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What is HRO?

High Reliability Organizing (HRO) developed as a means to make an organization or unit stronger. In its natural state we historically found it in environments of danger or uncertainty such as military combat, firefighting, or business activities. While proactive components (plans and anticipation) and reactive components (after action reviews) are necessary parts of HRO, High Reliability itself derives from the ability of the organization and individuals to interact in real time with uncertainty or threat from the external environment.

HRO describes on the organizational level the structure necessary for High Reliability, on the social level the collaboration found in response to threat, and on the individual level the satisfaction of problem solving while modulating threat responses. These three levels facilitate the free flow of information and the migration of action for a quick response to, and interaction with, surprise or accelerating events. The High Reliability Organization emerges from the interactions between people responsive to the environment in an organization that allows this.


Mr. Daved van Stralen

MD,FAAP, President

Van Stralen, Daved, MD, FAAP

Dr. van Stralen collaborated with Ronald M. Perkin, MD, FAAP, FCCM to create a Pediatric Intensive Care Unit at Loma Linda University Children’s Hospital. Dr. Perkin is a former US Navy Aviator who flew the A-4 in combat during the Viet Nam War. To create the PICU they used principles from pre-EMS ambulance, fire service, and US Navy Aviation which was later described by Karlene Roberts as High Reliability Organizing. He used his fire EMS background to improve the pediatric critical care transport service which had quality, safety, moral, and service problems and served a geographic area four times the size of Vermont. He also developed the nation’s first clinical academic Emergency Medical Care bachelor’s degree for paramedics that was not administrative. He then moved to a troubled pediatric nursing home where he used a fire service/EMS model with critical care principles to change it into the state’s model for subacute care. He collaborates with safety, risk, and reliability experts from wildland firefighting, business, and health care in the US and Europe to identify common approaches the individual uses to ensure safety and reliability. He has traveled extensively in Europe studying HRO in multiple industries and developed a relationship with the Bouches du Rhone Fire Service (SDIS 13) which became the source for the US Forest Service-SDIS 13 HRO collaboration.

He is an Assistant Professor of Pediatrics and a pediatric critical care physician on staff at Loma Linda University Children’s Hospital and Children’s Subacute Center at Community Hospital of San Bernardino (California); Adjunct Professor of Emergency Medical Service at Crafton Hills College, Yucaipa, California; medical director for American Medical Response, San Bernardino County; and President, Strategic Reliability, LLC. He served as Medical Director for San Bernardino County Fire Department (covering 20,000 square miles) for ten years. He worked in South Los Angeles as an ambulance man and fire department rescue ambulance driver for the Los Angeles City Fire Department in the 1970s. By one review, he is the first career paramedic to attend medical school. He has a Bachelor of Arts in Social Ecology and a Bachelor of Science in Biological Science from the University of California, Irvine; an MD degree from University of California at Irvine College of Medicine where he completed his Pediatric Residency. He completed a Pediatric Critical Care Fellowship at Children’s Medical Center and Parkland Memorial Hospital, Dallas, Texas.

Published Research:

Roberts K, Madsen P, Desai V, van Stralen D.  A case of birth and death of a high reliability healthcare organization.  Quality Safety Health Care 2005;14(3):216-220

van Stralen D. High reliability organizations:  Changing culture of care in two medical units.  Design Issues 2008; (24): 78-90

van Stralen D, Calderon R, Lewis J, Roberts K. 2008. Changing a pediatric sub-acute to increase safety and reliability in Patient Safety and Healthcare Management, Advances in Health Care Management, vol 7:259-282 (2008) EW Ford & GT Savage [eds] Macmillan Publishing Solutions

van Stralen D. High reliability organizations:  Changing culture of care in two medical units.  Design Issues 2008; (24): 78-90


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