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

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HRO Models

The Central Problem

Sudden and catastrophic business failure, economic collapse, injury, or loss of life, at some level, haunts anyone who has responsibility for others.  Though people and organizations maintain watch for signs of impending problems, it appears they either cannot or do not completely avert these problems.  Possibly they do not see the early signs of danger, they unconsciously accept only information that supports their success, or they reject signs that their system has begun to fail.

Crises and catastrophes begin as small events indistinguishable from normal occurrences or they arise from sudden demands on previously unidentified weak parts of the system.  Once the crisis begins, it entrains other events, consumes resources, and seemingly has the ability to find the weakest structures of the organization.

The Problem in Common- Business, Military, Public Safety, Healthcare
Though crises manifest themselves differently in business, industry, healthcare, military combat, and public safety, they share an underlying structure.  Modified from Raymond Novaco’s social ecology of stress, the environmental demands on the system or people’s expectations will exceed the intrinsic attributes and extrinsic resources of the organization.  Coping mechanisms can perpetuate the stress response and crisis or bring resolution and possibly strengthen the system or organization.  

Many of these organizations have in common the sense of vulnerability from performing in a threatening environment that one has no control over.  The untrained or inexperienced individual may respond with fear responses that turn the individual inward, relying on themselves for protection.  This self-reinforces vulnerability and further fear responses.  However, others receive training or have gained experience and respond to vulnerability by connecting with others.  When it produces a collaborative system in the organization this can serve as the source of high reliability.       

Business, whether large or small, responds and adapts to the economic environment.  But the presence of protracted financial growth, protective laws and regulations, and other social, regulatory, or financial safeguards can mask maladaptive traits that would otherwise harm the business.  This makes such traits indistinguishable from the adaptive behaviors that create productivity and ensure survival.  During a crisis these maladaptive traits easily become confused with adaptive traits and give feelings of security with a preference for maladaptive beliefs and behaviors at the expense of adaptive traits that provide reliability and safety. 

Paradoxically, the reliable and adaptive business traits from pre-war America, while they have diminished in the US, have become refined in Japan.  W. Edwards Deming helped introduce them to Japanese industry following WWII in efforts to improve production.

Veterans of combat from World War II through the Viet Nam War developed a culture to function in the face of immediate threat while in uncertain conditions and having limited time.  They valued steadiness under pressure or threat and discredited behaviors such as anger or excitement for the sake of thrills.  Self-protection came best through the protection of others around you and helping other members when they could not help themselves.  Duty to each other and a greater cause underlay their actions.  Problem solving came from a practical belief that each member was responsible to work toward a solution.  High trust, the willingness to trust unknown members to the extent of that individual’s abilities, promoted extemporaneous team formation.  Most valuable is the ability to shift values when the tempo of events changed.  Conformity in daily routine became creativity when faced with the unknown.  Obedience in the safety of deterministic settings became initiative for uncertainty and dynamic events.

Many of these veterans would apply these lessons learned to their business ventures and personal lives outside of the military.  The paucity of combat after the Viet Nam War gave the military few officers with more than 100 hours of combat experience as it entered the Global War on Terrorism.  The military then began an evaluation of combat methods and a turn toward high reliability techniques.

Public safety agencies have the duty to act (a legal term) when the environment becomes unsafe to the public.  They have the overarching goal of helping people when the person cannot help themselves.  By law, fire service and law enforcement are defined public safety agencies while some legal jurisdictions include the Emergency Medical Services (EMS). 

Over the last several hundred years these services have evolved a culture and technology to function in adversity.  All agencies focus on teamwork, judgment and decision making, and technical skills specific to their position.  This has sometimes developed through trial-and-error and sometimes through well thought out study.  With the decrease in urban fires and proscriptions on engagement by law enforcement, the “street smarts” of these agencies has begun to degrade.

Law enforcement, with the objective of keeping the peace in the social environment, enforces laws prospectively through education and patrol, interactively with criminal behavior, and retrospectively with criminal investigations.  The highest risk activities involve the unpredictability of human behavior from interactions with criminal actions and mental illness.  In these settings subtle clues and nuance give weak signals that the officer must interpret using the context given by the circumstances of the situation.

