question Three responses. Inclusion criteria for this coding were
individual employee behaviors that demonstrate characteristics of the KMO model: results,
behavior, learning, and reaction. Exclusion criteria were the measurement of overall
organizational or personal performance. Remembering that this model does not align with an
organization’s hierarchy is also important. Employees at every level and job need to know what
is expected of them when implementing HRO. In other words, people at all levels of the
organization want to know what behaviors they must change. They require training, tools, tips,
and techniques to align with the desired strategic organizational behavior. One participant said
this very well by sharing, “this is a culture change, and you start by telling people what you
need them to do.”
Participants whose comments aligned with the KMO best practice felt leaders could
benefit from “more clarity, focus, and accountability at the top for there to be any real
movement down at the bottom.” They wanted the organization to give them “visibility of a
system calendar” for the steps. They felt that their role was “translational practices” to make the
courses “relevant for the folks at each level,” stating, “it is our responsibility and our kuleana to
be the translator.” Participants felt that although “there were 10 courses, there was no follow
through” and that they “did not hear anything specific [in the courses] on expectations of our
behavior change” necessary for this program. They feared that for their people, they were not
sure “we have been able to connect the dots” and that it was essential for us to “tell people what
they are expected to do and what leads to cultural change.” One participant further stated: “give
people specific expectations of our behavior;” one leader even said, “As much as I hate roll
playing, that would stick better than power points,” with another one mirroring this thoroughly

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by stating: “show me what right looks like, and I will copy and repeat that.” The participants got
more granular, saying, “there is behavior change, and at a tactical level, what should be
happening?” They wanted a “roadmap of the tactical things that standardized how everybody
will do this.” One participant felt: “it is a journey. If we do not have the right tactics, follow
through, and communication, the journey becomes longer, and then you feel like you are not
hitting the right milestones.” This last comment shows the importance of KMO in implementing
change; in the end, you need to change organizational behavior to change a culture. KMO
provides a framework for program evaluation and implementation that is proven to impact
change.
Conclusion
In conclusion, the research resulted in 243 interview responses coded through thematic
analysis. The first level of coding resulted in assigning each response to one of the three
research questions. For Research Question One, 67 responses aligned with this aspect of the
study. Research Question Two had 62 responses aligned. Of the 243 responses there were 103
responses aligned with Research Question Three. The three research questions are below:
Research Questions
● RQ1: What are the lived experiences of healthcare leaders regarding HRO principles?
● RQ2: What are the challenges faced by healthcare leaders regarding HRO principles?
● RQ3: How can Healthcare leaders implement HRO principles?
After the first level of coding to a research question, the second level of coding was to
align each coded response to one of the five factors in the Burke-Litwin Model for
organizational change (Table 4). Along the Burke-Litwin model of environmental factors, there
were 14 factors aligned. The transformational factor of the Burke-Litwin model aligned with 74

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of the responses. The transactional factors aligned with 87 responses. There were 58 responses
aligned with the interpersonal factors of the Burke-Litwin model. Next, there were only 8
responses that aligned with organizational factors. Lastly, 2 responses aligned with all factors
due to the complexity and thoroughness of the participants' comments. The central themes for
this analysis were that more responses aligned with the 3 layers of the Burke-Litwin model that
closely measure the change model's internal strategic, operational, and tactical levels. This
becomes even more important as further coding offers leaders some insights into best practices
that may influence these levels of change in the organization.
Table 4
Thematic Analysis All Research Responses Coded to Burke Litwin Model
The third level of thematic coding was to take each response aligned with a factor in the
Burke-Litwin Model and further code those responses to one of the six best practices covered in
the literature (Table 4). Thirty-eight factors were thematically coded to align with storytelling.
Principles of transformational leadership aligned with 38 responses. Developing a learning
organization themes were found in 48 responses. Ensuring psychological safety in the

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organization aligned with 35 comments. The highest number of comments, 77, aligned with the
theory of knowledge transfer called Knowledge Management Overview, or KMO. Only seven
comments aligned with measuring success, the smallest number for any best practice measured.
Table 5
Thematic Analysis of All Research Responses to Best Practices
The thematic analysis allowed the research to focus on the participants' lived
experiences, challenges, and recommendations. The alignment to the Burke-Litwin theoretical
framework demonstrates where each research question aligned in the organization to
concentrate on change management. The further alignment of the research to a best practice
provides insights into what may be significant and of concern to those actively working to
implement change in the organizations. This insight supports the change models and helps the
organization develop strategies aligning with the participants' focus areas and concerns.

