Showing posts with label High-reliability Organizations. Show all posts
Showing posts with label High-reliability Organizations. Show all posts

Wednesday, October 28, 2009

Mindfulness and fighting wild fires, and the value of simulations for training

Professor Karl Weick at the University of Michigan has written extensively on the need for "mindfulness" in emergency situations, such as, literally, fighting forest fires.

A mindful crew or crew-chief will be aware that they are operating on a mental model, and that model may be incorrect, so they must be alert to even very small signs that they have completely misconstrued the situation.

There are lessons here, on a longer time scale, for every leader, civilian or military.

Here are some public documents on the subject.

http://www.wy.blm.gov/fireuse/2009mtg/presentations/HROs-mindfulness.ppt

Teaching Mindfulness to Wildland Firefighters (Fire Management Today, Spring 2008, Dave Thomas)

For the last 3 years I have taught half-day workshops, conducted 1-hour lectures, and provided general awareness speeches about the Weick/ Sutcliffe model of High Reliability Organizing as described in their book Managing the Unexpected: Assuring High Performance in an Age of Complexity.

This article is a series of musings, conjectures, and recommendations pulled from this teaching experience. My intent is to pass on some of the lessons that I have learned teaching High Reliability Organizing, and to pose recommendations for further study...

Today, however, mainly due to the heating of the Earth through global warming and a build up of fuels -firefighters are working within an environmental framework of weather and fuel never experienced before. Errors that we might have "got away with" in the past could more easily become catastrophic today....

Next, I explain the irrationality (mindlessness) of always learning our primary safety lessons through trial and error. It is our job to be better at anticipating errors before they occur, before a brutal audit forces us to notice the discrepant events in the fire environment. The following quotation, which reinforces this view, is taken from French disaster expert Pat Lagadec:

"The ability to deal with a crisis situation is largely dependent on structures that have been developed before chaos arrives. The event can ... be considered an abrupt brutal audit: at a moment's notice, everything that was left unprepared becomes a complex problem, and every weakness comes rushing to the forefront."...

High Reliability Organizing

NEW! France-USA High Reliability Organizing in Incident Management Teams Project
Just like NYPD detective "Popeye" Doyle, who traveled to Marseilles in the 1970s hit movie “the French Connection” so too, did a Forest Service NIMO team this past December. Only it wasn’t for crime busting this time. It was a landmark match-up between two French and American Incident Management Teams to capture what makes these teams so successful in complex, rapidly changing, stressful situations. It is hypothesized that they exhibit many of the behaviors that directly align with high reliability organizing (HRO) concepts and principles.

( More to come)


More information:

The France-USA HRO Project (French Web Site, from Bouches du Rhone with video)
http://hro-fires.com/exercices_live.html

High-Reliability Organizing - Roberts, with Weick and Sutcliff:
http://www.wildfirelessons.net/HRO.aspx

Center for Catastrophic Risk Management, Berkely CA
http://ccrm.berkeley.edu

Communication and Information technologies:
New tools for DISASTER management
Jean-Michel DUMAZ (1)
Bouches-du-Rhône Fire Department – MARSEILLE - FRANCE
2nd International Conference on Urban Disaster Reduction
November 27~29, 2007

The Bouches du Rhône
Fire Department


Wade

Monday, November 12, 2007

Communication and control - the LAPD and Moslems



A hornet's nest was stirred up by a recent announcement by the Los Angeles Police Department that it was collecting data on Muslim communities.

"LAPD to build data on Muslim areas; Anti-terrorism unit wants to identify sites 'at risk' for extremism.", Los Angeles Times, Nov 9, 2007, also titled "LAPD defends Muslim mapping effort". Those aren't available for free, but a brief restatement is on the LAPD weblog at http://www.lapdblog.org/

What went wrong, and how could this work better next time? One hint is that the LA Times story had over 250 comments posted, and the LAPD weblog story had two.

The core problem, as I see it:
=============

I think it is almost impossible to communicate to someone, you can only communicate with them. Otherwise, you are really only talking at them -- most of it is bouncing off unheard.

This is like the teacher who said "I taught that material - the students just didn't learn it." That's not teaching, it's spouting. A DVD can spout. It takes a human being to teach.

When the FAA wants to read a flight clearance to a pilot, where it matters if the message is received, it waits until the pilot says "ready to copy." There's no point in running the faucet if the glass isn't under it.

What our K-12 or college systems seldom teach, however, is a fact that's obvious when you think about it, but overlooked all the time in planning:
People are not machines.
I've gone on at length in prior posts about what this means, but the most important take home message here today is this:
Human communication paths are not copper wires
that are either "attached" or "not" -- they are dynamic paths that you have to grow from both sides and continually nurture and weed. The are, in most senses of the word, living things.


