Thursday, July 26, 2012

Errors, Midjudgments and Dishonesty- Creating a High Reliability Culture

Yesterday, I touched on four systemic barriers that leaders can establish....disciplined execution of standard operating procedures, sound project management methodology, simulations and emergency management/crisis management plans.  The effectiveness of these barriers is very dependant on the culture in which they exist.  This leaves open the question of what is it leaders can do to create a high reliability culture?
In his book, Complications:  A Surgeon's Notes on an Imperfect Science surgeon Atul Gawande describes the Morbidity and Mortality conference that is conducted weekly in most teaching hospitals in the United States.  Laws in most states protect the proceedings from legal discovery, encouraging absolute candor.  In these meetings "surgeons gather behind closed doors to review the mistakes, untoward events and deaths that occurred on their watch, determine responsibility and figure out what to do differently next time."  Gawande gives a compelling account of one such conference involving one of his cases on p. 58 of the book.

Likewise, the US Army's use of the After Action Review is a well documented example of another tool aimed at not fixing blame but identifying opportunities for improved performance.  Gen(ret) Gordon Sullivan, former Chief of Staff of the US Army describes this process, it's evolution and its importance in creating a high performance culture in his book Hope is Not a Method. This process  can be formal or informal and scaled to either large or small groups.    Key elements include an identifiable event, a statement of what was supposed to happen, a conversation about what actually happened, and why, and what will be done differently next time.  Key characteristics of a good AAR are that the environment is nonthreatening and participants are willing to take personal risk for  the team to learn and grow.  In the best ones I participated in, early in the AAR, senior officers admitted their own misjudgments, error and what they'd do differently.  This was a key step in creating the safe environment.

Root Cause Analysis is another such organizational process I observed in the oil and gas sector with the same goal of discovering "ground truth" and addressing.

The peer review process is common among many professional fields and is dominant in the field of academic journals.  I've also seen this process used in the oil and gas business.

Great leaders embed one or more of these processes into work and in so doing demonstrate to everyone in the organization that they recognize the possibility of failure.  These processes condition the work force to recognize and recover from errors and look for systemic fixes that prevent recurrence.  Repeated execution of these processes.....every day, every week, every month, every year, year after year after year.... are an important component of building a high reliability culture.

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