Monday, October 28, 2024

Containment: Deference to Expertise

The very nature of the environments that high reliability organizations (HROs) exist in precludes any kind of script, checklist, or playbook that covers every possible issue.  So how do HROs deal with this drawback?  They push decision making, especially in times of crisis, as much as possible to the frontline leaders and managers.  The true experts - the individuals who know their systems the best - are found on the frontlines and not in the board room!  Moreover, there is no way that an executive leader can have a full understanding of all the information that is at the frontline.  Even with the best communication plans and systems, the individuals who will have the most up-to-date and most accurate information will be the ones on the frontline.

Here is a list of all the posts in which the main (or at least a major) theme is "Deference to Expertise":

  1.   "Brace for Impact" (September 18, 2016)
  2. "Did he really say Shut up and listen?" (November 30, 2016)
  3. "HRO: Deference to Expertise" (December 5, 2016)
  4. "You know what to do..." (January 29, 2017)
  5. "...plans are useless, but planning is indispensable" (August 9, 2017)
  6. "Sua Sponte" (November 7, 2018)
  7. "Biblical Org Charts" (November 14, 2018)
  8. "The goal of all leaders should be to work themselves out of a job" (September 29, 2019)
  9. "Taming the chaos" (February 23, 2020)
  10. "Study the past" (March 11, 2020)
  11. "Hungry, hungry hippos" (May 27, 2020)
  12. "We rely upon your ability...you know what to do" (August 16, 2020)
  13. "The bureaucracy paradox" (February 21, 2022)
  14. "The definition of power is the transfer of energy" (May 7, 2022)
  15. "Serve and thou shall be served" (July 23, 2022)
  16. "We were soldiers once..." (July 30, 2022)
  17. "The six thousand mile screwdriver" (October 22, 2022)
  18. "Why Ted Lasso is the perfect HRO leader" (May 22, 2023)
  19. "Player, Manager, Coach" (May 24, 2023)
  20. "The few and the proud" (September 7, 2023)
  21. "White elephants and wheelwrights" (November 3, 2023)
  22. "The power of empowerment" (November 14, 2023)
  23. "The Nelson Touch" (February 19, 2024)
  24. "Leadership is not about solving problems??" (March 28, 2024)
  25. "Turning around the ship..." (May 5, 2024)
  26. "Better, stronger, faster, and flatter?" (August 28, 2024)
  27. "Empowering employees doesn't mean leaving them alone..." (September 7, 2024)
  28. "Improvise, Overcome, Adapt" (September 13, 2024)
  29. "Fix the environment, not the people..." (September 27, 2024)

Saturday, October 26, 2024

Containment: Commitment to Resilience

High reliability organizations (HROs) are 100% fully committed to resilience.  Resilience is defined as the capacity to quickly recover or "bounce back" from difficulties.  By their very nature, HROs are highly complex and tightly coupled.  In other words, these organizations are highly interdependent - a small error in one part of the organization can impact a completely separate part of the organization.  Furthermore, these small errors are often compounded and magnified.  HROs also exist in unforgiving environments where learning by experimentation is often neither feasible or safe.  In reality, by developing resilient systems with multiple back-ups and mitigation plans, HROs have made themselves even more complex and more tightly coupled!  But that is okay, especially if it means that mistakes and errors can be contained.  Errors will happen, but HROs are not paralyzed by them.

Here is a list of all the posts in which the main (or at least a major) theme is "Commitment to Resilience" (focusing on organizational resilience, not personal resilience):
  1. "HRO: Commitment to Resilience" (November 22, 2016)
  2. "Still I Rise" (February 12, 2017)
  3. "Be like Young" (June 14, 2017)
  4. "Enter the Dragon" (April 28, 2019)
  5. "Failure is not an option!" (April 17, 2020)
  6. "For want of a nail..." (April 14, 2021)
  7. "The grit in the oyster" (April 11, 2021)
  8. "The Oak and the Reeds" (April 9, 2022)
  9. "Disappointed but not defeated" (February 13, 2023)
  10. "Be like water" (September 1, 2023)
  11. "The Legend of the Spider" (March 22, 2024)
  12. "Resilience and grit" (October 1, 2024)

Thursday, October 24, 2024

Anticipation: Sensitivity to Operations

High reliability organizations are sensitive to operations, i.e. what is happening on the front lines of their operations.  They use standardization of best practices and elimination of waste to increase efficiency, lower cost, and minimize errors as much as possible.  