And, like the way you talk with your wife, one harsh word or insult, even if unintended, can shut the whole thing down in an instant. To do this right requires heavy lifting over a long period of time. It doesn't just "happen." It's worth it, but it doesn't come easily.

It's as if you each have very low power walkie-talkies with invisible antennas, but your antenna is at right angles to hers, and essentially no signal gets through. You have to jockey around for a while on each end to get them more closely aligned before you can carry on a conversation.

You can't make up for this with volume. If the person is misunderstanding what you mean by a word, shouting doesn't improve the communication. What helps is noticing that their face registered a blank, or anger, when you used the word, which you didn't intend as your message, and stopping right there to ask what they just heard instead of what you meant.

Except that, you have to do that several hundred times, and they have to do it several hundred times, with both sides making a good faith effort to avoid jumping to conclusions, for it to work. There is no way to avoid this step. People are not machines. There is no magic wire, no Mr. Spock kind of Vulcan Mind-Meld that will let you communicate directly.

And, as my other posts go into at length, we live in silos in very different worlds, where words are attached to very different meanings, and it is misleading that we might all speak English, say. Then we think what I mean by a word is what you mean by it, and that's not true at all. Actually, it's amazing we manage to ever communicate at all with other people.
"What you heard is not what I meant" is the norm.
Anyway, at the end of this give and take dance of adjusting our internal antennas to get more aligned, there is, in fact a sweet spot at which a new thing takes over. In signal theory this is called "phase lock". Suddenly, briefly, you are 100% aligned. For a moment, the air is crystal clear, not filled with smoke and debris. But, people are not machines and this doesn't last very long, per event. But it can happen. Then you have to repair the channel again.

Sometimes you see this in sports teams that "get their act together", for a few seconds they play as if mind-reading, like a single person, totally synchronized and coordinated. There's a joy in watching this few seconds that makes the rest of the miserable weather worth while.

LAPD and Muslims
==============

Anyway, what triggered this post was the announcement (above) this week by the Los Angeles Police Department that they were going to start ... and I should stop there, because at the next word, communication already broke down.

The LAPD, after some false starts and use of the term "mapping Muslim communities" changed to the phrase "engaging". Too late! The community heard "mapping, followed implicitly by forcing to wear stars, surrounding with barbed wire, and shipping off to concentration camps, or worse. "

Again the basic rule of communication had shown its face:
What you say is not what they'll hear.
So, which side is "right"? I have no idea what is "really" going on, in terms of engagement between the LAPD and Muslim communities, aside from noting the obvious dysfunctional communication that set things back quite a bit.

Is the conclusion "Oh, I give up. There's no way to talk to her?" No. But there's no way to talk "TO" anyone, as I described above, unless you actually plan to take a lot of time listening as well, hearing surprising things that you weren't originally aware were issues.

In other terms, your antennas or mental models of each other have to both shift around somewhat and play this dance that we used to hear computer modems playing, alternating various beeps and squawks at each other, searching for a communication protocol that both sides understood before trying to start the actual conversation.

That step cannot be skipped, or your faucet is over here and their glass is over there, and there ain't any water making it across the gap.


The LA Fire Department
==============
By a remarkable coincidence, this month's issue of the magazine "Government Health IT" had a story about the LA Fire Department's use of Web 2.0 technology, including Flickr, Facebook, YouTube, and Twitter, to build communication paths with the public.

The LA Fire Department weblog is here.

The whole point of "Web 2" or "Web 2.0" is that the communication goes both ways. In "Web 1" systems, the company posts a "website" and the viewers, as on TV, well, "view it". It goes one way, period. Sometimes a letter to the editor might get a tiny bit of feedback loop going, but not really -- it's to little, and too late. Delay time matters, to humans. Remembering your wife's birthday ON her birthday is way better than remembering it the next day.

All of the "Web 2" tools are different, and not different inside the box -- they are different outside the box. They are used differently. They are social-networking tools that allow communications to go BOTH directions.

So, like a weblog, not only does the blog owner get to post an item, but everyone and his brother gets to post a response. That's one cycle. Then, people start posting responses to other people's comments, and it takes off. It is, in some sense, much less controllable.

The trade off that makes it valuable, despite this lessened sense of control, is that it lets the customers stop being "viewers" and start being "participants." It goes from the world of "selling" to resistant "customers" to actually hearing what people are saying and asking for and changing the product line to fit those actual needs. This is the key of the whole Toyota Way, known to Toyota as "customer pull", and Toyota could not operate without it.
Toyota knows how to LISTEN.
It turns out, it is not trivial to listen. It is not even easy to listen. Being in the room with the TV on is not listening, it's being near something spouting. TV trains us to be "subjected to" messages, which is like standing under a cold shower. People "tune out."

