Developing a high reliability organization framework for the Indonesian hospitals

High Reliability Organizations (HROs) are entities that maintain consistently high performance in complex, high-risk environments by minimizing errors and enhancing safety. While HRO principles: Preoccupation with Failure, Reluctance to Simplify, Sensitivity to Operations, Commitment to Resilience, and Deference to Expertise, are well established in sectors such as aviation and nuclear power, their application in Indonesian healthcare remains limited. This study aims to explore, adapt, and validate an HRO model for hospitals in Indonesia, ensuring its cultural, operational, and contextual relevance. Methods: A sequential exploratory mixed-methods design was adopted. Phase 1 involved a systematic review using PRISMA guidelines across PubMed, Scopus, Web of Science, and Google Scholar (2012-2022) to identify HRO frameworks applied in healthcare. Phase 2 consisted of qualitative interviews with senior officials from four hospitals (types A, B, C, and D) in Bogor, Indonesia. Phase 3 used a quantitative survey to conduct Confirmatory Factor Analysis (CFA) to validate identified dimensions and indicators. Results: The systematic review identified five key HRO dimensions and 24 reliable indicators (Outer Loading > 0.7). CFA confirmed construct validity (AVE > 0.5) and reliability (Composite Reliability > 0.8). Notably, three new indicators relating to innovation were integrated into the Commitment to Resilience dimension. The validated model is context-specific and applicable across different hospital types in Indonesia. Conclusion: The study presents a validated five-dimension, 24-indicator HRO model suitable for Indonesian hospitals. Implementing this model can enhance patient safety, strengthen operational resilience, and optimize quality management systems

Confirmatory factor analysis · Exploratory factor analysis · Indonesian · Systematic review · Validity · Healthcare Quality and Management · Occupational Health and Safety Research · Patient Safety and Medication Errors