High Reliability Organizing (HRO):The Third Component of a Safe and
Productive Unit
Presented at the Pacific Northwest Fire Operations WorkshopPortland, OR – March 17, 2010
by David Christenson
Already an HRO?
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Respect feedbackRespect feedback
Be willing to shareBe willing to shareconcernsconcerns
Be a studentBe a student Rules don’t and can’t cover every
situation
2 J
ust
Rep
ortin
g
Lear
ning
Flex
ible
Safety Culture
Three Components of A Safe And Productive Unit
Track small failures Resist oversimplification Sensitive to operations Maintain capabilities for resilience Take advantage of shifting locations of expertise
HRO Principles:3
Fundamental to success in HRO implementation are the connection of people and the trust necessary for optimal knowledge flow.
Building on Strengths
Thrive or Survive?
Study: Since the year 2000 about seventy-five percent just survive at work.
My Experience
Since 1978 my experiences have taught me that:The tools of:
Organizational LearningLeadership Developmentand High Reliability OrganizingAre effective ways to begin connecting people
and engaging them in their work.
1978- 1982
1994
Human Factors & Org. Learning
Roberts
Weick
Sutcliffe
Vulnerable --- FalliblePressure
SocialPoliticalEconomicPeer
Human FactorsStressFatigueEgo
Challenges that Call for HRORoberts & Rousseau, 1989
Hypercomplexity Tight Coupling Extreme Hierarchical Differentiation Multiple Decision-Makers in a Complex
Communication Network High Degree of Accountability Need for Frequent, Immediate Feedback Compressed Time Constraints High Workforce Mobility
Swiss Cheese ModelJames Reason’s Epidemiological Model Analogy
The Field Guide to Understanding Human Errorby Sidney Dekker, 2006
Swiss Cheese Model vs. Metaphor
Conditions
Conditions
Recognition Primed Decision-MakingGary Klein
S CA 2007
S CA 2003
Recognition Primed Decision-MakingGary Klein
New: Critical Thinking Skills Training
A deliberate, systematic awareness of the process and products of one’s own thinking
Targets the common errors of:
Overlooking important details
Misinterpreting information
Making incorrect assumptions
Critical Thinking
Improving the probability of a desirable outcome by improving your judgment
Combine Both Recognition Primed Decision-Making and Critical Thinking
Recognition/ Metacognition
Critical Thinking Through Dialog
Teamwork and Communications ImproveDetermine the acceptability of a belief or
actionQ & A about alternative possibilities Improves understanding of the situation and
planLearn more about beliefs, assumptions and
interestsGenerate more successful decisions
and create novel solutions
AARs & Sand Tables
Dynamic Decision-Making
Principles of HRO
1. Tracking Small Failures2. Resisting Oversimplification
3. Sensitive To Operations4. Maintaining Capabilities For Resilience5. Taking Advantage Of Shifting Locations Of
Expertise
Weick & Sutcliffe, Managing the Unexpected 2001
HRO Audits & Implementation
Fundamental to success in HRO implementation are the connection of people and the trust necessary for optimal knowledge flow.
Is the HRO information arriving in the context of a fertile learning environment where people are connected, engaged, and where knowledge flows?
Context
“To treat information as context-free, that is, independent of circumstances, places us at risk for mindless thoughts, decisions, and behaviors. Placing information within context leads to mindfulness.”Ellen Langer, publishing Mindfulness. in 1989, and The Power of Mindful Learning in1997
We All Needed To Learn Quickly
Connected
“Mindlessness develops from automatic behaviors, repetition, and use of a single perspective.” (Langer 1989)
Mindfulness welcomes new information, becomes inclusive of the process used and the environment actors are in, rather than only on the outcome.
Soft Aspects?
Connection improves bothindividual and groupperformance
So paying attention to creatingan optimal work environmentrequires paying attention to theso-called soft aspects
Such as the meaning of work and the way people treat each other.
So What?
Connection in positive work relationships provides:A sense of well-being, minimizes stress, and
makes us more trusting.Without connection:
People feel lonely, isolated, confused and become distrusting, disrespectful and dissatisfied. ..Corrosive environments.Dr. Edward Hallowell at Harvard Medical School.
Costs
“The Gallup Organization conservatively estimates the annual economic cost to the American economy from the approximately 22 million American workers who are extremely negative or “actively disengaged” to be between $250 and $300 billion.”
Vision + Value + Voice = Connection
Vision when everyone is united by common values, proud of their unit’s reputation, and motivated by their mission
Value exists in an organization when everyone understands the basic psychological needs of people, behaves in ways that appreciates their positive, unique contributions, and acts to help them achieve their potential.
Voice exists in an organization when everyone seeks the ideas of others, share ideas and opinions honestly, and safeguards relational connections.
“Next step”in the evolution of organizations
Beyond masters of task excellence
Beyond “star systems”
…we in it shall be remembere’d,We few, we happy few, we band of brothers:
Inspirational Leadership
Leaders know that one of their main responsibilities is to inspire the people they lead.
