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

dchristenson@fs.fed.us www.wildfirelessons.net