High Reliability Organizing in High Risk Industries Banner - Artwork by E. Steele, for the Wildland Fire Lessons Learned Center

Updates:

Feb 26, 2009:
Created page

Carolyn Libuser

Process Auditing: An established system for ongoing checks designed to spot expected as well as unexpected safety problems. Safety drills would be included in this category as would be equivalent testing. Follow-ups on problems revealed in prior audits are a critical part of this section as well.
Reward System: The reward system is the payoff that an individual or an organization gets for behaving one way or another. In this case, we are concerned with risky behavior. As all organizational theorists know, the reward system within an organization tends to have a powerful influence on the behavior of individuals within it. Similarly, the reward system that exists inter-organizationally also influences the behavior of organizations.
Degradation of Quality and/or Inferior Quality: This refers to the essential quality of the system involved as compared to a referent system that is generally regarded as the standard for quality.
Perception of Risk: Two elements of risk perception are involved here. (1) Whether or not there was any knowledge that risk existed at all, and (2) If there was knowledge that risk existed, the extent to which it was acknowledged appropriately or minimized.
Command and Control: This factor is borrowed from Roberts (1989, 1988, 1992). Roberts outlined command and control elements as separate factors, but I am combining them here and listing her separate factors as sub-factors in my broader model. The command and control elements are:

Migration Decision Making, the person with the most expertise makes the decision;
Redundancy (people and/or hardware), i.e., backup systems exist;
Senior Managers who can see the “big picture”, i.e., they don’t micromanage; and
Formal rules and procedures, standardization where proper, a definite existence of hierarchy but not necessarily bureaucracy in the negative sense.
Authority Gradient, in the positive sense there is a deference to the one responsible for performance during the events with a reduction of authority gradient in the negative sense (when an individual cannot bring important information to the leader because of the difference in levels of authority) [this addition is from van Stralen after experience moving from Fire EMS to healthcare].

© Carolyn Libuser 1995

C Libuser's Dissertation
Part 1 Introduction & Literature Review
Part 2 Case Reports & Model
Part 3 Results
Part 4 Summary
Part 5 Methods & Material