human factors

COVID-19 and High Reliability Organisations

What are High Reliability Organisations?

Following the Three Mile Island nuclear power plant incident in 1979, Charles Perrow published “Normal accidents” (1984), which suggested that accidents in high-risk systems are inevitable, even ‘normal’. Subsequent research questioned this work by showing that some organisations operate in high-risk or complex environments where accidents might be expected to occur frequently, but they manage to avoid catastrophes. These became known as High Reliability Organisations, or HROs.

HROs therefore work in unforgiving environments where the consequences of incidents would be serious, but they actually have fewer than their fair share of adverse events. Despite their complexity, they can function with high levels of safety and reliability, and are able to ‘bounce back’ from surprises.

Besides having good performance over a long period, HROs constantly strive to improve safety and reliability performance. Should they experience an incident, they have the capability to recover quickly, reducing the potential impact.

However, recent thinking suggests that what defines a HRO is not safety or reliability performance, but how it thinks and acts. The key is that HROs anticipate the unexpected AND contain the unexpected when it occurs. In 2001, two researchers outlined five principles which have become the key attributes of a HRO (Weick and Sutcliffe, 2001). The first three principles relate to anticipation of the unexpected; and the last two relate to containing the unexpected should it occur. Any organisation can display some or all of these characteristics, to a greater or lesser extent. This is more helpful than simply stating that an organisation is, or is not, a HRO.

Although early work focused on high-risk and highly-complex industries, such as nuclear power generation and nuclear aircraft carriers, HRO theory has since been applied more widely to non high-risk industries.

Applying HRO principles to COVID-19

High Reliability Organisations would be expected to have a robust response to the COVID-19 pandemic caused by the SARS-CoV-2 coronavirus, as they already have high levels of leadership engagement, a positive safety culture, a sense of vulnerability and a collaborative approach that empowers problem solving. These characteristics would provide any organisation with a solid foundation for their response to COVID-19.

The current pandemic has highlighted the importance of the best practices from HRO theory. The key principles of High Reliability thinking can be used to assess and refine your approach to COVID-19 (and other unexpected situations).

1. Preoccupation with failure

To be preoccupied with failure is to be alert to subtle changes or anomalies that could be symptoms of larger problems. These may be small, emerging failures or indicators that something is not right elsewhere in the system. The high reliability approach treats unexpected events as a big deal – rather than viewing them as acceptable. (See my article on Normalisation of Deviance). This principle requires listening to (and discussing) different points of view, as well as seeking feedback and criticism.

Your organisation should have a healthy fear of failure – anticipating what could go wrong (and how). For example, during the early phases of COVID-19, a high reliability approach may have included requiring a small group of employees to work from home in order to identify emerging issues, before working from home became mandatory for all staff.

If you are a Leader, do you actively seek out bad news, or are you a passive receiver of whatever news comes your way? To keep information flowing freely, focus on improving the processes that failed, rather than blaming the people involved. In responding to the COVID-19 pandemic, organisations should have a clear system for the reporting and analysis of local data.

Preoccupation with failure means thinking of, and planning for, the next unexpected event. For example, the widespread wearing of face masks and physical distancing measures to control COVID-19 may disrupt the transmission patterns of endemic diseases such as influenza; and this may amplify future outbreaks of these seasonal diseases. A high reliability approach may examine such challenges and prepare for them.

The following prompts may help you to become more preoccupied with failure:

  • What does failure mean in your organisation?
  • What needs to go right? What are the errors that you don’t want people to make?
  • Does your culture encourage staff to report near-misses, errors and risky situations/conditions?
  • Do you actively seek out early signs of trouble (‘weak signals’)?
  • Do you see failures as an opportunity to improve?

2. Reluctance to simplify

Simplification will tend to conceal details – particularly unexpected or unwanted details. Instead, be open to exploring new information fully, rather than fitting it into an existing category. At the start of this year’s pandemic, we saw simplification in action, as early (incorrect) assumptions were made about the transmission routes of COVID-19.

Be wary of giving something a name too quickly, as this suggests that you may be simplifying what you’re seeing. Generalisations are the enemy of HROs. This principle involves slowing down the process of thinking that ‘you’ve seen something like this before and therefore it’s not an issue‘. Ideally, you want people to assume less and notice more.

To reduce simplification, consider adding more variety into your systems and processes. For example, a leadership team composed of people with diverse skills and backgrounds will be more sensitive to concerns and better-placed to respond.

