Learning and Culture: Bringing Together the Sharp End and the Blunt End

1. Learning and Culture:Bringing Together the Sharp End and the Blunt End John S. Carroll MIT Sloan School of Management Presented at The Quality Colloquium, Harvard, August 2008

2. Panel: Patient Safety Lessons from Other Industries • Prof. Carroll’s Focus: Recognize that attention to culture and learning is necessary to bring the sharp end and blunt end together • OBJECTIVES: Present ideas and examples from nuclear, chemical, etc. Recognize the “hidden system” of culture and politics. • SUMMARY: • Focus on vertical (blunt/sharp) end misalignment. • Activities such as incident investigations not only identify issues and underlying causes but more importantly create a culture of safety and learning through collaborative reflection and change. • POC: Prof. John S. Carroll, Morris A. Adelman Professor of Management, MIT Sloan School of Management • (617) 253-2617 (O) or (617) 529-2617 (Cell)  • jcarroll@mit.edu

3. Organizing for Safety • Every organization must align local and collective activities in the value stream • Horizontal misalignment or “silos” • Vertical misalignment, as in the front-line unable to “sell” management on issues, or the “clay layer” that resists change • Exacerbated around systems issues such as safety, especially in complex and highly-coupled high-hazard organizations

4. Acting On the System • Managers typically strengthen alignment by “strategic-design” efforts, such as incentive systems, rules/procedures, planning/prioritizing, monitoring, training, reorganizing, mission statements, process reengineering, IT/SAP • But those efforts can only succeed if embedded in the organization’s culture and politics (the “hidden system”)

5. Example: Incident Investigation • We know how to set up incident reporting, analysis, corrective action systems • But it’s how people enact the system that determines its effectiveness • How much is reported? How quickly are issues identified? How deep are the analyses? How just and credible are the results? Are changes implemented?

6. Misalignments • “To get their attention, management only wants to hear what the bottom line is -- what should be done -- they don’t want to hear about the details. When outsiders identify problems... they get attention. Outsiders have more clout.” • “[A weakness of the report is] blaming the worker, who made the decision to perform the work, instead of ‘why did management allow the design problem to exist for so long?’” • “If top level managers aren’t willing to listen to the people doing the work, and respond to their findings, it all becomes a waste!” […or if teams don’t understand strategic issues or know how to persuade managers!]

7. A Learning Failure at NASA • What was learned from Challenger (1986)? • Pressures for production outweighed expertise • Normalization of risk (accepting known problems) • What happened with Columbia (2003)? • Back to business as usual; “didn’t get it” • More production pressure • Leadership that tolerated no dissent • Lack of independent voice for safety • Safety/quality people are promoted: message? (From Columbia Commission report, 2003 and Leveson et al, 2004)

8. Time Pressure  Quick Fixes Working harder Performance Time  Working smarter Performance Repenning, N. & Sterman, J. Nobody gets credit for fixing problems that never happened. California Management Review, 2001 Time 

9. Learning Together • In the “hidden system,” incident investigations are not just a search for the true causes (or someone to blame), but an occasion for collective reflection and conversation • Demonstrate that people can talk to each other candidly and respectfully, and work together toward shared goals • In one company, investigations have as their purpose “educating management”

10. Changing Culture • It is hard to change culture by directly opposing it, e.g., a direct assault by new senior managers with widespread change of personnel, new incentives, etc. • Often, success comes by building on existing cultural strengths, i.e., by inventing and celebrating new ways to solve common problems that reinforce and reinterpret the culture and add new desired elements • Start where people are now; different starting points require different approaches and expectations (e.g., a reactive vs. proactive culture)

11. Safety Culture Content In how people work together to learn from problems and make changes, they create “safety culture” (Reason, 1997; Weick et al., 2002): • High priority on safety • Informed, reporting • Mindful, heedful, questioning • Just, fair, respectful, caring • Flexible, decisions migrate to front-line experts • Learning, developing for the long-term

12. Building On Cultural Strengths • An alternative to opposing an existing culture is to identify cultural strengths that can be drawn upon for support and then “tilt” the culture (Schein, 1992; 1999) • At Millstone Nuclear Station, deep cultural values of “excellence,” “professional integrity” and “safety” were reframed to support new values of “mutual respect” and “openness”: • “excellent managers have no problems”  “excellent managers want to hear about problems and surprises in order to prevent more serious problems” • “professionals have deep knowledge in their field of training”  “professionals listen to and learn from other professionals in order to enhance safety”

13. Principles • Start where people are; listen to and understand them • Engage broad participation • Work on things that matter to people with visible resources/commitment • Communicate; create shared symbols • Walk the talk: actions speak louder than words • Build relationships • Cultivate distributed leadership • Look for partners and role models inside and outside • Align structures and people with the mission: incentive systems help, but people use them to get what they want