Learning and Culture:Bringing Together the Sharp End

and the Blunt End

John S. CarrollMIT Sloan School of Management

Presented atThe Quality Colloquium, Harvard,

August 2008

Panel: Patient Safety Lessons from Other Industries

• Prof. Carroll’s Focus: Recognize that attention to culture and learning is necessary to bring the sharp end and blunt end together

• OBJECTIVES: Present ideas and examples from nuclear, chemical, etc. Recognize the “hidden system” of culture and politics.

• SUMMARY:• Focus on vertical (blunt/sharp) end misalignment.• Activities such as incident investigations not only identify issues and

underlying causes but more importantly create a culture of safety and learning through collaborative reflection and change.

• POC: Prof. John S. Carroll, Morris A. Adelman Professor of Management, MIT Sloan School of Management

• (617) 253-2617 (O) or (617) 529-2617 (Cell) • jcarroll@mit.edu 

Organizing for Safety

• Every organization must align local and collective activities in the value stream– Horizontal misalignment or “silos”– Vertical misalignment, as in the front-line

unable to “sell” management on issues, or the “clay layer” that resists change

• Exacerbated around systems issues such as safety, especially in complex and highly-coupled high-hazard organizations

Acting On the System

• Managers typically strengthen alignment by “strategic-design” efforts, such as incentive systems, rules/procedures, planning/prioritizing, monitoring, training, reorganizing, mission statements, process reengineering, IT/SAP

• But those efforts can only succeed if embedded in the organization’s culture and politics (the “hidden system”)

Example: Incident Investigation

• We know how to set up incident reporting, analysis, corrective action systems

• But it’s how people enact the system that determines its effectiveness

• How much is reported? How quickly are issues identified? How deep are the analyses? How just and credible are the results? Are changes implemented?

Misalignments

• “To get their attention, management only wants to hear what the bottom line is -- what should be done -- they don’t want to hear about the details. When outsiders identify problems... they get attention. Outsiders have more clout.”

• “[A weakness of the report is] blaming the worker, who made the decision to perform the work, instead of ‘why did management allow the design problem to exist for so long?’”

• “If top level managers aren’t willing to listen to the people doing the work, and respond to their findings, it all becomes a waste!” […or if teams don’t understand strategic issues or know how to persuade managers!]

A Learning Failure at NASA

What was learned from Challenger (1986)?– Pressures for production outweighed expertise– Normalization of risk (accepting known problems)

What happened with Columbia (2003)?– Back to business as usual; “didn’t get it”– More production pressure– Leadership that tolerated no dissent– Lack of independent voice for safety– Safety/quality people are promoted: message?

(From Columbia Commission report, 2003 and Leveson et al, 2004)

Time Pressure Quick Fixes

Time

Time

Working harder

Working smarter

Performance

Performance

Repenning, N. & Sterman, J. Nobody gets credit for fixing problems that never happened. California Management Review, 2001

Learning Together

• In the “hidden system,” incident investigations are not just a search for the true causes (or someone to blame), but an occasion for collective reflection and conversation

• Demonstrate that people can talk to each other candidly and respectfully, and work together toward shared goals

• In one company, investigations have as their purpose “educating management”

Changing Culture

• It is hard to change culture by directly opposing it, e.g., a direct assault by new senior managers with widespread change of personnel, new incentives, etc.

• Often, success comes by building on existing cultural strengths, i.e., by inventing and celebrating new ways to solve common problems that reinforce and reinterpret the culture and add new desired elements

• Start where people are now; different starting points require different approaches and expectations (e.g., a reactive vs. proactive culture)

Safety Culture Content

In how people work together to learn from problems and make changes, they create “safety culture” (Reason, 1997; Weick et al., 2002):

• High priority on safety• Informed, reporting• Mindful, heedful, questioning• Just, fair, respectful, caring• Flexible, decisions migrate to front-line experts• Learning, developing for the long-term

Building On Cultural Strengths• An alternative to opposing an existing culture is to identify

cultural strengths that can be drawn upon for support and then “tilt” the culture (Schein, 1992; 1999)

• At Millstone Nuclear Station, deep cultural values of “excellence,” “professional integrity” and “safety” were reframed to support new values of “mutual respect” and “openness”:

“excellent managers have no problems” “excellent managers want to hear about problems and surprises in order to prevent more serious problems”

“professionals have deep knowledge in their field of training” “professionals listen to and learn from other professionals in order to enhance safety”

Principles

• Start where people are; listen to and understand them• Engage broad participation• Work on things that matter to people with visible

resources/commitment• Communicate; create shared symbols• Walk the talk: actions speak louder than words• Build relationships• Cultivate distributed leadership• Look for partners and role models inside and outside• Align structures and people with the mission: incentive

systems help, but people use them to get what they want