Maintaining High Reliability

Chapter 9

Objectives (1 of 2)

• Define the term high-reliability organization.

• Describe the importance of mindfulness in maintaining safety.

• Describe how mindlessness leads to accidents.

• Describe how to assess the ability to inquire, doubt, and update.

Objectives (2 of 2)

• Describe the dangers to the team when there is a preoccupation with failure.

• Describe the importance of a reluctance to simplify.

• Describe how to build a commitment to resilience.

• Describe why deference to expertise is necessary.

Introduction (1 of 2)

• Maintaining reliability in organizations that perform dangerous work in dynamic environments is difficult.– Time consuming and expensive– What is practical and easy is not always safe.

• Maintaining a culture that supports CRM requires mindful, careful review of problems and points of conflict.

Introduction (2 of 2)

• High-reliability behaviors are essential for team leaders to:– Remain vigilant– Ensure a safer workplace– Minimize errors

• They are critical to building an organizational culture that supports open, collaborative communication.

Introduction to High-Reliability Organizations (1 of 2)

• Karl Weick and Kathleen M. Sutcliffe’s Managing the Unexpected: Resilient Performance in an Age of Uncertainty– Describes the characteristics of

organizations that operate in high-risk environments, yet strive to maintain a learning atmosphere so as to minimize chances of error

Introduction to High-Reliability Organizations (2 of 2)

• Critical high-reliability organization (HRO) components:– Mindfulness– An inclination towards inquiry and doubt – Attention to the complexities of an

emergency incident– Commitment to resilience– A willingness to defer to expertise

Develop a Habit of Mindfulness (1 of 3)

• Team members need to be mindful of: – Their operations– Patterns of behavior– Skills and abilities of peers, superiors, and

subordinates

• Maintaining mindfulness is difficult when teams are subject to repeating the same routines.

Develop a Habit of Mindfulness (2 of 3)

• The term frequent flyer is used in EMS to describe individuals who call 9-1-1 repeatedly, often for nonemergency situations.– When one person becomes angry or

stressed, it is important for him or her to speak up.

• Teams can become content with the status quo and never question the risks.

Develop a Habit of Mindfulness (3 of 3)

• To evaluate team mindfulness, leaders should ask:– Is there a sense that the team, or

organization, is susceptible to the unexpected?

– Does everyone feel accountable for their actions, and do they value quality?

– Does the team understand what can go wrong, and how?

Avoid Mindlessness (1 of 2)

• Mindlessness is the absence of mindfulness.– Susceptibility to falling into a routine and not

paying attention to cues accumulates over time into one major incident.

• People become mindless when:– They are expected to perform their jobs in a

particular matter without deviation– They work under severe time pressure– They are tired

Avoid Mindlessness (2 of 2)

• Mindlessness promotes the loss of situational awareness and leads to many accidents and errors.

• Good teams identify characteristics of a situation that can lead to mindlessness, and institutionalize methods to ensure that team members avoid mindlessness during critical operations.

Assess the Ability to Inquire, Doubt, and Update (1 of 4)

• Ability to inquire– In good team environments, individuals

feel free to inquire about what is going on and why.

– Inquiry is often stifled by organizational hierarchy or a culture that discourages people from questioning a procedure.

– Leaders should assess whether they are receiving inquiries that challenge the norm.

Assess the Ability to Inquire, Doubt, and Update (2 of 4)

• Ability to doubt– In a team setting, it is common for

members to silently watch someone deny a problem evident to everyone else.

– Team leaders sometimes ignore a problem in the belief that the existence of a problem will reflect badly on them.

– HRO performance is directly tied to open communication without reservation.

Assess the Ability to Inquire, Doubt, and Update (3 of 4)

• Ability to update– A shared understanding of a situation is

impossible without regular updates from team members.

– In the CRM loop, updating takes place during the observe and critique phase.

