I read an interesting tweet yesterday. Apparently, the Canadian Nuclear Safety Commission (CNSC) recently released a new regulatory document (REGDOC-2.1.2) that details new requirements and recommendations for "fostering a healthy safety culture" for nuclear facilities and uranium mines. To be fair, the document that was released is actually a draft that is open for public comment. These kinds of regulatory requirements are actually not new. The United States Nuclear Regulatory Commission released a similar guideline (NRC-2010-0282) that requires "individuals and organizations performing or overseeing regulated activities establish and maintain a positive safety culture commensurate with the safety and security significance of their activities and the nature and complexity of their organizations and functions." The tweet I received regarding the CNSC guideline questioned whether it was appropriate, indeed whether it was possible, to mandate a safety culture.
The NRC defines "safety culture" as "the core values and behaviors resulting from a collective commitment by leaders and individuals to emphasize safety over competing goals to ensure protection of people and the environment." Culture is frequently described as "the way we do things around here." There are a number of high-profile accidents that detailed investigations implicated the lack of an adequate safety culture , including the accidents at Three Mile Island, Chernobyl, and Fukushima Daiichi nuclear power plant, as well as the space shuttle Challenger and Columbia disasters, Piper Alpha oil production platform accident, and Deepwater Horizon accident. Given the role that culture (specifically, the absence of a healthy, robust safety culture) played in the genesis of these catastrophic events, several industries have tried to identify ways to foster a safety culture. Health care organizations such as the Agency for Healthcare Research and Quality (AHRQ) have recommended certain practices aimed at safety culture that hospitals can use to improve patient safety.
So back to the original question posed in the tweet. If certain practices are believed to foster a healthy, robust safety culture, then why not mandate these practices? Unfortunately, I don't think that it is quite that easy. As Shawn Galloway stated in a blog post in 2013, "Cultures are not a program; they are the interconnectedness that explains why efforts work, don't work, succeed, and fail." He further calls on organizations to "stop trying to create a safety culture." In many cases, as Galloway suggests, the basic elements are already there and just need to be developed further.
Safety culture encompasses both visible, directly observable elements, such as policies, procedures, and behaviors, as well as invisible, hidden elements, such as beliefs, values, perceptions, and attitudes (see the Iceberg model of culture for a great description of this concept). Culture change takes time - in some reports, experts suggest that culture change may take an organization several years. Leadership engagement is absolutely essential, but it is not even close to being enough. While "top-down" leadership can set an organization on the proper course towards establishing a safety culture, true culture change needs to occur from the "bottom-up." Leaders need to "walk the walk" and "talk the talk," but front-line engagement is critical to the success of any culture change initiative. The CNSC suggests that safety culture is dependent upon the following:
1. Safety is a clearly recognized value in the organization.
2. Accountability for safety in the organization is clear.
3. Safety is integrated into all activities in the organization.
4. A safety leadership process exists in the organization.
5. Safety culture is learning-driven in the organization.
In my opinion, it is hard, if not impossible, to establish any of these 5 core elements without leadership at the highest level of the organization AND 100% engagement by front-line employees. While organizational leaders can and should set the tone and provide the necessary resources for any safety culture change effort, the kind of organizational change that is required to foster the kind of safety culture envisioned by both the NRC and CNSC (in other words, the kind of safety culture that will prevent accidents such as Three Mile Island, Chernobyl, and Fukushima Daiichi catastrophes) MUST develop from the "bottom-up." For this simple reason, I agree with my friends on Twitter that you cannot (and should not) try to "mandate" safety culture.
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