Here is a list of all the posts in which the main (or at least a major) theme is "Sensitivity to Operations":

Tuesday, October 22, 2024

Anticipation: Reluctance to Simplify

High reliability organizations (HROs) are characterized by a reluctance to simplify interpretation of events.  HROs understand that we live in a complex, unpredictable world and that the easiest explanation (often the first explanation) is usually not the complete story.  HROs conduct thorough, in-depth investigations of adverse events, usually interviewing multiple individuals to get different perspectives, in order to get to the root-cause of the event. 

Here is a list of all the posts in which the main (or at least a major) theme is "Reluctance to Simplify":
  1. "HRO: Reluctance to Simplify" (October 30, 2016)
  2. "The curious case of the missing dollar" (September 27, 2017)
  3. "The Alabama Paradox" (January 16, 2019)
  4. "Einstellung" (June 22, 2021)
  5. "Wicked" (September 18, 2022)
  6. "...like a stand of trees" (September 22, 2022)
  7. "My car is allergic to vanilla ice cream..." (November 29, 2023)
  8. "Why is a raven like a writing desk?" (April 3, 2024)
  9. "The SAT problem" (April 11, 2024)
  10. "1+2+3+4+...= ?" (May 24, 2024)
  11. "Things aren't always what they seem" (September 25, 2024)

Sunday, October 20, 2024

Anticipation: Preoccupation with Failure

High reliability organizations do not consider failures as things to avoid at all cost.  Rather, HROs believe that failures represent opportunities to learn and improve their systems.  As Thomas Watson, founder of International Business Machines (IBM) once said, "If you want to increase your success rate, double your failure rate."  Individuals in HROs report their mistakes, even when nobody else is looking!  HROs do not punish individuals who make mistakes.  On the contrary, in many cases, individuals who report their mistakes are often rewarded!

Here is a list of all the posts in which the main (or at least a major) theme is "Preoccupation with Failure":

Friday, October 18, 2024

Once again...High Reliability Organizations

It's been a couple of years since I first posted about High Reliability Organizations (HROs).  I wanted to re-visit the topic again in today's post.  HRO theory started with the analysis of three vastly different organizations - an US Navy nuclear-powered aircraft carrier (USS Carl Vinson), the Federal Aviation Administration's Air Traffic Control system, and Pacific Gas and Electric's nuclear power plant at Diablo Canyon - by an eclectic group of investigators - Rear Admiral (retired) Tom Mercer, Todd LaPorte, Gene Rochlin, and Karlene Roberts (all at the University of California at Berkeley).  Additional contributions to the HRO literature have been provided over the years by Karl Weick, Paul Schulman, and Kathleen Sutcliffe.  HROs are usually defined as organizations that somehow avoid catastrophic accidents, even though they normally exist in an environment where normal accidents can be expected to occur by virtue of the complexity of the organization and by the nature of the industry.  Examples of HROs have included flight deck operations on US Navy aircraft carriers, nuclear power plants, commercial aviation, NASA, and forest fire fighting operations. 

Interestingly enough, every single HRO has, at one time or another, has experienced catastrophic accidents.  For example, NASA has had the space shuttle Challenger and Columbia accidents, while the nuclear power industry has experienced the Three Mile Island and, more recently, the Fukushima Daiichi disasters.  Commercial aviation has become incredibly safe over the last few decades, but occasionally there are accidents that result in significant loss of life.  Even the highly acclaimed Toyota Production System (many experts have claimed that Toyota has been one of the more recent examples of a HRO) has experienced difficulties.  As such, there are certainly lessons that we, in health care, can learn from HRO's past successes and failures (see also my article "Organization-wide approaches to patient safety" published several years ago).  

Karl Weick and Kathleen Sutcliffe have written extensively on HRO principles in their excellent book entitled "Managing the Unexpected".  Weick and Sutcliffe explain that all HROs have five key organizational characteristics in common:

1. Preoccupation with failure
2. Reluctance to simplify
3. Sensitivity to operations
4. Commitment to resilience
5. Deference to expertise

Three of these organizational characteristics have been called "Principles of Anticipation" as they have more to do with prevention of errors.  These include (1) Preoccupation with failure, (2) Reluctance to simplify, and (3) sensitivity to operations.  The last two organizational characteristics are known as "Principles of Containment" as they involve minimizing the impact of an error once it has already occurred.  These include, (4) Commitment to resilience and (5) Deference to expertise. 

I have written a number of posts over the years, highlighting at one time or another each of these five organizational characteristics.  I wanted to make it easier to search this blog for older posts on what separates HROs from the rest of us.  So, in my next five posts, I will collect all of these older posts and list them in a post on each of the five characteristics listed above.

Wednesday, October 16, 2024

Are smart phones making us dumb?

