Daved van Stralen

Loma Linda University · Department of Pediatrics

When an organization has a learning orientation, operators are attracted to problems-a new learning experience. When the primary orientation is performance-based, operators become inclined to avoid problems, thus protecting themselves from criticism and failure. The combination of learning and performance orientation drives the organization to incr...

People are educated and trained in white noise environments, becoming acculturated to structured work settings and solving well-defined, information-sensitive problems. However, HROs operate in open systems with various patterns of energy fluctuations. The problems encountered are ill-structured and embedded into an environment. These problems are...

Before assessment, before full awareness, people respond to abrupt changes in their immediate environment. This trait, shared by a wide variety of animal phyla, is "animal personality" that covers three behavioral syndromes: boldness to shyness, exploration to avoidance, and level of activity. These phenotypic syndromes shape the animal's immediate...

An organization cannot become more robust and maintain stability by thinking, planning, or experts. When adversity exposes the organization's weaknesses, the organization can identify the traits and behaviors where learning must occur. While all organizations learn from adversity, some will direct learning to seek better homeostatic security. The H...

Becoming reliable and safe appears straightforward: identify effective traits from high-reliability organizations (HROs) in hazardous environments and adopt them in other contexts. However, adopting HRO principles in less hazardous environments has been limited and often misunderstood. Decades of research and attempts to incorporate HRO practices h...

Preparing for catastrophic events necessitates understanding the dynamic interplay between perceived reality and the objective world. However, severe crises can disrupt this process, leading to cognitive impairments and fear-driven responses. The gap between perceived reality and the actual world becomes pronounced during significant crises, prompt...

This discussion delves into the critical dimension of time in emergency response scenarios, highlighting its often-overlooked significance in decision-making processes and organizational frameworks. Drawing from a harrowing incident reminiscent of the 1992 Los Angeles riots, where assailants violently attacked a truck driver, the narrative unfolds...

In dangerous work domains, such as firefighting and military aviation, subjective reasoning, adaptability, and social knowledge play crucial roles alongside technical expertise. However, prevailing views often prioritize objectivity over subjectivity, leading to a skewed understanding of effective practices. Drawing on anecdotes from a Los Angeles...

The manuscript delves into the challenge of establishing order in chaotic, hazardous environments, emphasizing the interplay between human actions and dissipating energy. Identifying which actions resolve or worsen disruptions is complicated, often dependent on timing and context. The inadequacy in recognizing the capabilities of organized human ac...

How odd that we engage dynamic, accelerating situations with static, well-defined, and discrete concepts as our frames of reference. It does seem prudent to use well-accepted frames of reference for risky operations. For example, we commonly rely on standards of care and evidence-based medicine for routine and emergency care. Standardized frames of...

How we perceive time influences our study of time. We may perceive time as continuity or a series of instances. Most likely, we perceive time as a quantitative continuum that we add to – how much time? We discriminate quantitative measures by additive or “prothetic” processes. Time as a quantitative continuum is a “prothetic process.” Prothesis in...

This abstract summarizes critical insights from the manuscript, focusing on lessons learned in neonatal disaster response. The manuscript emphasizes the multifaceted challenges in such scenarios, including environmental issues, clinical care considerations, staffing concerns, communication difficulties, simulation needs, government agency collabora...

The gap between theory and practice is a liminal space with its own logic and language. To introduce HRO to a program, we can remove select words that interfere with thought. Replacement words from organization members will soon initiate the "HRO mindset." Terminating clichés, a method used in brainwashing, is unnecessary for thinking and discussio...

We encounter the unexpected without previous preparation. Likely , this occurs from energy entering our environment as a forcing function or causing abrupt change. Some rules continue to apply while others do not-and we cannot know which is which. Our theories and concepts become separated from our practice and what we are experiencing. Improvisati...

Red noise produces functions forcing a response from a population. Pink noise creates abrupt catastrophic change that may require resetting or changing learned behaviors at the moment, if not starting over. For some reason, the organized approaches for these situations derive from stable white noise environments. These environments differ significa...

