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Center for Health Equity Research and Promotion

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Health Equity key to High Reliability

VA is committed to equity as key to High Reliability Organizations

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

By VA Center for Health Equity Research and Promotion
Monday, September 20, 2021

Equity as Crucial Element of High Reliability Organizations

As many health systems have been working to become high-reliability organizations (HROs), health equity has been largely absent from discussions and applications of HRO principles. This is a serious oversight. Disparities in health and health care represent systematic failures to achieve reliable outcomes for certain groups. Acceptance of disparities is antithetical to the essential HRO goal of “zero harm.” We propose adding Equity to HROs in the most literal sense by designating it as a key component and achieving High Equity Reliability Organizations. We describe how equity should be a crucial element of all 5 HRO core concepts: sensitivity to operations, preoccupation with failure, deference to expertise, resilience, and reluctance to simplify. VA experts Drs. Ernest Moy, Leslie Hausmann, and Carolyn Clancy propose adding equity to the HRO framework to become a High Equity Reliability Organization (HERO). HEROs should make changes to care delivery to achieve equitable outcomes and not just eliminate disparities in processes. 



Ernest Moy, MD, Director of VA Office of Health Equity

Leslie Hausmann, PhD, CHERP COIN Investigator and Director of CHERP's Health Equity Capacity Building Core

Carolyn Clancy, MD, VA Assistant Under Secretary for Health, Discovery, Education and Affiliate Networks


American Journal of Medical Quality

Citation:  Moy, Ernest MD1; Hausmann, Leslie R. M. PhD2; Clancy, Carolyn M. MD3 From HRO to HERO, American Journal of Medical Quality: September 8, 2021 - Volume - Issue -
doi: 10.1097/JMQ.0000000000000020 


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

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

An early proponent of HROs, the Veterans Health Administration recently completed full-scale implementation of an HRO-guided framework at its Harry S. Truman Memorial Veterans’ Hospital. Following a study showing that the framework decreased mortality and complication rates, Veterans Health Administration is driving system-wide spread. Withmany other health care organizations doing the same, now is an opportune time to become a HERO.  The HRO philosophy enables organizations operating in complex, high-risk environments to minimize system failures and mitigate their effects..."

The contents of this article and this website do not necessarily reflect the views of the Department of Veterans Affairs or the US government.


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