You want people to "tune in", you need to go interactive, where both sides talk, AND, both sides listen. AND, both sides adjust their frequency and antenna position slightly to improve the channel bandwidth, and go through that mutual learning cycle over and over again, each time getting a little better at hearing.
It's a loop, like the clothes line pictured above. It either goes both ways, or it doesn't go at all. If there's no loop, you're simply trying to "push with a rope."
If you want them to hear you, you have to spend a lot of energy listening to and hearing what they are really trying to tell you. The "density" is a property of the CHANNEL, not either side. If your listener seems "dense", it's because the whole communication LOOP isn't flowing adequately, full cycle.

Anyway, what's the LAFD doing?

Brian Humphrey and Ron Myers are described as having 80 different Web 2.0 efforts in the works, at the LA Fire Department's public information office.

I quote the Government Health IT article (Nov 2007, pages 42-43, Crisis Communications 2.0")
Humphrey and Myers see the new tools as opening more channels of communication between the department and the public. "Some might make the mistake of thinking these web 2.0 tools will allow us to get our message out louder and to more people," Humphrey said. "I think that is is wrong. What they enhance is the ability to listen."

He said some emergency agencies seek to control the public. "Instead, we want to empower them," he added. "And that lends itself to Web 2.0"
Well, I mostly agree. I am afraid that their phrasing could be heard as saying that it is not important to get OUT the message, and that it is not important to have public control and order."

In point of fact, as a friendly amendment, the reason for listening better is that you have to listen better IN ORDER TO get your communication channel built, IN ORDER TO be able to get your message not only broadcast and spouted, but actually heard and understood correctly.

The listening part is not just "for nice". The honest listening part is part of the requirement humans have to build a channel.

And, providing a spot for comments that are ignored is not "listening".

True story - once at Cornell the Building and Grounds department decided they were going to undertake some ill-advised project, which I think involved demolishing part of the beloved "Arts Quad" to put in something ugly. There was a huge outcry over the fact that this had not been discussed in public and there had been no chance for public input. As a result, the B&G department scheduled a huge public hearing. I went. They started off the meeting with, as near as I can recall, these words. "Thank you for coming tonight. We welcome your input. After the discussion, on your way out, please pick up your copy, from the boxes in the back,
of the booklets that describe the construction we will be doing next week. "

Communication only has value if it contains surprises. This is a basic law of signal theory. If the communication has no news in it, it's pretty useless. We already know that.

Which means, if you want to communicate, and build this loop, you need to accept the astounding fact that the party you're talking with knows something that you don't.

And the point of the conversation is to mutually surprise each other with facts that the other side didn't realize. This only works if both sides are willing to be surprised with information as good as, or better than, the information they had been working with and assumed was true.

The notion of "fairness" is very strong in human communication, unlike computers. People really resent being talked down to, and shut down the link. On the other hand, people sit up and take notice when their comments are heard and responded to, and come sit closer and start listening themselves. But it takes time. And humility. And listening. And hearing. And responding to what is heard by updating your mental model of what is going on.

The other point I have to disagree with, or tweak, in the statement above by the LAFD, is the implication that this communication process could lose "control".

As I've discussed before, no company or hospital or armed force is going to abandon the level of control they worked so hard to get, to be able to deliver their mission. BUT, they can, and must, adjust their internal mental model of what they thin they're doing, based on real information from the real world, not on some old, outdated concept of reality. Or, there's no point in "control" - you get that level of "control" by welding the steering wheel in place as the car drives off a cliff. You see that level of control in GM as they refuse to hear the message that people want cars with better mileage.

So, even the US Army, with a very strong hierarchy and a very strong need for control, has embraced the idea that they also need how to listen. (See the US Army Leadership Field Manual, FM22-100.)

The core "cybernetic" loop requires two things -- that the body respond to the brain's control commands, and that the brain stay current on what's going on in the body. Then it's a win-win.

Brains issuing controls based on how the world was last week or last year or "when I was in school" are like driving a car with the windshield blocked with a full-size photograph of the road taken last month.

Two kinds of authority
==================

As I've discussed elsewhere, the two meanings of "authority" have to be disentangled. Authority, in the sense of being able to issue lawful orders has to be retained, and enhanced.

Authority, in the sense of being right and being up to date an an authority on a subject, has to be obtained, and can only be obtained, by listening to real-time updates from the field, and being prepared to be surprised with what you hear.

The two together is a terrific combo. Control without actual paying attention is very short-lived, and expires at the next bend in the road one wasn't expecting or that wasn't on the Mapquest or Google Map of our planned route -- it is pointless.

The communication and response loops are key. One, vertically, has to let the guys at the top listen to, and actually hear, what they guys at the bottom are saying. One, horizontally, has to let everyone hear what the customers are actually saying. Then, you have a recipe for a very agile and adaptive powerhouse. Otherwise, you have a blind monster at large.

Wade

Related posts:

Unity in diversity and the two feedback loops (horizontal and vertical):

Nature of Feedback

(photo of man and woman , "Worn out" by by Avid Maxfan)

Friday, August 31, 2007

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