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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2/27/2013 4:41 PM
Karl Weick told me that when he and Kathleen identified preoccupation with failure they were looking at system mindfulness and system failure. He did not consider failure of the individual in this concept. Those of us who came from high-risk activities automatically thought preoccupation with failure applied to us as individuals.
On another occasion, an academic group discussed with Kathleen Sutcliffe the use of the word “preoccupation” in Preoccupation with Failure. While Dr. Sutcliffe insisted that the word "preoccupation" was significant and critical others criticized it because some managers felt it meant we should constantly be thinking about it. Organizations seem to have an image problem with this.
As a participant I think she had very good reasons to use preoccupation as, on an individual level during high-risk processes, I am preoccupied with my failure that could harm other people or me. Unfortunately, we do not always know our procedures are high risk and, besides, this becomes habit much to the consternation of others without these experiences.
The culture I developed in came from men who experienced live-or-die situations and I have experienced my own on more than a few occasions. I look back to the events seconds, minutes, or hours earlier to see how I could have avoided the situation I found myself in. I don’t want to do it again. I guess you could say I am preoccupied with failure.
A better way to describe it is looking for early heralds of failure. In the intensive care unit I taught caregivers to look for covert, compensated states of physiologic dysfunction. These early heralds were precursors to shock or respiratory failure. It is at this point our interventions are easiest, cheapest, and have the greatest effectiveness with the least risk. It is a routine activity for us to always look for the early signs of deterioration. This is preoccupation with failure.
As paramedics working in an area with high drug use and gang activity we were vigilant for early heralds, subtle nuance, or vague signs of problems developing. We would watch for the subtle eye movement or nuanced behavior that would tell us the call was turning the wrong way. We were vigilant in the same manner towards our patients, before paramedic school all we had was observation and a few treatment tools. This carried over to my work in healthcare where I taught my students to look for signs of subtle change despite the difficulty of clearly understanding what was happening.
Vigilance for early signs of failure also gives you boundaries within which you can feel safe. This produces the paradox of feeling secure because you look for the danger. To those without this insight we seem to be pessimistic, always looking for the dark side.
My question is, "Can we make preoccupation with failure a habit without creating pessimism?"
Karl Weick told me that, in his estimation, preoccupation did not have an action component in it while in the world of operators it drives anticipation, action, and learning from action. He also stressed that preoccupation with failure presumes that the organization has good communication. Nothing really matters much if there is not good communication in the organization. Communication is another blog.
One complaint about preoccupation with failure is whether it takes away from other duties and whether it creates an image problem to the organization. Preoccupation with failure means searching for early failure points, which means looking for bad news. In, as one administrator told me, to discuss openly improvement is to imply we were doing poorly. At the worst, the individual preoccupied with failure is considered disloyal while at the best individual is criticized for "crying wolf," overreacting, or acting the Cassandra.
But if you look for bad news and you can correct it earlier then it is more amenable to intervention, the intervention has less risk, and you correct the problem before it becomes systemic. In the HRO, leaders in the organization consider "bad news" a "good sign" and seek bad news to improve the organization.
The organization will seek out hidden failure, that is, the failure people consider inevitable or part of the job. When there is open discussion of problems, those who have solved the problem can share their solutions with those who believed it was unsolvable. This requires not only open communication but also requires frank discussion of all outcomes. In this manner, the organization creates a common language and grammar.
I asked a US Army Sergeant, a veteran of the war in Iraq, how the Captain of his Company found out about important information, such as weaknesses in the Company or outside threats, when the men did not talk about it. He said the captain would come by and play cards with the men and eventually they begin talking to him. Management by Walking Around sounds nice but if the leader is on a pass-through it accomplishes little. It is simply "showing the flag." While this is also a leadership issue it is and organizational issue because it can act as a conduit for information flow between line workers, administrators, and executives.
For another discussion, are we preoccupied with failure in communication?
My question is, "How can an organization make looking for bad news a good thing?"