The Three Sub-Phases Before a Crisis: Evaluating Preparations for the COVID-19 Pandemic Through the Lens of High Reliability Organizations and Resilience Engineering

This study investigates how a selected regional public healthcare system (RPHS) in Sweden prepared for and responded during the pre-crisis phase preceding the COVID-19 pandemic. Employing a qualitative methodology, eight semi-structured interviews were conducted with employees from the RPHS, and the data were analyzed using thematic analysis. Six key themes emerged from the analysis: understanding the situation, preparations, applying the pandemic preparedness plan, organizational changes, challenges, and co-operation. A significant contribution of this study is the identification of three distinct sub-phases within the pre-crisis phase: (1) actions undertaken preparing for an unknown future pandemic, (2) precautionary measures initiated following the emergence of initial reports of COVID-19, and (3) escalated preparations when a local outbreak became inevitable. The findings were further contextualized through the theoretical lenses of High Reliability Organizations (HRO) and Resilience Engineering (RE), offering deeper insights into the underlying processes of the pre-crisis phase. For instance, the HRO principle of reluctance to simplify was reflected in the theme understanding the situation, where the RPHS's initial underestimation of the crisis delayed critical organizational changes, such as the establishment of the regional medical command and control team for disaster response (RMC2). Similarly, the RE concept of anticipating potential challenges was evident in the themes of preparations and challenges, highlighting how the RPHS anticipated the need for specialized competencies but failed to sufficiently predict the demand for personal protective equipment. This paper contributes to the area of cognitive ergonomics by analyzing how healthcare and crisis management professionals perceived, anticipated, and responded to an unfolding crisis (i.e., the upcoming local outbreak of COVID-19). Using empirical data and theoretical lenses from HRO and RE, it is revealed how cognitive processes, such as sensemaking, attention allocation, and decision-making under uncertainty, shaped outcomes. These insights can inform the design of future systems, interfaces, and training aimed at supporting cognitive work in complex, high-stakes environments.