Because of the risks of these behavioral changes, which can kill innocent citizens, and the rapidity with which they occur society has given law enforcement the ability to stop these behaviors quickly.  However, the amount of force necessary, the stopping power, can kill which places the officer in the predicament of making irreversible, lethal decisions within seconds.  To increase safety to the innocent and improve reliability in life-threatening situations law enforcement programs study human performance and stress physiology in the social-technical environment.               

The fire service developed from efforts to extinguish fires and to prevent their spread.  It now responds to general threats from uncontrolled energy (fire, chemical, ionizing radiation, kinetic, and potential).  Their skills provide physical rescue of trapped victims and containment of hazardous material including biologic agents. 

The technical nature of the threats responded to by the fire service lead to greater predictability.  However, the magnitude of the threat and the larger scale can maintain the threat beyond minutes to hours and even days.  The fire service, then, has a focus on technical skills and team formation.  The team formation in the fire service has two functions, (1) organize around a common threat and (2) provide protection to the members during hazardous operations.  Organizing around a threat requires common language and clear communication that facilitates the flow of information.  Protection derives from the simple concept that, when focused on problem, a person can watch the safety of others better than for him or herself.  If all the members watch for the safety of everyone but themselves, then all are covered and each can focus on problem solving.

The emergency medical services (EMS) evolved from the need to move sick or injured victims to the hospital when they could not travel in the seated position.   In the 1950s physicians studied the use of lessons learned from combat medical care in WWII and the Korean Conflict.  At the same time, combat veterans brought their experience to those who provided ambulance care.  These two groups, enlightened physicians working with ambulance and rescue personnel having experience in emergencies, provided the basis for today’s EMS system in the US.

Today’s Healthcare developed from approaches designed to support and heal the sick or injured patient.  If the physician could make the proper diagnosis, then the proper treatment with the least harm would affect a cure or alleviate suffering.  Developments in medical care have increased the complexity of care to the degree that the care that helps may also harm.

With increased effectiveness of treatments physicians could treat diseases in earlier states of development.  However, similar diseases share similar signs and symptoms in the early stages without sufficient differentiating markers.  This complicated the selection of specific therapies that would not harm the patient and required more effective means to diagnose and greater vigilance in treatment. 

More effective treatments lengthened the time from onset of a debilitating or chronic disease until death.  Additional diseases, either acute or chronic, could now occur and complicate the care of the patient as treatment for one disease may exacerbate the other. 

Intensive and critical care developed in the 1950s and 1960s from physician’s efforts to delay death in the hospital in the search of an effective treatment for the patient.  As patients remained alive longer their pathophysiology became more complex with an increased possibility for errors and complications.  Extension of this approach to people arriving at the hospital created the field of Emergency Medicine.  Veterans of public safety and military combat, with their culture and thought processes, worked with physicians and nurses to extend resuscitation techniques to the field and the creation of the Emergency Medical Services (EMS).  Military Contributions to EMS

Deterministic approaches to care, such as the central authority of the doctor, treatment protocols, deterministic, evidence-based methods of medical care, and expectations of a specific diagnosis, all reduce error in deterministic states.  However, public safety and military combat veterans have found that, while decreased variability aids in uncertainty, it remains that variability of the system must match the variance of the environment.  Deterministic approaches work well when they are chosen rather than compelled.       

Solutions to the Problem- Reliability

One approach to this field of crisis and catastrophe management is High Reliability Organizing, an approach that came out of codification of the performance of air operations on US Navy aircraft carriers which was then used to evaluate impending bank failures.  This crossover speaks to the utility of using human performance and social interactions for the unexpected problems found in uncertain environments. 

In 1985, to better learn how to create a safe and reliable working environment, Thomas A. Mercer, Captain of the USS Carl Vinson, brought in Karlene Roberts, PhD, a professor from the Haas School of Business, University of California, Berkeley.  Capt. Mercer and Dr. Roberts focused on the rare event as an audit for success as the rare, unexpected event is the one that can destroy people, planes, and ships.  Through her observations and background in organizational psychology she identified five principles of HRO that separate the successful organization from the unsuccessful.  In 1994, Carolyn Libuser, PhD, would later identify these processes in five successful commercial banks and the failure of these processes to operate in five failed commercial banks.