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Chapter Five: Summary, Implications, Conclusions
Summary of Research
Healthcare leaders have often counted improving their organization’s safety culture as a
critical strategic initiative since the initial publication of “To Err is Human” (Institute of
Medicine, 1999), highlighting the frequency of medical errors. Healthcare initially looked to
other industries, such as the airline and nuclear industries, for guidance in improving their safety
culture (Roberts, 2021). Then Weick and Sutcliffe (2015) developed the five operational
principles of becoming a highly reliable organization (HRO); preoccupation with failure,
reluctance to simplify, sensitivity to operations, commitment to resilience, and deference to
expertise. Unfortunately, there continues to be variation in how organizations implement HRO
or embark on the journey required for culture change (Veazie et al., 2019).
The literature reviewed four organizations that designed implementation models: the
Agency for Healthcare Research and Quality (AHRQ), the American College of Healthcare
Executives (ACHE), the Air Force (AF) Trusted Care, and the Institute for Healthcare
Improvement (IHI). IHI partners with Vizient and Safe and Reliable Healthcare for their model
and evaluation of the model (Frankel et al., 2017). Each model has strengths and weaknesses,
but none aligned their entire program to an organizational change model that has been proven to
effect change. The exception is the AF Trusted Care model, which discusses the importance of
Kirkpatrick’s Model of Organizational Change in training (AFMS, 2015). KMO is a model used
for training effectiveness evaluation.
To further understand how healthcare leaders may develop their own HRO strategies
and implementation models, this research utilized the overlying framework of the five Weick
and Sutcliffe (2015) HRO principles, the SCORE™ evaluation survey, and the Burke-Litwin

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change model to consider best practices. The Burke-Litwin model is used as an organizational
cultural change model supported by research to improve cultural change (Spangenberg &
Theron, 2013).
The research aimed to review the lived experience of participants who have experience
implementing HRO. This was a phenomenological qualitative study of one health system. The
research questions were as follows:
Research Questions
● RQ1: What are the lived experiences of healthcare leaders regarding HRO principles?
● RQ2: What are the challenges faced by healthcare leaders regarding HRO principles?
● RQ3: How can healthcare leaders implement HRO principles?
Discussion of Findings
The findings showed that the participants’ comments had the most significant alignment
with transformational and transactional aspects of the Burke-Litwin model. The Burke-Litwin
model (Burke & Litwin, 1992) demonstrates that transformational factors include mission,
strategy, leadership, and organizational culture. Transactional factors include structure,
management practices, systems, policies, and the unit culture (1992). Thematic coding of
participants’ comments aligned one hundred and sixty-one of two hundred and forty-three
comments to these two areas of the Burke-Litwin model. That is sixty-six percent (66%) of all
comments. This is statistically significant and warrants consideration of best practices that
healthcare leaders should consider when developing their model of HRO implementation.
Recommendations for Practice
The recommendations in this section are intended for healthcare leaders considering
how they may improve or develop their own HRO implementation model. Although this paper

