Secrets of High Reliability Organizations

[ originally published 8/29/06 in my "Systems Thinking in Public Health" weblog. ]

Wow.

I just found an astonishingly delightful, insightful, and immediately helpful paper on the roots of the conflicts between control-cultures and learning-cultures in the high-risk workplace: "Organizational Learning From Experience in High-Hazard Industries: Problem Investigation as Off-Line Reflective Practice", on the MIS Sloan School of Management Working paper site (Working paper #4359-02, March 2002). It is by John S. Carroll, Jenny W. Rudolph, and Sachi Hatakenaka.

It's on the Social Science Research Network Electronic Paper Collection at
http://papers.ssrn.com/sol3/papers.cfm?abstract_id=305718

Here's a few snippets:

This paper confronts two central issues for organizational learning: (1) how is local learning (by individuals or small groups) integrated into collective learning by organizations? and (2) what are the differences between learning practices that focus on control, elimination of surprises, and single-loop incremental "fixing" of problems with those that focus on deep or radical learning, double-loop challenging of assumptions, and discovery of new opportunities?

and

These four stages contrast whether learning is primarily single-loop or double-loop, i.e., whether the organization can surface and challenge the assumptions and mental models underlying behavior, and whether learning is relatively improvised or structured. We conclude with a discussion of the stages, levels of learning (team, organizational, and individual), and the role of action, thinking, and emotion in organizational learning.

and

We focus this paper on the differences between a controlling orientation and a rethinking orientation (cf. "control vs. learning," Sikin et al., 1994; "fixing vs. learning," Carroll, 1995, 1998).... We argue that it is very challenging for organizations to develop a full range of learning capabilities because assumptions underlying the two approaches can be in conflict and the controlling approach is strongly supported by cognitive biases, industry norms, professional subcultures, and regulatory authority.

and

The controlling orientation attempts of minimize variation and avoid surprises (March 1991; Sitkin et al., 1994). ... compliance ... deviations ... record keeping ... more controls ... a prevention focus that is associated with anxiety, loss aversion, avoidance of errors of commission and a strong moral obligation to comply with rules (Higgins, 1998). Within the controlling orientation, problems stimulate blame that undermines information flow and learning (Morris & Moore, 2000; O'Reilly, 1978). [ emphasis added] Causes are found that are proximal to the problem (White, 1988), with available solutions that can be easily enacted, and are acceptable to powerful stakeholders (Carroll, 1995; Tetlock 1983). Observers commonly make the fundamental attribution error of finding fault with salient individuals in a complex situation. (Nisbett & Ross, 1980) such as the operators or mechanics who had their hands on the equipment when the problem arose ...

Both the engineering profession and the US management profession are trained to plan, analyze complex situations into understandable pieces, avoid uncertainty, and view people as a disruptive influence on technology or strategy.

and

As Weick, et al. (1999) state, "to move toward high reliability is to enlarge what people monitor, expect, and fear." The rethinking orientation is based on attitudes and cultural values of involvement, sharing, and mutual respect. ... Assumptions about authority, expertise and control give way to recognition of uncertainty and the need for collaborative learning. There is a climate of psychological safety that encourages organization members to ask question, explore, listen, and learn. ... increase monitoring and mindfulness ... based not onlyl on a desire to improve and mutual respect among diverse groups ... gain insights, challenge assumptions, and create comprehensive models. [many cites omitted for clarity ]

and finally

Participants transcend component-level undertanding ... to develop more comprehensive and systemic mental models ....

and

Despite a desire to improve, investigators and managers seldom look for fundamental or deep, systemic causes in part because they lack ready-made actions to address such issues and ways of evaluating their success ...

=======

I was informed after I wrote this that John Carroll also addresses these same issues, but specifically in the health care area. See:

Redirecting Traditional Professional Values to Support Safety:
Changing Organizational Culture in Health Care

John S. Carroll & Maria Alejandra Quijada, MIT Sloan School of Management

Qual Saf Health Care 2004;13:ii16-ii21
accessed 8/29/06

At March 14, 2007 5:20 AM, Anonymous said...

I agree. A great paper. Did you check out the High Reliability Organizations conference 2007? It takes place in Deauville in France, and it has two interesting panels on healthcare. The link is http://www.hro2007.org/Agenda2.html