Rather than describing the environment as a structural entity, the HRO views the environment as the flow of environmental energy. Energy has frequencies, and we can use sound and light to model characteristic energy flow patterns. White light contains all wavelengths of visible light. Long wavelength light (low frequency or long period) is red. Red...

We engage contingencies to make them more orderly. Removing context supports objective approaches that are also more orderly. 'Subjective' becomes a derisive term. Preparation for abrupt change includes well-developed plans and people who follow those plans. The event itself is not a part of the planning. This resulting normative stance is transpor...

Full-spectrum analysis: A new way of thinking for a new world (1). Dennis Kowal, a neuropsychologist with the Institute for Defense Analysis, was working with us regarding the psychology of HRO. He introduced us to your paper shortly after it was published, advising us that "Full Spectrum Analysis" (FSA) had a major influence on military tactics an...

Information has specific qualities that adapt it for engagement. Correlation as a descriptive term strengthens engagement, while causation as an explanatory term can mislead engagement. Information flows and has a contextual range of values and can combine with local experience. Information is stored as revisable (belief) versus not revisable (know...

The characteristics of abrupt crises are the elements that cause stress and fear. Stress impairs cognition, fear generates defensive behaviors, and existential threat drives aggressive behaviors. Nobody wants this; organizations expend effort to prevent or mitigate stress and fear. Unfortunately, these efforts promulgate and normalize belief in the...

Understanding and engagement have a strange relationship with a situation. We fit the situation into our understanding, then use the situation to extend our understanding. We do this through engagement. Engagement is what bridges the gaps between objective knowledge and subjective experience. The situations we engage in are moving toward disorder....

Organizations do not engage. People engage. There are circumstances we encounter when we cannot choose not to act. Unfavorable risk-benefit ratios are not a reason to decline. Lack of Engagement becomes Karl Weick's 'enacted failure by not acting.' Engagement is contextual acting within an unstable environment, and that acting removes constraints o...

Random, stochastic variation creates fluctuations in the environment. The organization must respond as these fluctuations become forcing functions or create an abrupt catastrophe. This variation is described by the color of noise-reddened noise frequencies or pink noise. Operations during these events uncover gaps between theory and practice, which...

Lessons Learned programs are continually at risk for “conceptual arrest” – the Lesson Learned that is a concept, an abstraction, something that has not, and cannot, be contextualized. A disaster creates abrupt gaps between what we thought we could do with what we must do, with the urgent necessity to engage the situation. Lessons Learned convert th...

We reviewed published first-person accounts of NICU staff who experienced disasters and were published in the medical literature. A disaster comes from stochastic environmental noise acting as ‘forcing functions,’ the strength of the environment to force a system or population to respond. The sensory effects in a disaster are overpowering – sounds,...

High-Reliability Organizations emerged as an effective response to consequences. Designing a response from the antecedent events, causation, or the situation misses vital subtle, and nuanced information. Immediate consequences from apparently mundane circumstances, forcing functions, or abrupt catastrophic events share the same possibility of outco...

The human brain evolved to act against consequences, yet decision making models rely on information processing. Crises occur in volatile environments, yet organizations rely on plans and planning. The gap between fluctuating events and static concepts and models creates inconsistencies that are solved under pressure at the local level. We identify...

HRO emerged from engagement with a flux of contingencies to make them more orderly. We cannot treat these environments as isolated systems with demarcated boundaries. Instead, the environment comprises of open, contextual systems always in flux. These sequential events are better viewed as ‘state vectors’ acting like arrows in time, rather than dis...

High Reliability Organizations engage threats and adversity to maintain reliable operations. Human stress, fear, and threat responses drive safe and effective engagement of environmental threats. The executive functions integrate perception from opposite ends of the brain, hastily created plans, and motor activity. During a crisis, the hypothalamic...

The human mind evolved to naturally engage adversity – whether in the environment or from an enemy. Behaviors and our environment will be unpredictable because they are continuously oscillating, creating frequencies, and some of those frequencies have long periods. It is the long period frequency, acting alone or with other long period frequencies,...