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included many best practices, this section will concentrate on the three that the research
demonstrated were significant, as well as a theoretical framework for HRO implementation. The
study revealed three recommendations as best practices: the importance of storytelling related to
transformational leadership and implementing a KMO framework for program evaluation of
knowledge transfer and becoming a learning organization. The last recommendation is that the
theoretical framework followed for this study, the Burke-Litwin organizational change model, is
an essential framework for utilization by healthcare leaders who are developing a strategy for
HRO implementation. Lastly, a model for implementation is introduced for healthcare
organizations to consider when developing their journey to HRO.
Recommendation 1: KMO
The research strongly supports the participants' need for additional help translating the
information they learned about the HRO program into action. They commented on the need for
tactical demonstrations through comments like, “Show me what right looks like,” and “We do
not have the right tactics,” as well as, “There is behavior change at the tactical level; what
should be happening?” Thematic coding resulted in seventy-seven comments across all research
questions, demonstrating that enhanced support from a knowledge framework was essential to
the participants. KMO is a best practice that provides a research framework for knowledge
transfer. Transferring learning to behavior adoption is where the Kirkpatrick Model of learning
is most effective (Kirkpatrick & Kirkpatrick, p. 6, 2016). This framework is recommended as a
best practice for healthcare organizations to adopt when implementing HRO as a safety culture.
Changing behavior is ultimately how an organization develops the culture that they want to see.
Adopting an effective training model is critical to that change.

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Recommendation 2: Transformational Leadership
The research also suggests that the participants felt that the transformational factors of
the Burke-Litwin model were important. For this case study, seventy-four comments were
coded to the transformational factors and thirty-eight to the best practice of transformational
leadership. Storytelling translating the “why” for the organizational change also received thirtyeight codes. This is an essential aspect of the research for healthcare leaders to consider. The
participants felt it was important for the organization to have transformational leadership that
could tell the story of why the journey was necessary. The participants had visionary guidance
such as, “I would love to have very direct and intentional conversations around centering Native
Hawaiian values and HRO and visioning what an integration would look like.” This
demonstrates the need for the transformational leader to tie it all together, explain why the
organization is embarking on the journey, and at the same time, show the organization how it
will get there. A transformational leader can provide transparent communication and trust and
establish shared problem-solving (Northouse, 2022). There is a thread that connects a
transformational leader to the desired change the organization is seeking (Denning, p 293,
2011). The need for transformational leadership allows healthcare leaders to be bold in their
style and anticipate the need for others in the organization to see, hear, and feel what they want
from them.
Recommendation 3: Learning Organization
Another consideration from the research is the need for the organization to develop a
culture that supports its journey toward becoming a learning organization. The participants
made forty-eight comments that correlated with a learning organizational culture. One comment
includes, “What is important and a big part of making these changes is listening to the people

123
that do the job on the frontline daily.” Another participant stated, “If you listen as a leader, you
are going to get an amazing amount of feedback where people know what is not working
correctly,” both of these correlating directly to the HRO principle of deferring to expertise and
demonstrating the importance that learning organizations who are pursuing safety, must learn
from the frontline as experts in the processes they engage in daily. One way healthcare fuels the
learning process is through teaming and collaborating with groups of people who all bring their
expertise to a problem (Edmondson, p. 14, 2012). When a safety culture is visibly prioritized in
an organization through everyday behavior, information sharing, and actions, that is how
change occurs (TJC, 2017). This shared landscape of knowledge allows for the growth of a
learning organization. There are many other behaviors to consider on the journey to high
reliability, and developing practices that enhance the organization's performance as a learning
organization is a key best practice.
Model for Implementation
With no agreed-upon HRO theoretical model for organizational change supported by
research, this study offers a model (see Figure 14) for consideration and further development.
The Burke-Litwin organizational change model provides a framework for change management
that focuses on areas of concern within the organization. Further, it ties the importance of the
environmental influence, in this case, the implementation of HRO and an improved safety
culture, to organizational strategy. In the model represented as transformational factors, the
organizational strategy is the opportunity for the organization’s leaders to tell the story of the
“why” change is needed and set the vision for “how” the change will occur over time. The part
of the model that is important to develop in an organization to ensure change is the transactional
factors, which are the structure, management practices, and policies that begin to lay the

