Maintaining High Reliability
-
Upload
benedict-cooke -
Category
Documents
-
view
38 -
download
1
description
Transcript of Maintaining High Reliability
![Page 1: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/1.jpg)
Maintaining High Reliability
Chapter 9
![Page 2: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/2.jpg)
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.
![Page 3: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/3.jpg)
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.
![Page 4: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/4.jpg)
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.
![Page 5: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/5.jpg)
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.
![Page 6: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/6.jpg)
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
![Page 7: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/7.jpg)
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
![Page 8: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/8.jpg)
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.
![Page 9: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/9.jpg)
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.
![Page 10: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/10.jpg)
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?
![Page 11: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/11.jpg)
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
![Page 12: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/12.jpg)
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.
![Page 13: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/13.jpg)
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.
![Page 14: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/14.jpg)
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.
![Page 15: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/15.jpg)
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.
![Page 16: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/16.jpg)
Assess the Ability to Inquire, Doubt, and Update (4 of 4)
![Page 17: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/17.jpg)
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.
![Page 18: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/18.jpg)
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.
![Page 19: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/19.jpg)
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.
![Page 20: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/20.jpg)
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
![Page 21: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/21.jpg)
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.
![Page 22: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/22.jpg)
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.
![Page 23: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/23.jpg)
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
![Page 24: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/24.jpg)
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
![Page 25: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/25.jpg)
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.
![Page 26: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/26.jpg)
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
![Page 27: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/27.jpg)
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.
![Page 28: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/28.jpg)
Commit to Resilience (3 of 3)
![Page 29: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/29.jpg)
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.
![Page 30: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/30.jpg)
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.
![Page 31: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/31.jpg)
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.
![Page 32: Maintaining High Reliability](https://reader033.fdocuments.us/reader033/viewer/2022042703/56812a8e550346895d8e3a1b/html5/thumbnails/32.jpg)
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.