Later, Karl Weick, PhD, and Kathleen Sutcliffe, PhD, with a background in social psychology, identified mindfulness as a key for individuals to begin collaborating as they anticipate and contain the unexpected event before and when it occurs.  They further identified five elements of mindfulness integral to managing the unexpected.

Daved van Stralen, MD, with a background in biology, moved from ambulance work through fire department emergency medical services (EMS) to medicine and healthcare.  With first hand experience working in live-or-die emergencies he drew upon what others had taught him from their combat experience and experience in the fire service, law enforcement, and early ambulance work.  Searching for a biological, psychological, and sociological bases that explained what his mentors taught him, he identified methods that individuals use at the beginning of a crisis that contribute to successful outcomes.

The High Performance Organizations (HPO)
Bert Slagmolen applied the work of Roberts, Weick, and Sutcliffe to Dutch organizations where high risk events are not lethal but represented by poor customer service.  The reticence of these organizations to learn Weick and Sutcliffe’s mindfulness led Slagmolen to modify the information more suitable for a service organization.  Though this approach did not change the congruence of his work with HROs he called this modification High Performance Organizations (HPO).

Do Culture and Lessons-Learned Translate to Others?
Karlene Roberts codification of the culture of the USS Carl Vinson under Capt. Thomas Mercer starting in 1985 informed the work of her graduate student, Carolyn Libuser for her dissertation on banking.  In 1994 Libuser applied Roberts’ HRO codification to the commercial lending divisions of a set of 10 banks.  She chose banks because most other researchers chose organizations that were highly technological in nature.  She fund that, with some anomalous findings among one or two banks, successful banks conformed to the HRO model while banks in poor financial condition and/or under regulatory constraints had non-HRO behavior patterns.   This direct application demonstrates that the principles of HROs can cross organizational boundaries of dissimilar organizations.  

Model Confusion – Is It about Size?
Threats to organizations and the uncertainty of the situation affect organizations at various levels.  Response to these events, as collective behavior, initially comes through the individual before interactions between people and then entering the organization’s structure.  At each level interactions vary, from the internal thoughts of the individual to the social interactions between individuals with continuous feedback.  The organization also has structure that permits or restricts certain actions.  Though the models appear to be different, they describe different levels of function in the HRO.

One interaction does change in organizations.  The human body evolved to respond to physical threats and survive.  Those mechanisms for physical survival now are the person’s responses to abstract crises.  Self-preservation for physical survival is now also for financial survival.

For some, self-justification becomes the driving force.  A decision or image is supported with a search for confirming evidence (confirmation bias) and a failure to search for disconfirming evidence or evidence of danger (error bias or “Am I wrong?”).  Distance from physical threats increase the potential for self-justification to influence one’s behaviors. 

A culture of reliability
Is there a culture of reliability?  Culture derives from shared beliefs, behaviors, and values.  In reliability the culture for stable times does not fit the culture necessary for dynamic events.  This ability to move into a new cultural context may confuse observers and outsiders but is a necessary adaptation.

Behaviors such as steadiness under pressure or threat are valued.  Steadiness as a behavior includes more than a calm and thoughtful demeanor.  Steadiness precludes both anger and excitement for the sake of thrills.  Team behavior changes as the team moves from a static “team by rigid hierarchy” to “team by shared objective.”  The best protection for self comes from the protection of others.  Team behavior also changes in the manner of interactions for safety and mutual support.  You do for the others because they will also do for you.  This makes it safe to, at times, be weak. 

Beliefs, another component of culture, include duty to a greater cause, belief in self (self-efficacy), belief in the team, and belief that the larger organization will support the member.  Problem solving beliefs include self-efficacy and the willingness to act even if in error because one has the ability to correct errors rapidly.  The acceptance of uncertainty and the ability to act, and act capably, before sufficient information is available.  There is the duty to act as in public safety because inaction, or doing nothing in order to do no harm, is harmful. 

Values include high trust and the willingness to trust unknown individuals to the extent of the individual’s abilities.  The shift in values during dynamic times is missed by observers.  When necessary, HROs shift values from conformity to creativity and shift obedience to initiative.