124
Figure 14
Burke Litwin HRO Theoretical Implementation Model
foundation for change that the leadership lays out in their vision. Further, the model
emphasizes the importance of providing individuals with tasks and motivation to change their
behaviors. The research supported the participants' feeling that the organization needed to give
the individuals tactical tools, tips, role modeling, and job aides to help change behavior. Lastly,
the Burke-Litwin model recommends that an organization focus on the measuring factor. The
SCORE™ is a measurement tool that supports this model. The SCORE™ survey is a tool that
helps measure an organization’s readiness for change (Safe & Reliable, 2023). The model in
Figure 14 visualizes what this may look like for organizations to follow when implementing
change.

125
Limitations and Delimitations
Limitations
This study has a few limitations that readers should consider. The phenomenological
case study limitation includes a limited ability for generalizability. The research may have
unintentional bias and subjectivity, specifically during thematic coding. This study may also be
difficult to replicate, although the research interview questions and thematic coding matrixes are
included (see Appendices A and B) to help with that. Further, this study demonstrated the
complexity of HRO implementation by overlaying the conceptual framework of the five HRO
principles with a theoretical framework of the Burke-Litwin model. This complexity may
introduce the potential for misinterpretation. Moreover, the study duration and type results in
limited triangulation, limiting the robustness of the study conclusions (Creswell & Creswell, p
2018, 200). When reviewing the study results, others must consider these limitations and
determine how to strengthen them with further research.
Delimitations
In considering this research and its applicability to other research or healthcare leaders'
utilization of the findings, one must consider the delimitations. The first is time; this study spans
a four-month timeframe. A more extended study may help improve the understanding of the
findings. Secondly, there is a geographical limitation, with this study reviewing one health
system in one state. Third, the qualitative research concentrates on the demographic of senior
leaders with experience implementing HRO. While reading this, one may consider how this
research changes if applied to broader participation. These are a few of the research
delimitations.

126
Recommendations for Future Research
As stated at the beginning of this study, there is a great need to implement a safety
culture across all healthcare settings. The need is great, and there is no agreed-upon
implementation model. Weick and Sutcliffe have given us a framework of five core HRO
principles. However, an approved model for implementing those principles to improve the
healthcare safety culture needs to be implemented.
To improve on these challenges, further research is recommended to consider how the
Burke-Litwin model facilitates a framework for organizational cultural change. It is also
essential to study the impact of implementing a KMO knowledge transfer model to evaluate the
effectiveness of training programs in achieving the cultural change necessary to improve safety
culture. There is also a need to study what transactional factors, described in the Burke-Litwin
model as structure, management practices, systems and policies, and unit climate, are practical
tools for leaders embarking on this journey towards high reliability. The foundation for this
research is to demonstrate the need for a theoretical framework to improve cultural change and
to improve understanding of the importance of the KMO model for program evaluation.
Although this research shows that leaders' lived experiences, challenges, and recommendations
align well with these recommendations, this study needs to assess what is required for those
areas to enhance a safety culture and leadership knowledge transfer. Further research is
necessary to determine if those recommendations effectively improve participants'
understanding of their role in the change and their satisfaction with the organization’s journey.
Conclusion
Over two decades after To Err is Human was published, the article that sparked attention
to safety in healthcare, we are still in the Bronze Age of improving healthcare (Bates & Singh,

127
2018). Harm events remain a leading concern for healthcare leaders. Although Weick and
Sutcliffe (2015) introduce five organizing principles for healthcare organizations implementing
HRO, it remains that there is no agreed-upon model for implementation across the industry
(AHRQ, 2008; ACHE, 2016; AFMS, 2015; IHI, 2017). Healthcare organizations agree they
want to learn from each other how to implement HRO better (Hines et al., 2008). This research
provides qualitative information on the lived experiences, challenges, and recommendations of
senior healthcare leaders actively working to implement a safety culture in a complex healthcare
setting. Their feedback aligns with the recommendations of a theoretical approach to
programmatic implementation through a model such as the Burke-Litwin organizational change
model and the importance of evaluating training programs with a theory-driven approach such
as Kirkpatrick’s Model of Organizing. Both models have published literature to assess further
effectiveness for healthcare organizations seeking a better implementation process for culture
change and knowledge transfer. Additional research is needed to study these issues further. This
study offers an approach that was not easily discoverable in the research, appears to be available
through vendors, or is readily discoverable in the study as a proven HRO implementation model
for cultural change. That lack of an implementation model and the findings in this study offer
insights for healthcare leaders to contemplate as they begin their journey toward delivering
highly reliable care.