  • Do you communicate frequently with staff to understand the unique circumstances and challenges that they face? How do staff feed concerns up the hierarchy?
  • How do you understand the local capabilities and potential constraints?
  • How are you using real-time data to monitor the situation and make decisions that could reduce the impact of COVID-19?

3. Sensitivity to operations

This principle relates to understanding how operations (work/activities) are performed (rather than how they were planned or intended). It’s about knowing what is going on now, in the present. This means not being distracted, but being fully present in the moment. Leaders should consider how they can enable and support their teams to have real-time awareness.

This is not simply having situational awareness, it is about understanding the interdependencies between all components of a system. People should have a sense of how their work is connected with the work of others. Everyone should understand how their activity fits into the big-picture. In relation to COVID-19, there should be a process for rapidly sharing key information and how it impacts other activities.

  • Do you understand ‘work as performed’, rather than ‘work as imagined’?
  • Do you ask yourself why your operations are successful?
  • Do those on the frontline have an opportunity to influence the design of systems, processes and equipment?
  • Do you understand where future surges in demand will arise?

4. Commitment to resilience

HROs are defined not by being error free, but by the fact that errors don’t disable them. These organisations can maintain their functions, even when the unexpected happens. They can absorb change and disturbances. HROs may get stretched, but they do not break. In order to enable this resilience, HROs continuously build the competence of people, for example by providing experiences that ‘stretch’ them, rotating their positions, or by increasing their networks. During this pandemic period, there should be an explicit focus on the wellbeing of all employees.

Throughout COVID-19, we have seen many examples of resilience in action, such as restaurants offering take-away services, medical professionals providing video consultations, gyms providing video workouts, and for many organisations, a rapid shift to working from home. Some of these innovations will continue beyond the pandemic.

  • Do you recognise that, despite your best efforts, human errors will occur?
  • How do you support your staff to embrace the ‘new normal’ in their workplace?
  • Do you practice responding to unexpected events or worst-case scenarios?
  • Do you know what areas of the business will require extra people and resources?
  • Have you assessed novel partnerships and collaborations, to create more resilient supply chains?

5. Deference to expertise

HROs have flexible decision-making structures. They place decision-making with those who have the greatest ability and insight, regardless of their position in the hierarchy. Decisions may be pushed down to the lowest level possible. But it’s not just about deference in the act of decision-making. This principle includes deference to those with more context and knowledge of the situation, so that the decision-maker is better-informed.

In HROs, people know the limits of their own experience and knowledge: ‘knowing what you don’t know‘ is a key skill. HROs do not assume that authority equals expertise.

During the current COVID-19 pandemic, we have seen reliable sources of information emerge, as well as much false information. Unfortunately, modern technology has led to some poor information travelling as fast as the virus itself.

  • Are alternative points of view encouraged, voiced and entertained?
  • Are people wiling to ask for help – and know where to get that help?
  • Do you encourage two-way communications, rather than a one-way push of information?
  • How do you capture local innovations and share them widely?

Managing the unexpected: Key lessons

In the continuing response to the COVID-19 pandemic, adoption of the five HRO principles can play a key role. The above structure is a good reminder to consider both the anticipation of problems and unexpected events, as well as planning for the successful containment of problems should they occur.

Companies may benefit from reviewing the characteristics above in order to identify any areas that may improve their response to the current pandemic. Learning from the High Reliability Organisation approach will also improve preparation for any future crises (we know that they will happen).

“Ask yourself, can I alter our ways of working so that it is easier for people to puzzle over small disruptions, question familiar labels, understand what they’re currently doing, enhance their options, and identify the expertise that is needed?”

Weick and Sutcliffe, Managing the unexpected, (2015)

In order to sustain the high reliability principles in your organisation, you may need to make some structural changes:

  1. Embed the above principles into your norms, values and processes.
  2. Expect, and prepare for, the unexpected. Besides COVID-19, your organisation may likely face future challenges such as environmental disasters, new ways of working, trade barriers, cyber security impacts, banking crises etc.
  3. Consider what innovations have emerged during the COVID-19 pandemic that you wish to retain in the ‘new normal’, as well as those working practices that are no longer appropriate.

We have lost so much during the COVID-19 pandemic, but we can make the most of the lessons that are there to be learnt. No doubt, many of these lessons will remain valuable beyond the current pandemic.