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Managing the Unexpected

High Reliability develops an organization’s strengths through individual actions.
Shared attitudes fill the gap between organization and the individual to determine High Reliability.

Title: High Reliability


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2/27/2013 3:31 PM


What is High Reliability?

While training to drive a rescue ambulance for the Los Angeles City Fire Department my instructors impressed upon me the importance of hurrying when you are told to do a job, including turning out of the fire station in 60 seconds from alarm. During my probationary period a new station commander transferred in. An alarm sounded and I ran to my rig, nearly colliding with my new captain who was holding a full cup coffee. He held out his arm to block me and said, "Davey, you cannot help anybody with a broken ankle." It took me the rest of the afternoon to appreciate his point; “doing your job" and  "doing your job safely" are the same.

Throughout my career in EMS and healthcare I learned reliability, resilience, safety, effectiveness, and efficiency are different aspects of the same thing – operations. We are reliable –we maintain our performance despite changing circumstances. We are resilient – we bounce back from difficulties. We are safe – we prevent and minimize injury while doing our job. We are effective - we reach our goal. We are efficient – we don’t waste resources while reaching our goal. In operations we treat uncertainty and threat the same.

Making a distinction between safety, quality, and productivity comes at the risk of depreciating safety to improve productivity and quality. This may make sense for intellectual and administrative purposes based on outcomes but from an operational sense it does not. Though we may identify and manage error during operations for dynamic events differently than for stable situations, the focus is more on immediate consequences rather than classification of consequences in either event. The experience of commercial aviation shows that safety done right saves money. The error is operational but the outcome is interpreted for administrative purposes. It defies my logic to separate them during operations.

It is almost magical how an experienced individual can orchestrate a team to smoothly resolve a time-constrained threat. The outsider sees none of the changing balances and shifts in authority much as one cannot see the strokes of the brush or cuts in the stone of a great work of art. We see the result but we cannot identify from observation alone the methods used by the master.

In the ambulance and fire service in the 1970s what we call high reliability was considered routine work. In the first month or so when I was assigned to fire Station 66 three men were killed when a wall fell on them. There was discussion not about what they did wrong but how we could make better decisions next time. Bad things happen and it is our duty to learn from them.

When I entered healthcare I found people hesitant to make decisions. I found people did not want to talk about possible mistakes. I found people did not help each other in the way we did in ambulance work and the fire service. I began to focus on making decisions when we only had imperfect information and had time constraints. Also critical to engaging an unexpected problem was teaching people to identify and managing their fear, helping them identify what makes them calm under pressure to help them focus on working the problem and work and act under pressure. Later, Karlene Roberts characterized my work as high reliability.

My question is, "If there is an academic and management distinction between reliability, resilience, and safety, is there also an operational or functional distinction?"

Reference:
Roberts KH, Yu K, van Stralen D. “Patient Safety is an Organizational Systems Issue: Lessons from a Variety of Industries” in The Patient Safety Handbook, Second Edition ed. Youngberg BJ (Burlington, MA: Jones & Bartlett Learning, 2013).

Do Safety, Reliability, and Costs Compete?

Chris Hart, Vice Chairman of the National Transportation Safety Board, gives a wonderful talk about how collaboration in the commercial aviation industry in the middle 1990s created not only a safer means of travel but also reduced daily costs. These savings did not occur because of the decrease in air crashes but because of improved daily performance and productivity. This required people who did not work with each other to come together for collaboration. This included executives, managers, and line staff. This included unions, industry, and regulators.

Matt Boyne, a retired US Navy Aviator and now commercial pilot and business consultant, described to me his deployment on an aircraft carrier with a tour commanding the machine shop. He couldn’t tell if a damaged bushing was a safety, productivity, or a quality problem as it could take two years until someone was hurt, they had to remake it, or it damaged a plane. But it did not matter at the same dynamics applied to safety, productivity, and quality.

How we approach error and our error management determines our success at managing the unexpected. We do not process errors that cause safety, productivity, or quality problems in different parts of our brain.

However, when executives and managers use these as distinct entities we see competition and amongst the choices productivity too often wins over safety.

My question is, "What can we do in our organization to bring safety, productivity, and quality into alignment?"


 
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