128
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Protocols
The following appendices provide the reader with the information necessary to review
the research protocols utilized in the study. The list of semi-structured interview questions is
provided and used to conduct interviews in this qualitative study (Appendix A). Finally,
Appendix B introduces the methodology for thematic coding of the qualitative data. This
provides a framework to improve coding validity, reliability, and repeatability. These two tools
are available for other researchers to determine their organizations' readiness to adopt the five
HRO principles; preoccupation with failure, reluctance to simplify, sensitivity to operations,
commitment to resilience, and deference to expertise.

145
Appendix A
Qualitative Interview Prompts
Interview Questions Potential Probes
Bogdan and Bilken (2007)
offer the following
potential helpful probes:
1. What do you mean?
2. I am not sure that I
am following you.
3. Would you explain
that to me?
4. What did you say
then?
5. What were you
thinking at the time?
6. Give me an
example.
7. Tell me about it.
8. Take me through
the experience.
RQ
Addressed
Key Concept
Addressed
1. Are you aware of the term
HRO, short for high-reliability
organization?
High-reliability training is a
framework to improve the
safety culture in an
organization. Does that
seem familiar?
What are the most
important concepts behind
HRO?
Can you elaborate on that?
Do you have an example?
RQ1 Lived
experience as it
relates to HRO

146
2. When were you first aware
of it?
If they answer not aware
even after the prompts
above, they would not be a
good interview candidate,
and the interview would
likely terminate.
If they are aware,
Can you remember what
you first thought about this
concept?
Can you elaborate on how
you felt about the concept
when you learned the
organization would offer
training to all managers?
RQ1 Lived
experience as it
relates to HRO
3.What is your training on
HRO?
Can you remember critical
concepts or takeaways from
the training or overall
theories?
Would your initial training
be well supported by
refresher training?
Were you given any
behavior activities you
were asked to change due
to the training?
RQ1 Lived
experience as it
relates to HRO
5. How do you feel about the
implementation of HRO in
your workplace?
Can you provide any
examples of where this
concept has been easy or
hard to implement?
RQ1 Motivation as it
relates to HRO
6. What motivates you to
participate in HRO initiatives?
If there is no answer, then
a better question is, are you
motivated, and if not, why?
What makes it hard for you
to be motivated to
participate?
RQ1 Motivation as it
relates to HRO

147
7. What are your concerns
about implementing HRO in
your department or
organization?
Please tell me more about
why you think that is.
Can you elaborate or
provide a scenario?
RQ1 Motivation as it
relates to HRO
8.What do you think are the
benefits of HRO for patient
safety?
Have you seen a situation
where HRO principles
would have provided
additional safety?
Do those same concepts
benefit staff?
RQ1 Motivation as it
relates to HRO
9. How can HRO be
implemented in a way that is
motivating and supportive of
healthcare workers?
Do you feel that HRO is
helpful to staff?
Do staff understand the
purpose behind the
principles?
RQ1 Motivation as it
relates to HRO
10. What are your suggestions
for improving the
implementation of HRO in
your workplace?
Do you have an example of
what is working well?
RQ1 Lived
experience as it
relates to HRO
11. What do you think are the
biggest challenges to
implementing HRO in
healthcare?
Can you tell me more about
that?
RQ2 Barriers to
implementing
HRO
12. Can you give me an
example of when you
experienced a challenge with
implementing HRO?
How did that make you
feel?
RQ2 Barriers to
implementing
HRO
13. How could these
challenges be overcome?
Can you elaborate more on
those challenges and
solutions?
Do you have any
examples?
RQ2 Barriers to
implementing
HRO

