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: Sensitivity to Operations I

Posted by davedvanstralen VIP     0 Comment(s)    Add a Comment  comment-icon.png
10/19/2013 4:33 PM

Minutes from a meeting to discuss Weick and Sutcliffe’s Five Principles of HRO

 One physician advised a resident physician that, once she mastered a procedure she should teach it because in life she will be teaching her subordinates as she is performing the procedure. She came to him excited, she did not know all the things that went on while placing a tube into a patient's windpipe (endotracheal intubation). During the evolution of dynamic events we easily cone our attention to what we are doing, shutting out other activities as we concentrate. One of the first things we must teach a rookie is to be aware of all that is around him. 

 Sensitivity to operations is not customary for people, they have to learn how to do it, learn how to actively monitor. But we cannot do things on automatic.


In Naval operations the operator must manage the bubble in situational awareness, that is, what is happening all the time. As managers we may become automatic and loses awareness of what is happening. In Naval systems they use a system response, did the actions you take affect outcome?

Can we distinguish between situation awareness and sensitivity to operations on an organizational level? This is the key- Individual situation awareness in the larger organizational view. How do you reach that level? In part it is how you structure the organization but also security, lack of fear from speaking up, and appreciation of even negative information (what can hurt).  It is a system, organizational, human dynamic that moves information up and down and laterally. This makes the organization acutely aware of where going, where came from, and where you are right now.

In a hospital, one physician will ask someone to contact an administrator-on-call or medical consultant. The person often responds with "what can they do?" His counter response is, "If I knew, I would do it myself." This is part of a complex system. It suppresses the drive to ask for assistance. Is this the antithesis of sensitivity to operations?

Query - what would you be asking administrator to do? A child critically ill, in deteriorating condition, needed transfer to the pediatric intensive care unit. The parents were Jehovah’s Witnesses and refused to grant permission to transfer unless he could guarantee no blood transfusion. By law the physician could have transfused if necessary a parent’s permission. Sometimes the wisest use of power is not to use it. The administrator calmed the family, explaining procedures. The parents then allowed transfer of the child. The physician had no idea how the administrator would fix the problem when he made the request. The administrator was very sensitive to the complexity of the situation.

 In fire fighting work things can inhibit information flow – procedures, task completion, personalities. One chief said to the captain on an incident, " The only thing I want to see in your hands is a radio mic." He found that if they help the firefighter then the information flow stops. You need to have pockets of information to communicate with each other. In time compression and short looped decision-making you need information flow to stay on top of the situation and the organization.

 For information flow, what kind of assistant do you have to escalate information flow? How do you create a system allows escalation information flow without overtaxing the system? Information cannot get to CEO for every issue. We cannot communicate linearly for everything. Sometimes you have to skip layers, but how do you manage this without breaking down the system? Need a workable system that works when you need it.

 If I have a question, I have to be sensitive that the resources I am drawing are not available to the rest of the organization. In human factors they use individual, team, in top leadership for organizational performance. Your organization structure is connected, when things go wrong there is a disconnection and they lose the shared perception of what is going on.  STO to has to occur at each level.

 Social media can support the attitudes of high reliability. It is a tool that can give us authenticity and transparency. We value authenticity and transparency but we then shut them down. Charlene Li visited the USS Nimitz and ascribed a night landing. Landing at night is frightening. Every time you land you die a little death. This is transparency and authenticity. Think of information flows that go on simultaneously, a tool that gives us authenticity and transparency (even though many educators want to shut it down in their environments), strengthens the ideas of HR, mentioned Charlene Li and the experience she related as a blogger visiting Nimitz (wrote a book about it).

 Transparency can be confusing. Information is fine but you do not want everything to pass through-you need some prejudice. Internally, for operational effectiveness, they are constrained in using information that is applicable yet you also want external flow see how you work. Transparency is useful externally so people trust you. Internally you have to limit/constrain information to correct terminology, need internal information flow that is appropriate and correct, two different dynamics. 

Who knows to know what and when do they need to know it? We are poor at this in healthcare because they lack the culture of safety and tend not to share information when things are going wrong rapidly enough. It would help patients when we bring in additional assistance.

 In a United Kingdom chemical plant they had an alert system of "nonconformance."  They would meet and talk about it the next day. They found a corroding tank and cleaned it the next day when they found it had nearly leaked. They were sensitive to the situation, investigated it in a controlled manner, and responded appropriately to fix it. How do you filter information so that too much does not go too high, bogging things down? If people saw something not right they would write a note about nonconformance. The tall caustic tank manhole looked extra corroded, took cover off to look into it, found corroded elbow at the bottom of the tank, found that it was about to fail, now escalated to urgent thing to replace elbow. Had it failed it would have drained tank. They investigated in control manner to prevent catastrophe, work later on why the piece failed, this group had a system of escalating concern and risk.

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