Continuing with last week’s subject, some days we forget that there are four understandings when it comes to any system. First, there is the boss’s understanding of how the system works. Next, there is an employee’s understanding of how the system works. Third, there is other peoples’ understanding of how the system works, and finally there is the reality of how the system actually works. Often, these four levels of perception are in conflict and can be the source of why a system is not functioning properly and why it is difficult to change.
Many years ago, I worked with an organization that wanted to improve it’s systems. Their goal was to be a High Reliability Organization or HRO. An HRO is an organization that has succeeded in avoiding catastrophes in an environment where normal accidents can be expected due to risk factors and complexity.
The best resource on this subject is the work of Karl Weick , and Kathleen M. Sutcliffe in their book, Managing The Unexpected: Resilient Performance in an Age of Uncertainty. John Wiley & Sons, Inc, 2007. As the authors write, “Our basic message is that expectations can get you in trouble unless you create a mindful infrastructure that continually does all of the following: tracks small failures, resists oversimplification, remains sensitive to operations, maintains capabilities for resilience, and takes advantage of shifting locations of expertise.” As they continue, “Moving toward a mindful infrastructure is harder than it looks because it means that people have to forgo the “pleasures” of attending to success, simplicities, strategy, planning, and superiors.... The ability to deal with a crisis situation is largely dependent on the structures that have been developed before chaos arrives.”
There are five key HRO principles as outlined in the aforementioned book. They are as follows:
- # 1: Preoccupation with Failure. HROs are distinctive because they are preoccupied with failure. They treat any lapse as a symptom that something may be wrong with the system, something that could have severe consequences.
- # 2: Reluctance to Simplify. Another way HROs manage for the unexpected is by being reluctant to accept simplifications. It is certainly true that success in any coordinated activity requires that people simplify in order to stay focused on a handful of key issues and key indicators. Knowing that the world is complex, unstable, unknowable, and unpredictable, HROs position themselves to see as much as possible.
- # 3: Sensitivity to Operations. HROs are sensitive to operations. They are attentive to the front line, where the real work gets done. The “big picture” in HROs is less strategic and more situational than is true of most organizations. When people have well-developed situational awareness, they can make the continuous adjustments that prevent errors from accumulating and enlarging.
- #4: Commitment to Resilience. No system is perfect. The essence of resilience is therefore the intrinsic ability of an organization or system to maintain or regain a dynamically stable state, which allows it to continue operations after a major mishap and/or in the presence of a continuous stress. The hallmark of an HRO is not that it is error-free but that errors don’t disable it. Resilience is a combination of keeping errors small and of improving workarounds that allow the system to keep functioning. They image worst-case conditions and practice their own equivalent of fire drills.
- # 5: Deference to Expertise. HROs cultivate diversity, not just because it helps them notice more in complex environments, but also because it helps them do more with the complexities they do spot. Rigid hierarchies have their own special vulnerability to error. Errors at higher levels tend to pick-up and combine with errors at lower levels, thereby making the resulting problem bigger, harder to comprehend, and more prone to escalation. To prevent this deadly scenario, HRO’s push decision making down and around. Decisions are made on the front line and authority migrates to the people with the most expertise, regardless of rank.
When seeking to become an HRO, there are three critical questions according to the previously mentioned authors. First is the “hands on” question: What activities involve the most direct human contact with the system and thus offer the greatest opportunity for human decisions or actions to have an immediate, direct, adverse effect upon the system? Second is the “criticality” question: What activities, if performed less than adequately, pose the greatest risks to the well-being of the system? Third is the “frequency” question: How often are these activities performed in the day-to-day operation of the system as a whole?
This week, think about becoming an HRO and consider reading Karl Weick and Kathleen M. Sutcliffe’s book, Managing The Unexpected: Resilient Performance in an Age of Uncertainty. John Wiley & Sons, Inc, 2007. It is full of good insights.