The aviation industry operates in an environment where forcing functions and catastrophes can be deadly to the public and not easily explained away. The industry formed a safety improvement collaboration known as CAST, the Commercial Aviation Safety Team. Within ten years, the fatal accident rate decreased from the pre-CAST rate by more than 80% wh...

To prepare for and operate in stochastic environments we study, and even master, academic models. The environmental stochastic noise separates the world of practice from scientific theory. Oscillating and fluctuating processes create frequencies of power, the color of noise, and unpredictability. These environments also contain the determinants of...

Oscillatory processes, basic to the functions of life, are intrinsic to the stability of physiological systems. After oscillations gain stochastic resonance, the power spectrum increases in lower frequencies as environmental stochastic noise, uncommon events gain greater influence on the system. Even weak or relatively small stochastic noise can cr...

The Hurricane Environment. For those who do not live where hurricanes are common, we offer a short glossary of terms to better appreciate the events and threats during a hurricane.

NICU preparation for a hurricane includes evacuating or sheltering neonates, agreements to transfer neonates, communication, and emergency transport systems to move neonates to safer ground. Under-represented are identifying the skills and capabilities to support a neonate for hours, if not days, in an austere and adverse environment. The successfu...

The frequencies of stochastic noise inherent to the environment can be described as colors. The various colors of noise refer to the disruptive potential of stochastic energy within the environment and its characteristics. The meaning of the type of noise lies in the unpredictability of events and the 'forcing functions' of energy. That is the stre...

An abrupt disaster brings the environment physically into the NICU. We describe immediate evacuation measures taken because of a ruptured water pipe, hospital fire, unexploded WWII bomb, and two earthquakes. These abrupt changes thrust the Neonatologist into an environment with new structures, rules, and threats. The intruding environment dictates...

A disaster is an environmental disruption of medical care, a victim generator that disrupts the ability to treat multiple patients. We classify to understand and make sense of the world, but a disaster has flux, uncertainty, and ambiguity, bedeviling our ability to classify. Structures in the abstract are more amenable to classification and give a...

Wildland fire threatens the hospital, evacuation routes, and even the use of vehicles. Smoke-filled air endangers the neonate inside the NICU or ambulance, while poor visibility can ground helicopters. The wildland fire environment is continuously changing from fire behavior determined by topography, fuel characteristics, and wind. This creates a f...

Disasters that affect health care delivery seem to be happening with increased frequency and can be found all around us. Within the last month, the Caldor Fire in Northeast California resulted in the evacuation of Barton Memorial Hospital in South Lake Tahoe, August 30, 2021. Hurricane Ida caused the loss of electrical power and loss of water to Ne...

A disaster is an environmental disruption of medical care, a victim generator that disrupts the ability to treat multiple patients. Death can come from physiological, physical, social, or behavioral threats within the disaster environment. Legal or administrative definitions of disasters are necessary for out-of-area resource allocation. Topologica...

We view and understand the world through our internal logic, both public and private internal logic. The logic of practice differs by the frame of reference – a fixed point or within the flux of events, which can have “cosmology episodes” that collapse sensemaking. We have different perceptions and capabilities from the differ- ent reference frames...

Organizations do not make decisions; people do. The entropy of any system moves toward disorder of its elements and the corruption of information as it is transmitted. This flux creates uncertainty. As we gain additional information, we find that the property of monotonicity from classical logic and scientific reasoning does not allow us to change...

We find descriptions of the use of common sense in the domains of anthropology, artificial intelligence, and psychiatry. This is the common sense for adaptation, a form of practical intelligence that better predicts success in everyday experiences, if not real-world survival. This common sense is experienced-based knowledge, rather than rule-based....

Neonatologists built the science of neonatology with logic and rationality. The cognitive processes of scientific rationality and classical logic, developed for a structured environment, are poorly defined for operational use. The first impairments from even mild uncontrollable stress are in the cognitive and memory areas of the brain. A 'cosmology...

Neonatology began with the extension of care to smaller babies born earlier in gestation and now extending into the threat of COVID-1. Extending operations into a new environment places everyone in novel situations. Emerging from actual operations within dangerous contexts, HRO extends operations and the organization into uncertain, adverse, and ho...

