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 4:28 PM
Minutes from a meeting to discuss Weick and Sutcliffe’s Five Principles of HRO
We must simplify to gain a grasp of things and also to teach but we must also accept that there is more in these events than we can understand. How do we balance simplifying so we can think and talk about it yet accepting the complexity of events?
In building fires, we would ventilate the building to let out heat and smoke. We did this be putting a hole in the roof. We learned that it pulled fire through the building. Rather than releasing heat and making the situation better, we made the situation worse. We simplified and later found the simplification caused damage.
In aviation the cockpit checklist has become a ritual for errorless tasks. Ritual in the checklist becomes a trap, though. The pilots went through the checklist and, though they called it out, they do not take the action necessary in an ice storm. They were tropical pilots and glossed over the ice storm checklist. This "error of habituation" led to their deaths.
In a nursing home they use consistent staffing to have the same nurse on the same resident. They become so habituated on the drug regimen they continued giving the old drug dose not the new, changed drug dosing. The nurse said, "I been doing this for two months so I knew what to do."
In situation awareness when the situation changes the people must alter the task. In confirmation bias we look for information that confirms our conclusion. It is challenging to recognize that bias in ourselves.
In shortcuts, experienced staff who have served as mentors do not want to give the shortcuts out first. They show the actual way to do it. One individual read about FBI training to find a counterfeit bill. They must first learn what the real bill looks like so the odd bill will stand out. In shift work when returning from a long period of time off, the first change is long and detailed. The next night they want to say, “Nothing has changed,” in order to make the procedure faster.
We are probably not simplifying, we are just slowing it down. Weick (personal communication) emphasized the "reluctance to" as simplification is not bad in itself. In responding to a fire you have seen this before and you have not seen this before. You are reluctant to simplify but you will do it.
There is intentional simplification and unintentional simplification. If you have intuitive impressions, are you backing them with facts? Fact-check your intuitive feelings. Intentional simplification may have ulterior motives. For example, the manager may want to increase productivity at the expense of safety.
You can put trigger points or milestones into your decision-making. "I think the situation is… So we can expect…" He gives milestones and triggers. If it is not going the way we expect and we must reevaluate. Do we hurt our culture in fire to make it task, task, task, but not why? Firefighters have so much experience with the norm that they do not question. When things are not normal is when our programs again to falter.
Practical advice is missing on "reluctance to simplify" and making a prediction does that. It is a "test" of your assumptions.
We have become satisfied with policies and procedures and want all to go well. Then someone comes and says we can do it differently but our people do not want to change.
Confirmation bias, also optimism bias, you start to see things that confirm your belief. Our ingrained nature is to be optimistic. You want to find you are successful and see it working.
On the flight deck of an aircraft carrier they start off in blue shirts (call plain pushers) to learn but senior people quickly watch for those who have better awareness of what is going on. Then they are selected towards the yellow shirt, which is a director. Before that they are paired up with someone who has more experience (even if it is only 5 to 6 months more).
In the chemical industry they struggle with compliance, which people believe can be met by doing the task rather than engagement when you understand the "why." In chemical process safety, they have task-oriented procedures to ensure consistency. The practices are usually not seen in current procedures. They make it into simple steps then shortcut with no bad consequence. They do not know if they are lucky or good in this change but it then becomes fixed. Chemical process safety does have a management change process where they can discuss these changes.
Is it easier to achieve reluctance to simplify in a group setting? We tend to make it a simple problem with a simple solution. How you shape and define the problem helps you understand the solution. But some times we have a solution in search for a problem. Simplifying the problem and the solution can be dangerous.
What is the problem? There is an ad hoc committee in the hospital for "never events." They want to simplify to come up with the most obvious proximal cause. If they were reluctant to simplify, they would continually ask questions to find the true root cause. The logistical problem of hospitals and hospital boards is they place excessive efforts in quality solely with credentialing the physician. They equate the quality of a hospital on how they judge a physician.