148
14. What do you think is the
most essential factor in
successfully implementing
HRO?
What do you mean by that? RQ2 Barriers to
implementing
HRO
15. What are some of the
benefits of implementing HRO
in healthcare?
What makes you feel that
way?
How do you think others
feel?
RQ2 Barriers to
implementing
HRO
16. What are some of the
challenges that healthcare
workers face in their daily
work?
Do you have thoughts on
how that may improve?
RQ2 Barriers to
implementing
HRO
17. How can HRO help to
address these challenges?
How do you work through
that?
Can you tell me more about
that?
RQ2 Barriers to
implementing
HRO
18. What changes would you
like to see in your workplace
to improve patient safety in
your workplace?
Tell me more about that.
How does your
organization leave you
feeling?
RQ2 Barriers to
implementing
HRO
19. Can you describe any
cultural shifts or mindset
changes you have observed
within your healthcare
organization due to HRO
implementation?
Can you tell me more about
that?
How do you think others in
that scenario were feeling?
RQ3 Tips and tools
for
implementing
HRO
20. Could you share any
examples of successful
collaboration or partnerships
with external organizations or
experts supporting your HRO
efforts?
Were there any unexpected
outcomes with this
collaboration?
RQ3 Tips and tools
for
implementing
HRO

149
21. What strategies do you
employ to continuously learn
and adapt in the ever-evolving
healthcare field while focusing
on reliability and safety?
Can you provide a specific
example or case when this
occurred?
RQ3 Tips and tools
for
implementing
HRO
22. What strategies or
approaches have you found
effective in fostering a culture
of safety and reliability among
healthcare teams?
Can you walk me through
the steps you took to see
this change or process
evolve?
RQ3 Tips and tools
for
implementing
HRO
23. What are the most critical
elements that healthcare
leaders should prioritize when
implementing HRO
principles?
Why do you feel those are
important?
Are there other issues to
consider?
RQ3 Tips and tools
for
implementing
HRO
24. What strategies or tools
have you found helpful in
monitoring and measuring the
progress of HRO
implementation in your
healthcare setting?
How do you ensure the data
is available when you need
it?
How does the data inform
decision-making?
RQ3 Tips and tools
for
implementing
HRO
25. How do you ensure that
HRO principles are integrated
into your organization's
everyday practices and
decision-making processes
within your organization?
Can you tell me more about
that?
Is there a situation or a case
that you could elaborate
on?
RQ3 Tips and tools
for
implementing
HRO
26. From your experience,
what advice would you offer
to other healthcare leaders
looking to implement HRO
principles effectively?
Did you get any advice
from others when you first
learned about HRO?
How do you feel that
advice has served you?
Do you have any closing
thoughts?
RQ3 Tips and tools
for
implementing
HRO

150
Appendix B
Code Book for Analysis
Code
(word or phrase)
Description of Code
(Inclusion/exclusion criteria for each code?)
Example from Data
(quote)
RQ1 Research Question 1: Lived experiences implementing HRO What motivated me is you can save
lives
RQ2 Research Question 2: Challenges implementing HRO They don't really care about [the
actual] organizational solution
RQ3 Research Question 3: Recommendations on how to implement HRO
There is an opportunity to be much
more clarity, focus, and
accountability at the top for there to
be any real movement down at the
bottom.
BLM_EE Burke Litwin Model_External Environment; legislation, press, community engagement, board
Exclusion – anything inside of the organization
Inclusion – environmental pressures from external to the organization
People have experienced an
historical trauma in the state, and
inflation and food prices are 30%
higher.
BLM_TF Burke Litwin Model_Transformational Factors; Mission and Strategy; Leadership; Organizational Culture
Exclusion – anything external to the organization or below the senior executive level
Inclusion – Transformational vision and strategy from senior executive level to influence the organization
HR has a leadership and
knowledge component [to
contribute], and Native Hawaiian
Health has an important cultural
component to provide empathy,
compassion, and showcase how
this impacts people on a social and
emotional level.
BLM_TXF Burke Litwin Model_Transactional Factors; Structure, Management Practices, System Policies and Procedures;
Exclusion – policies, procedures, practices and structure above or below the management level of the organization
Inclusion – policies, procedures, practices and structure inside of the organization that are put in place to implement
the strategic vision of the organization’s leaders
Healthcare is complex, but I don't
think we are so complex that we
can't focus on the right thing\, at the
right time, with the right person.

