w6 making decisions in risky situations - simon pollard
TRANSCRIPT
Uncertainty, risk and decision making in local government
‘Localism works’, LG Group Annual Conference, ICC Birmingham
Simon Pollard, Sophie Rocksand Mark Smith
[email protected]/sas/risk
Risk - some observations
• We are all risk managers; personally, professionally• Historic focus on analysis and process, less so on systemic
understanding and human factors• ‘Risk assessment’ has a mixed reputation in the public mind
– bureaucracy, tick box, nanny state?• Resource constraint - ‘measured risk-taking’ (not
recklessness) if services are to change• Fragmentation of oversight is a possibility• Technical silos and the language of risk• Risk governance – people, organisations, evidence,
accountability, responsibility, risk culture
What drives risk?(an analytic perspective)
Potent hazards (sources) become available (pathways) to things we value (receptors), posing them harm (loss of value)
Different characteristics for risks
• Extreme risks (safeguarding vulnerable adults and children);
• Moderate risks (crime and community safety, including fire);
• Natural hazards (preparation for severe weather events, for health pandemics);
• External threats (terrorist activity);• Treasury management and investments; and • Risk of failure in major service redesign.
(after Lyons, 2007)
Risk domains in local authority settings
Individuals care of elderly
Authority initiated
reorganisation
Unable to controlhealth
pandemics
Groups of individuals
environmental pollution
Risks to communities
Risks from events
Risks from decision making
processes
Risks to vulnerable
adults
LARCI funded research –motivations
• Partnership working with democratic accountability
• Desire for ‘fit for purpose’ risk appraisal• Expectation of taking more risk, but in a
measured way• Expectation of increased accountability and
empowerment by actors• ‘Nuanced approach’ to what works• Practitioner focus – best judgement at all times
and seek to improve your judgement
“A repertoire of ideas of
practical value and use, to
inform risk strategies”
Methodology
Seven themes that emerge from 12 interviews
Emergent theme (no. sources, no. references to) • Learning (9, 82)• Responsibility (9, 78)• Process (9, 55)• Uncertainty (9, 54)
• Communication and consultation (9, 25)• The strategy-operational gap (8, 24)• Weight of evidence (8, 18)
N Maturity Mode / Style Process characteristic and effect
5 Optimised Adaptive Double loop learning
The organisation is ‘best practice’, capable of learning and adapting itself. It not only uses experience to correct any problems, but also to change the nature of the way it operates.
4 Managed Quantified Single Loop learning
The organisation can control what it does in the way of processes. It lays down requirements and ensures that these are met through feedback.
3 Defined Measured Open loop
The organisation can say what it does and how it goes about it but not necessarily act on its analyses
2 Repeatable Prescriptive The organisation can repeat what it has done before, but not necessarily define what it does.
1 Ad hoc Re-active Characterises a learner organisation with complete processes which are not standardised and are largely uncontrolled
0 Incomplete violation Incomplete processes, criminal, deliberate violations
Interpretation of maturity level
Risk and organisational learning – the change agenda
orga
nis a
tiona
l val
ue
Organisational learning- ‘maturity’ within public sector organisations
(Marsh, 2009)
present in silos
processdriven
towardsstrategic
value-added
Good risk governance creates value – a power utility’s risk journeyin practice
Process sophistication
Org
anis
atio
nal v
alue
Risk specialization
Enterpriserisk awareness
Risk management integration
Risk/mitigation optimization
6 months 12 months 18-24 months 24-48 months
Senior Managementand Boardinformation needsevaluated;
Preliminary risk profiledeveloped;
Policies established or refined;
Standard terminology,techniques, documents established;
Functional unitaccountabilities clarified
Risk Profile refined(focus is on residual risks and tolerances);
Regular reporting toSenior Managementand Board of Directors established;
Corporate risk assessmentembedded in businessplanning process;
Local risk ownersidentified; local riskmanagement expertiseidentified; skills andknowledge transferoccurring
Corporate performancemeasures refined torecognize risk tolerancesand priorities;
Risk assessment andprioritization fully embeddedin business planning;
Risk profile interdependenciesrecognized;
Local risk managementprocesses fully active
Clear ties between stakeholder value andrisk management activities;
Comprehensive riskportfolio created; newrisk exposures identified early; appropriate priority and mitigation determined quickly;
Risk management embeddedall key business processes,including strategic planning;
Local risk managementprocesses fully aligned withCorporate objectives
(after Fraser, 2005)
Responsibility (to act) and accountability(to supply resources)
• Risk appetite – has it been discussed?• Zero risk is not an option• Difficult to empower others if not• Keeping risk live and risk registers active• Power and personality – better, facilitative regulation
(Davies, 2010)
The ‘Just culture’ movement – balancing accountability, organisational learning and acceptable behaviour
Aviation and patient safety reporting; see Sidney Dekker and James Reason on balancing safety and behaviour.
Signals – pay attention to them, investigate them, don’t normalise them
Genesis of industrial accidents; seeAndrew Hopkins on mindful leadership
Situational awareness, cognition, task performance and team behaviours
Cognition and human factors in the workplace; see Rhona Flin on situational awareness
Process – latent flaws in real systems
(after, Reason 2000)
Process – how accidents happen
Human error: types• slips• lapses• mistakes• violations
Human error: causes• skill• rule• knowledge
Assessment tools for safety management
systems
Socio-technical systems failures
Management and organisational factors: management control
Management theory
Ergonomics
Safety cultures issues. Attitudes
to safety
Failures of safety
management systems
Assessment tools for safety cultures and attitudes to
safety
People failures:Hierarchical
Task Analysis.Human reliability
Assessments
The underlying basis of human actions/beliefs
•psychological•sociological•cultural•political•economic
People problems
System problems
(after Hurst, 1998)
Technical problemsTechnical hardware
Failures:Reliability
EngineeringDesign
Accident
Assessment tools for
hardware and the impact of
failure
Uncertainty in decisions
“we have formal evidence based processes which are based on big issues, but still need local knowledge to understand and
interpret it”
(adapted from Snowden and Boone, 2007)
• what sort of uncertainty is it?• is it resolvable?• care on paralysis by analysis• are we safe now?• are we doing enough to keep us safe?
(Miles, 2002)
Better risk governance - conclusions