Vision represents the cultural element of inspiring identity
Inspirational Leadership
Human value in a culture is: About treating people with
respect and dignity About empowering them to
achieve their potential.
Leaders need to identify and remove the obstacles that make people feel devalued.
Delete What Devalues
Eliminating disrespectful, condescending and rude behavior.
Going easy on criticism. Minimizing unnecessary rules
and excessive controls. Eliminating excessive signs of
hierarchy. Getting rid of devaluing
managers.
Add Elements that Enhance Value
Making a human connection with as many people as possible.
Treating and speaking to employees as partners. Helping employees find the right roles. Educating, informing, and listening to employees. Decentralizing decision making. Recognizing the human need for work/life
balance
Leaders Increase Trust
“Contrary to what most people believe, trust is not some soft, illusive quality that you either have or you don’t; rather, trust is a pragmatic, tangible, actionable asset that you can create – much faster than you probably think possible…I contend that the ability to establish, grow, extend, and restore trust is not only vital to our personal and inter-personal well being; it is the key leadership competency of the new global economy.”
Stephen M. R. Covey, The Speed of Trust: The One Thing That Changes Everything
Trust – The Hidden Variable
Strategy x Execution = Results
should be changed to show it by:
(Strategy x Execution) Trust = Results Following charts from: a study of trust in business by LogicaCMG and
Warwick Business School in 2005; another by Watson Wyatt, WorkUSA study in 2002; and another study about trust in schools presented by Stanford professor Tony Byrk, in 2004, published in 2002.
The 60% Tax (Very Low Trust)In the organization… In personal relationships…
•Unhealthy working environment
•Unhappy employees and stakeholders
•Intense political atmosphere with clear camps and parties
•Excessive time wasted defending positions and decisions
•Painful micromanagement and bureaucracy
•Hostile behaviors (yelling, blaming, accusing, name-calling) followed by periods of brief contrition
•Guarded communication
•Constant worrying and suspicion
•Mistakes remembered and used as weapons
•Real issues not surfaced or dealt with effectively
The 40% Dividend (World-class Trust)In the organization… In personal relationships…
•High Collaboration and partnering
•Effortless communication
•Positive, transparent relationships with employees and all stakeholders
•Fully aligned systems and structures
•Strong innovation, confidence, and loyalty
•True joy in family and friendships, characterized by caring and love
•Free, effortless communication
•Inspiring work done together and characterized by purpose creativity and excitement
•Completely open transparent relationships
•Amazing energy created by relationships
Inspiring trust
Extending “smart trust,” restoring trust when it has been lost, and developing a propensity to trust.
“…where people begin to trust each other and share ideas…(changes occur.)
Cultivating “Knowledge Flow” increases connection and people begin to make better decisions, increase creativity, and inspire innovation so they start thriving in a healthy environment.”
Knowledge Flow The expanded connection
component called Voice Increases creativity and
innovation Sgt. Curtis Cullen’s idea for the
Rhino tank when it quickly made its way to Gen. Omar Bradley in time to liberate France in WWII
AIM-7F and Raytheon Missile Systems
After Action Reviews
What “Learning Organizations” Do
Learning organizations becomeskilled at continuously:
1.) Creating, acquiring, interpreting, transferring and retaining knowledge
2.) And at purposefully modifying their behavior to reflect new knowledge and insightsDefinition by David Garvin in Learning In Action: A GuideTo Putting The Learning Organization To Work, 2000
A Litmus Test
Does my org. have a defined learning agenda?
Is my org. open to discordant information?Does my org. avoid repeated mistakes?Does my org. lose critical knowledge when
key people leave?Does my org. act on what it knows?
A Supportive Learning Environment
Psychological safetyAppreciation of
differencesOpenness to new
ideasTime for reflection
Leadership & Reinforcing Learning
Invite inputAsk probing questionsEncourage multiple
points of viewProvide time for reflection
Information to Knowledge
Informed Culture
Timely AvailableCandid Disseminated
Learning Culture
“If timely, candid information generated by knowledgeable peopleis available and disseminated, an informed culture
becomes a learning culture.”
Weick & Sutcliffe, Managing the Unexpected 2001
HRO = A Mindset
Total Immersion In A Mindset That Holds Our Foundations Together
Fundamental to success in HRO implementation are the connection of people and the trust necessary for optimal knowledge flow.
You can do this!
Not everyone will right away Org. Learning, Leadership & HRO thinking,
behaviors and principles are worth the effort Quality – Likelihood of harm to your processes and
products will be reduced Safety – Likelihood of harm to your people and
your publics will be reduced Reliability – Absence or reduction of harm in
extreme, uncertain, or unexpected environments. Trust and confidence will increase internally and
externally
Questions? Need Resources?
Contact information: David Christenson Wildland Fire Lessons Learned Center National Advanced Fire & Resources Institute
[email protected] www.wildfirelessons.net