There was a time several years ago when I subscribed to both the Wall Street Journal and the Financial Times newspapers.  I enjoyed reading both, but it just got to be too much.  I soon found myself just throwing the daily edition of each newspaper unread (or partially read) into the recycle bin.  I have to be 100% honest though, while I thought the writing was slightly better in the WSJ (and more focused on current events in the US), the articles were shorter and easier to digest in the FT.  I've posted in the past about how much I like to read, but more recently I've found myself enjoying shorter books, magazine articles, and newspaper articles.  So, I started wondering if something was going on with my reading habits.  Have they changed?  As it turns out, there may be a very logical answer and explanation.

The American writer and journalist, Nicholas Carr, wrote an article for The Atlantic in 2008 entitled, "Is Google Making Us Stupid?"  He expands on this theme in his excellent book, The Shallows: What the Internet Is Doing to Our Brains. He suggests (and provides convincing evidence) that our online reading habits have changed not only how we read, but also how we think.  Consider this - studies show that when we read online, we skim over information and bounce around the Internet using either the embedded hypertext links or by starting a completely new search.  Just like my preference for the shorter articles of the Financial Times compared to the Wall Street Journal, we've all lost our ability to read lengthy passages of text.  Our brains have become permanently accustomed to the 280 character count of Twitter or the short messages with all the emoji's that we send and receive in a text!  As Maggie Jackson writes in her book Distracted, the Internet, social media, and email are all set up to distract us and keep us distracted.  Carr describes the changes in his reading habits by stating, "Once I was a scuba diver in a sea of words.  Now I zip along the surface like a guy on a Jet Ski."  Case in point, in his book Carr references an article that appeared in New York magazine in 2009 written by Sam Anderson, entitled "In Defense of Distraction."  I took a look, but when I saw how long it was, I quickly skimmed through it!

Even traditional forms of media have been forced to adapt to our new reading habits.  Television programs add text crawls at the bottom of the screen, while magazines and newspapers (if they are even around) have shortened their articles (see my point on the Financial Times above) or provided abstracts or summaries of the longer articles.  I've even heard of e-books that have started to look more like the Internet, complete with hypertext links, pop-up advertisements, and rolling text crawls.  

What if the Internet has changed more than just our reading habits?  What if it has fundamentally changed the way we think?  Carr starts and ends both the Atlantic article and his book with a famous scene from Stanley Kubrick's 1968 movie, 2001: A Space Odyssey.  Astronaut Dave Bowman is slowly turning off the computer HAL-9000, which had tried to kill him earlier in the film (and actually did kill his fellow astronauts).  At first, HAL-9000 admonishes, "Dave, stop. Stop, will you? Stop, Dave. Will you stop?"  As the astronaut continues to shut off HAL's circuits, one at a time, the computer responds with "I can feel it. I can feel it. I'm afraid."  Carr ends the article (and the book) with, "That's the essence of Kubrick's dark prophecy: as we come to rely on computers to mediate our understanding of the world, it is our own intelligence that flattens into artificial intelligence."  It's a haunting prediction, but one that doesn't seem all that far off.  

Carr writes, "The Net grants us instant access to a library of information unprecedented in its size and scope, and it makes it easy for us to sort through that library - to find, if not exactly what we are looking for, at least something sufficient for our immediate purposes.  What the Net diminishes is...the ability to know, in depth, a subject for ourselves, to construct within our own minds the rich and idiosyncratic set of connections that give rise to a singular intelligence."  To be blunt, the Internet is driving our brain into the shadows!

There is evidence to suggest that "how" we read helps to shape the neural circuits inside our brains (called neuroplasticity - for another example of neuroplasticity, see my post "London Hackney" on the neuroplasticity found in London taxi drivers).  For example, experiments have shown that readers of written language that uses symbols (e.g., Chinese characters, called Hanzi, that are among the oldest writing systems in the world) develop different neural circuitry compared to those whose written language uses an alphabet.  Similarly, studies have shown that our online reading habits ("power browsing" to use a term by another author) form different neural circuits in our brain compared to our traditional way of reading, where we become deeply engrossed in an article or book.

As it turns out, people have been worrying about how advances in technology can change us in dramatic ways since the time of the ancient Greeks.  In Plato's Phaedrus, Socrates laments how writing has made people forget how to think.  Socrates argues that the written word is "a recipe not for memory, but for reminder."  And as people use the written word as a substitute for the knowledge that they used to carry around in their heads and recite by memory, they will "cease to exercise their memory and become forgetful."

Maybe Nicholas Carr is right.  Maybe our smart phones have made us less intelligent.  Technological progress has become, to use Socrates' analogy, a crutch that in the long run will only make us less intelligent, less resilient, and less independent.  Carr carries on this theme with his book on the dangers of automation, The Glass Cage: How Computers Are Changing Us, but that is a topic for another post.