HRO has become better studied, producing concepts that bring clarity to its structure and function. Reliability, safety, and resilience, as concepts, do not carry the same immediacy of a fellow worker in danger or bringing a novice into the workforce in a way that that novice may save you. Reviewing how workers did their jobs while ensuring their o...

Life abruptly becomes chaotic. This is much like crossing a threshold into a room where we don't belong. The chaotic situation entrains energy and resources, forming a trajectory to cascading failure. The HRO accepts this trajectory and members of the HRO engage in events even as they do not know how to bring it to an end. This is the liminal perio...

Not by leaders, nor by rules, nor by design does the individual engage in a turbulent scene. The individual must have “the kind of knowledge which is supported only by observations and is not yet proved,” Leonhard Euler. The Art of Neonatology is the art of observation. Let your looking teach you. Even in complexity and chaos, we observe elements t...

Attempts to climb Mount Everest failed for thirty years until a mountain climbing physiologist joined the efforts. This story demonstrates the value of context, inductive processes, and pragmatism to generate local knowledge and solutions in austere, hazardous environments. In these environments, imperfect information and inaccurate models can kill...

COVID-19 has changed the social, financial, and political environments for healthcare. Healthcare organizations have abruptly changed operations for a new environment due to pervasive threats to the organization, patients, and healthcare professionals. While the direct, infectious presence of COVID-19 as a threat would seem to cause the greatest st...

Stress has become an organizational characteristic. Organizations work toward stress reduction, seek stress management, increase cognitive capacity, attend to our mindfulness, and refer staff for anger management. The HRO acknowledges that stress, fear, and threat are natural elements of dangerous work. In fact, they are integral to, and support, a...

Stress and fear have biological functions that, when neuromodulated, make adaptive otherwise maladaptive responses. While the concept of a defensive cascade supports cognitive understanding and hypothesis testing, approaching this domain by function using an ecological approach brings the pragmatic stance with methods for prevention and interventio...

An organization’s High Reliability Organization (HRO) attributes can become impediments to generating reliability and safety in ill-structured, dangerous, or life-preservation contexts. To what extent do subjective perceptions of what constitutes “reliability” develop into attack vectors for self-inflicted organizational sabotage? How could interna...

A pregnant mother with a highly infectious disease delivers an infant who does not have the infection. Management of the mother and infant follow published guidelines. The mother and infant are discharged without complications (1). Free of context, the reader could view this case report as trivial. The reader would then miss the influence of pandem...

The threat of COVID-19 to professionals has become personal. Professionals in neonatal healthcare can acquire infection and unknowingly become a vector, infecting babies, and their colleagues. A pragmatic stance of leadership, derived from leadership in extremis, communicates to subordinates that leaders have their immediate well-being in mind whil...

The COVID-19 crisis has created a physical environment where neonatologists and neonatal staff face exposure to an easily transmissible, potentially fatal infection in the course of their duties. Leaders cannot reject an assignment, such as a resuscitation of a newborn, because of risk. As in military operations, safety and capability cannot be sep...

The Covid-19 crisis demonstrates the difficulty of translating a method of organizing developed for extreme hazards to organizations with similar demands to be failure free but in a markedly less hazardous environment. Three central reasons for this, discussed in this paper, are 1) the incomplete translation of HRO theory into practice, 2) the char...

Several consequential factual errors have led some authors to misunderstanding of the public safety response to the San Bernardino Terrorist Incident. Victim extraction by law enforcement began five minutes after entry, completed in 18 minutes. Within 18 minutes the fire department triaged, treated, and initiated transport for 14 patients, none of...

High Reliability Organizing (HRO) describes an effective approach to engage an active, complex environment with little, if any, identifiable structure. The authors use multiple scientific disciplines to discuss how these situations arise and the basis of effective responses to prevent or respond to these crises. Though addressed to healthcare, the...

The San Bernardino City Fire Department responded to an active shooter incident. Probation officers joined police officers to extract 15 patients to a casualty collection point, then by vehicle to the triage area. A team of firefighters with a tactical medic entered the hot zone to aid in care. Within 18 minutes the fire department moved 14 patient...