151
BLM_IPF Burke Litwin Model_Individual and Personal Factors
Exclusion – Issues above the unit level
Inclusion – Climate, tasks, KSA (knowledge, skills, and abilities), motivation, needs, and values of the individual or
the individual’s work setting
Healthcare workers are burnt out
across the nation. There isn't
anything new here. We need tiered
organizational solutions that
address the problems.
BLM_IOF Burke Litwin Model_Individual and Organizational Performance
Exclusion – Items that do not measure the performance of either the individual or organization
Inclusion – Items that measure the performance of the individual or organization We scored 4% negative burnout in
our last survey, which eradicated
our ability to meet our Kai Ike Pono
goals.
BP_S Best Practice_Storytelling
Inclusion – Practices that allow the organization’s leaders and employees to understand the impact of the external
factor on the decision for change
Exclusion – Practices that tell an internal story
Leaders need to share this is a 3-5
year journey, and we are unlocking
little pieces over time. They need to
be transparent about where we are
and the pieces we are unlocking.
BP_TL Best Practice_Transformational Leadership
Inclusion – Items that demonstrate the need for or practice of transformational leadership behaviors such as setting
a vision, goals, transparency, modeling desired behavior, accountability, process improvement, and safe learning
environment
Exclusion – Items that are external to the organization or below the senior leadership level A unionized environment [makes it
difficult to implement change that]
could tip the neutrality of the
bargaining table.
BP_LO Best Practice_Developing a Learning Organization
Inclusion – Items that demonstrate the importance of learning as a system, growing from adversity, sharing best
practices, and adopting technology, frameworks, and operations that improve as a whole
Exclusion – Items that are at the unit level I have never seen more convoluted
process[es] in my life, and as a
result, they need more staff.
BP_PS Best Practice_Psychological Safety
Inclusion – Behaviors in an organization that help others feel safe and included to share and are proactive at
avoiding safety events.
Exclusion – Transformational leadership individual behaviors.
People have psychological safety in
their units until the VP level, with
some relative safety beyond the VP
level.
BP_KMO Best Practice_Knowledge, Motivation, and Organization Theory
Inclusion – Individual employee behaviors that demonstrate characteristics of the KMO model results, behavior,
learning, reaction
Exclusion – Behaviors that measure overall organization or individual performance. [People need] tools and a
framework [for HRO
implementation]

152
BP_MS Best Practice_Measuring Success
Inclusion – Tools or techniques that measure organizational success
Exclusion – Tools that measure a limited change in behavior such as an individual’s performance on a single test We scored 4% negative burnout in
our last survey, which eradicated
our ability to meet our Kai Ike Pono
goals.

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Asset Metadata

Creator Gormont, Kara Ayn (author)

Core Title Healthcare leaders developing highly reliable organizations

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2024-08

Publication Date 07/17/2024

Defense Date 04/30/2024

Publisher Los Angeles, California (original), University of Southern California (original), University of Southern California. Libraries (digital)

Tag Burke-Litwin,highly reliable,high-reliability,HRO,KMO,learning organizations,OAI-PMH Harvest,transformational leadership

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Language English

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Advisor Riggio, Marsha (committee chair), Allen, Todd (committee member), Madni, Ayesha (committee member), Trahan, Don (committee member)

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