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.
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10/19/2013 4:38 PM
Notes from a panel of people experienced in HRO
One person was taught in the fire department to "work through the problem." In other words, keep working, don't give up, help will come to you but stay engaged which ties in with Weick's concept of enactment. Resilience is to maintain stability during all hazards. Think of a gyroscope, we are the gyroscopes of the organization.
When you are being knocked down, how do you get back up into the fight? This requires emotional self-assurance, self-understanding, and patience with self and people. You must speak the truth of what people want and what they want you to do. You must deal with the disappointment.
Cowboys have the phrase "get back into the saddle." In many ways, cattle drives in the American West were the original high reliability organizations. They moved cattle from Point A to point A overcoming the obstacles, they were vigilant for anything that could cause a stampede or loss of a cow, they were gentle in order to keep the cows calm, and they could not turn back.
There is the individual level and the organization level of resilience. The job of the leader is to stay on top of the chaos and to persevere. The leader must go back to the action plan and monitor its effectiveness. This keeps the momentum going forward to keep the organization from being gripped with actions that are counter to the organization's culture and direction. This requires regular meetings with staff.
Experts look for bad news. When things are going perfect you start looking for bad news. You are Resilient if you see bad news sneaking up on you that others do not see. Many leaders avoid conflict and bad news. Situations may force the conversation to get information about the scenario that is not going right.
To bring out resilience one person has the group plan to develop group solutions; they can change things in early stages. They closed the discussion with the statement that the solutions they come up with are not going to be the answers to the situation. The real problems will not be the problems out there and the solutions we develop will not be the ones we use. We look for indicators and establish trigger points.
In Costa Rica, one speaker was limited by the fire service in what she could do so she watched out for her colleagues to help them protect themselves. In the hospital, it is almost impossible when you are a participant to not make a mistake. She observed in the hospital and people will deny something happened even though she saw them do it.
A surgeon discussed how, in surgery, you enter and cannot back out. Things do not progress in a linear fashion so you must have multiple plans. Yet, in the hospital, most people, especially physicians, are viewed as being error-free who do not plan to fail.
A chemical professional does “premortems” for preparation and then do a postmortem later where you consider a failed output as well as the success.
In petrochemical, there are layers of protection- they do a “layer of protection” analysis. One of the last barriers in place is operations. How to be resilient in operations is important but it is their weakest place. You have a support, or oversight, manager on call. Resilience can be in design (in situ) and then when the event occurs.
Layers of protection analysis (LOPA) is also to plan ahead. In the chemical process safety field they have process analysis. The hazard is loss of containment and operations is one area of protection. When it gets out of the pipe we have to change our approach to emergency mode. Resilience is when the situation occurs and we do not have time to think. The plan is not going according to plan so resilience comes when the plan fails. We must identify it at an earlier stage.
Resilience is preparing for potential failure of our actions. The process of planning for failures is good but when the plan fails you become stressed. Mental preparation for these events can stop them from cortisol blocks that occur when events do not work out. You build up a mindset that you expect things to go wrong.
Highly successful teachers have a higher level of resilience to keep their class on track. Each student has different things going on and brings that to the classroom. Can you plan for resilience? This involves how kids learn and what happens to their ability to learn. There are limiting factors to learning, which educators need to know and to accommodate to.
Resilience is learned through training, from mentors, and by your practice. How willing are you to call colleagues for assistance, adapt to the changing situation, and collect additional information? You must learn to respond to your own brainstem and adapt. On the institutional level resilience can be planned by enlarging the repertoire of people.
There is a feeling of safety around us. You may need coaching in real time. There is a video of an autistic child being taught by the teacher. Watching the video can give feedback to the teacher if this is done in a supportive approach, especially with the child, parent, and teacher being filmed.
From a teaching faculty standpoint, this is not so much fear as it is trust.
From this group’s perspective, to be at the top of you game you must be self-reflective and want to improve. Not everyone is like this. One person described how he models this behavior as a leader and he has people model it out loud for the team.
Many HRO principles do not stand-alone. Of all of them, resilience is a combination of what happens when you bring the other four principles together.