Introduction: The California Prehospital Antifibrinolytic Therapy (Cal-PAT) study seeks to assess the safety and impact on patient mortality of tranexamic acid (TXA) administration in cases of trauma-induced hemorrhagic shock. The current study further aimed to assess the feasibility of prehospital TXA administration by paramedics within the frame...

Although concepts of high reliability are promoted widely in acute care, little is known about the extent to which the core processes of high reliability have been applied to infection prevention practices in nursing homes and assisted living facilities. In a previous article, the authors reported use of high reliability concepts in current literat...

Though concepts of high reliability are promoted widely in acute care, little is known about the extent to which core processes of high reliability have been applied, directly or indirectly, to infection prevention in nursing homes and assisted living facilities. In this review, we sought to identify examples of effective or innovative infection pr...

The smaller and incompletely developed organ systems found in infants and children, necessary to facilitate birth, can create diseases and medical conditions not found in adults, affect the child's physiologic ability to respond to illness or injury, and influence pediatric therapeutic modalities. This can perplex medical caregivers not trained in...

The smaller and incompletely developed organ systems found in infants and children, necessary to facilitate birth, can create diseases and medical conditions not found in adults, affect the child’s physiologic ability to respond to illness or injury, and influence pediatric therapeutic modalities. This can perplex medical caregivers not trained in...

We use the principles of HRO as characterized by Karlene Roberts to initiate mechanical ventilation in a free standing pediatric subacute care facility. We do not have available laboratory or radiologic studies and must use the process of HRO and clinical judgment. There is no physician on site.

Ambiguity is a central problem for operators working in dynamic, high-risk environments. Operators must decide on a course of action before knowing with certainty how the system will respond. Though ambiguity is expected, how it presents is unexpected. We reduce ambiguity when we can give meaning to information and events through use of context, re...

Special Operations Forces (SOF) may use mechanical ventilators in operational and austere settings. In the intensive care unit ICU) the settings for mechanical ventilation (MV) are guided by blood gas analysis and Patient-Ventilator Asynchrony (PVA) is commonly managed using drugs. However, long-term care facilities manage ventilator-dependent pati...

We describe a case of a soldier with upper airway obstruction from an explosion where a delay establishing a surgical airway occurred because of difficulty evaluating the functional status of the airway. We then describe how a rapid, visual five-point respiratory exam can be used operationally. A five-point respiratory examination that is rapid, do...

Enactment describes how we engage the situation to make sense of it. But by our engagement, we also change the situation. Our presence, alone, will change the situation. At times, we may fail to act. Here, we are at risk of interpreting this as a sense of personal "limitation" in what we can do. This will inhibit us in engaging in other incidents....

To offer a theoretical explanation for observed physician resistance and rejection of high reliability patient safety initiatives. A grounded theoretical qualitative approach, utilizing the organizational theory of sensemaking, provided the foundation for inductive and deductive reasoning employed to analyze medical staff rejection of two successfu...

Creation of a High Reliability Pediatric Subacute Care Facility without a budget or the knowledge and permission of the larger organization.

In the trench warfare of WWI, the U.S. Army assigned nonphysicians to the trenches for treatment of casualties. In WWII, these first aid men entered combat, becoming the corpsmen and combat medics in service today. Also during WWII, the Army introduced air transport of the injured; followed in the Korean Conflict and the Vietnam War by helicopter t...

A disaster will displace technology-dependent children from their medical home. Existing receiving facilities are limited to acute care hospitals for emergency departments (ED) for evaluation, acute care ward for placement, and, in some cases, the intensive care unit (ICU) for ventilator support. A pediatric subacute care facility (SCF) can serve a...

This chapter describes the efforts of a team of health care workers to make a sub-acute health care facility (SCF) serving profoundly damaged children into a high reliability organization (HRO). To obtain this goal, the health care team implemented change in four behavioral areas: (1) risk awareness and acknowledgment; (2) defining care; (3) how to...

We use the five principles of High Reliability Organizing, identified by Weick and Sutcliffe, to socialize staff into High Reliability Organizing and creating a safety/HRO culture.

