Every organization wants to have highly reliable performance and fewer problems. That means highly reliable safety performance, highly reliable environmental performance, highly reliable customer service, highly reliable operations, etc.
How do organizations achieve high reliability? According to Karl E. Weick and Kathleen M. Sutcliffe who wrote “Managing the Unexpected,” first published in 2001, High Reliability Organizations (HROs) exhibit five key characteristics:
As an instructor, I spend a good part of my time in training trying to encourage people to ask more Why questions and get more specific while using the Cause Mapping® method of root cause analysis. I wanted to spend some time talking about how one of these characteristics, “Reluctance to Simplify,” fits into that discussion.
It is incredibly common for investigations or root cause analysis (RCA) teams to stop asking questions once they have gotten to a predetermined set of acceptable answers. Perhaps the list might include “procedure not followed,” “human error,” “lack of communication,” “training deficiency” or “poor planning.” While it might feel good to get to the end of an investigation and be able to close it out with an “answer,” these bucket or category-type causes do little to actually determine what the organization should do to mitigate risk going forward.
For example, if you chalk a problem up to “human error” – what does that tell us to do to reduce the potential for a similar issue occurring? How does your organization typically respond to that type of cause? Let me guess... Retrain? I believe that organizations (and investigation methodologies, for that matter) have attempted to create these pre-determined stopping points to standardize answers and allow for data mining and trending. But in creating these pre-determined acceptable answers, we have also created stopping points that can prevent us from identifying effective, actionable solutions that may improve the organization’s performance and move us closer to high reliability. And high reliability, by the way, is exactly the point of the investigations in the first place.
HROs are reluctant to simplify. Why? HROs know that there is more specific detail past these common, bucket-type causes that will allow us to better understand the incident and better understand how to prevent it in the future.
If we identify one of the causes as “procedure not followed,” follow it up by asking another Why question. Ask for more clarification. If there was a “human error,” what does that mean? If there was a “training deficiency,” what specifically about the training was deficient? Somehow, many of us got the memo that the purpose of an investigation is to find the most important cause (and label it). But really, the purpose of the investigation is to find the best solutions to improve our performance, and the only way to do that is to get into the details. So the next time you get to one of those stopping points where you think you are done analyzing, ask one more Why question and see what happens. That one more Why question may put you on the road to becoming a highly reliable organization.
Interested in learning more about how to stop simplifying causes and find more effective solutions to become an HRO? Check out one of our upcoming free webinars or register for our two-hour online short course, High-Reliability Leadership.