Assess the Ability to Inquire, Doubt, and Update (4 of 4)

Become Preoccupied with Failure (1 of 2)

• Why focus on failure? Why not celebrate success instead?– Success might be the result of luck.– Success might be the result of a well-

developed process or procedure.– Success might only be apparent because

the failure points of the outwardly successful incident have not yet been identified.

Become Preoccupied with Failure (2 of 2)

• Every PIA, regardless of the incident outcome, provides teams with the opportunity to learn valuable lessons.

• A focus on failure means that organizations actively seek out and capture the casual factors of any accident.– They create an environment where

nonpunitive near-miss reporting is the norm.

Be Reluctant to Simplify (1 of 4)

• It is tempting to provide simple explanations for complex events.

• By providing them, teams fail to become learning organizations.– Looking deeply into failures in a nonpunitive,

comprehensive way takes time and resources.– By carefully choosing events, organizations

can dissect incidents to find trends that are likely causing mistakes.

Be Reluctant to Simplify (2 of 4)

• Attempts to standardize and simplify complex operational practices can have unwanted consequences.

• Good field procedures or protocols should:– Provide guidelines– Be brief– Outline risks– Mention any key issues that operators should

consider

Be Reluctant to Simplify (3 of 4)

• One place where simplification can be helpful is in standardizing equipment.– Reduce operational ambiguity.– Improve training.– Reduce errors related to equipment

unfamiliarity as operators move between stations and units.

Be Reluctant to Simplify (4 of 4)

• Organizations that simplify explanations miss the rich learning embedded in each event.– Practical drift: policies and procedures

become background context for most operators, particularly veterans

– HROs focus on failure because that is where the true learning is.

Be Sensitive to Operations (1 of 3)

• Operations refers to functions considered front line.– HROs are sensitive to what is happening at

every point where policy meets practice.

• Written protocols, procedures, policies, and directives are important.– Particularly if they are relevant and up to

date

Be Sensitive to Operations (2 of 3)

• These parameters are rarely in place when the operations are taking place in a highly complex and dangerous environment.

• Operators will more likely use:– Procedures that align with organizational

culture– Stories associated with previous outcomes– Repetitive high-fidelity training

Be Sensitive to Operations (3 of 3)

• HROs understand that someone with authority and expertise must be available at all times during an operational phase.– 24/7, 365 days a year– Supervisors need to understand the

processes they are responsible for and pitch in and help whenever necessary.

Commit to Resilience (1 of 3)

• An HRO does everything possible to ensure stability during times of turbulence and ambiguity.

• One resilient behavior is instituting, supporting, and continuing high-fidelity training.– Situation-based, hands-on, low-frequency,

high-risk-event practice, where teams are regularly tested under demanding conditions

Commit to Resilience (2 of 3)

• Watching an HRO in action during times of ambiguity and stress is like observing a symphony or a theatrical play.– Everyone understands their mission and

role.– They know the roles of others.– They are talented enough to cover or

improve when someone misses a cue.

Commit to Resilience (3 of 3)

Defer to Expertise (1 of 2)

• Experts are necessary resources within an HRO.– Individuals who have a deep understanding

of a particular domain are valuable assets.

• An important attribute for the high-reliability team is a collective understanding related to the power of the team’s diversity.

Defer to Expertise (2 of 2)

• Deference to expertise is already an ingrained practice within certain HROs.

• Leading dynamic teams can be a challenge.– Experts often have a certainty in their methods

and a level of confidence built on repetitive success in their domain.

– An effective leader keeps the team focused on the mission goals while allowing creative energy to flow.

Summary (1 of 2)

• High-reliability organization (HROs) operate in high-risk environments, yet maintain a learning atmosphere to minimize chances for error.

• Inquiry is often stifled by an organizational hierarchy or culture that discourages people from questioning standard procedure.

Summary (2 of 2)

• Policies and procedures should remain only as background context for operations in the field.

• Good team environments foster a culture in which individuals feel free to inquire about what is going on and why.