We use the culture of wild land firefighting and the methods of High Reliability Organizing as a benchmark for culture change in a pediatric subacute care facility.

Nursing homes often do not follow prescribed protocols as California State law does not allow the use of protocols in a nursing home. Physicians are rarely present when respiratory failure occurs in a Subacute Care Facility (SCF). We describe the use of the Boyd OODA Loop by RCPs in these situations. We evaluated the process of using OODA Loop by m...

This paper addresses the effectiveness of RCPs as a source of reliability in the face of unexpected respiratory failure in a high performing subacute care facility (SCF). SCFs specifically provide care for technology-dependent residents (ventilator, tracheostomy and gastrostomy) at a higher level of service than nursing homes but below that of acut...

The use of the Boyd OODA Loop by bedside Respiratory Care Practitioners to initiate mechanical ventilation for acute respiratory failure in chronically ill, technology-dependent pediatric patients.

It is a strongly held belief in respiratory and critical care that mechanical ventilation is a severe burden that causes a great deal of physical and psychological stress. This is also missed as most Quality of Life measures do not use smile or laughter as a parameter. After the initial critical illness, our experience is that the ventilator can be...

A nursing home has sufficient resources for the needs of nursing home patients. Subacute Care Facilities (SCF) specifically provide care for technology-dependent residents (ventilator, tracheostomy and gastrostomy) at a higher level of service than nursing homes but below that of acute care hospitals. The level of service increases from nursing hom...

High reliability organisations (HROs) are those in which errors rarely occur. To accomplish this they conduct relatively error free operations over long periods of time and make consistently good decisions resulting in high quality and reliability. Some organisational processes that characterise HROs are process auditing, implementing appropriate r...

Free-standing subacute care facilities does not have laboratory or radiologic services immediately available. In addition they are not constantly staffed by physicians. Consequently, bedside Respiratory Care Practitioners must adjust the ventilator by clinical examination. This study presents our experience using a five-point respiratory exam to gu...

Thick secretions interfere with mechanical ventilation, particularly with children, who have narrow, small airways. They also contribute to development of atelectasis and increased risk for pneumonia. Therapies for thick secretions include chest physiotherapy, mucolytics or mechanical devices (High Frequency Chest Wall Oscillation [VEST], cough ass...

PTSD in children gained recognition with the first report after a Buffalo Creek dam collapse in 1972 (Green, et al., 1991). Stressors such as acute trauma, loss of a caretaker, and personal lack of safety have been identified and researched extensively. The current study examined the effects of invasive medical procedures on the levels of PTS sympt...

Studies indicate that medical procedures may cause post-traumatic stress (PTS) symptoms (fear, avoidance, irritability) in children. It is suggested that midazolam hydrochloride, a sedative/amnesic medication used in pediatric intensive care units (PICU), may prevent the development of PTS symptoms. This study examined if PTS symptoms are related t...

When paramedics arrive on scene a subacute care facility they may have to transport a ventilator-dependent child. Nursing homes are not allowed to sedate residents. Paramedics can immediately learn to hand ventilate these children.

Nursing home staff provide long-term care with few acute changes while EMS providers work in an episodic nature with dynamic, high-risk problems. Intuitively, and by experience, they have conflict. Our experience is that by understanding the purpose of each and the nature of their interactions we can reduce the natural friction between them.

Children in long term care who are profoundly disabled have limited means to communicate comfort or discomfort. Consequently it is difficult to know if the care provided brings them comfort let alone pleasure or happiness. Demands of clinical care and intrusive technology, coupled with severe developmental delays, often preclude the emergence of ex...

The use of High Reliability Organizing to develop a pediatric skilled nursing facility into a subacute care facility providing safe and reliable chronic intensive care.

Paramedics arrive on scene and are taught the specific method and pattern for a ventilator-dependent patient being transferred to the Emergency Department

A pediatric subacute care facility is an unrecognized resource for the surge of a terrorist event. Staff are familiar with mechanical ventilators and providing intensive care in an austere environment relatively independent from immediate oversight by a physician