Joseph Duhig – Co-founder
“You don’t know what you don’t know.” “Trained professional vs. well-intentioned amateur.”
I have used these two phrases often in my 30+ year career as an improvement professional and healthcare leader. However, the saying was always applied to others attempting to acquire knowledge in my areas of expertise in lean production, six sigma, quality, change management, analytics, business process management, human centered design and the alphabet soup of change initiatives that have come and gone over the decades.
When I picked up the book “High Reliability for a Highly Unreliable World,” I expected an easy read providing confirmation of what I already knew with perhaps a few useful insights gleaned from aviation. About halfway through Chapter 1, I realized I was in for a long journey of learning and self-reflection…I did not know what I did not know. I was both excited by the opportunity to apply my new knowledge while concerned that my professional colleagues would dismiss the need to challenge the status quo. After all, like me, they have enjoyed long and successful careers helping their clients and organizations learn and apply the science of improvement and leading complex change.
However, I have always been troubled by the need to solve the same problems again and again and again. The knowledge we gained while doing the hard work of improvement had a short half-life once the project concluded and people went back to their regular work…their real jobs. Only 30% of our improvements sustain for 1 year. When I worked with executive leaders and boards, we’d spend hours dissecting and trying to understand what made their dashboards green, yellow or red. Was achieving the goal and turning the dashboard green a result of our intentional effort or did we just get lucky…you hire good people, give them support and they will find a way to achieve the results we desire. We’d affectionately refer to our dashboards as Christmas Trees with blinking colors as our status changed from good to bad and bad to good.
Upon careful thought and reflection as a process engineer, I realize we have over-engineered our processes for trying to sustain improvements over time. What works in a stable, predictable environment does not work in an unstable, unpredictable environment…and like it or not, healthcare is often unstable and unpredictable. How we think and make decisions in a stable environment is different from how we perform in an unstable environment. High Reliability places a priority on practical wisdom and the interaction between cognitive processes and affective processes. High Reliability unlocks the keys to the human brain and how we make decisions. I did not understand the important distinction between problem solving versus decision making. In improvement science, we rely heavily on problem solving using our cognitive thinking to move from our current state to a desired future state defined by a measurable goal. In High Reliability, we focus on how people make decisions in real-time to move towards a desired outcome to a situation…did our actions make the situation better, worse or no change?
“People will always do what makes sense to them at the moment and will make decisions based on their sense making efforts. All beliefs and behaviors in complex, dynamic environments are logical at the time they are used. What we are doing in this handbook is changing your logic from what you may have learned as well as reframing the sense making you have been using.” High Reliability for a Highly Unreliable World, page 105.
This simple statement struck me as a fundamental truth often not acknowledged in our Performance Improvement / Lean Thinking disciplines. Sense making…we do what makes sense at the moment…is the key to sustainability.
“High Reliability operators are vigilant for the discrepancies, either unexpected or out-of-place observations, events or responses. These are investigated through observation, interaction, or discussion with somebody who has more knowledge or experience. With practice, the arousal from these discrepancies will drive actions toward reaching the more desired end-state.” High Reliability in a Highly Unreliable World, page 107.
We need trained High Reliability Professionals who can mentor, teach and coach our highly trained health care professionals in sense making and decision making in unstructured environments. We need to be able to recognize when the environment crosses the threshold from being structured and predictable to unstructured and unpredictable. We need to partner with our High Reliability colleagues to understand how our brains make decisions under stress and how to teach decision making to take appropriate actions as we work towards resolving a situation to a desirable outcome. I realize I am a trained professional in improving a system towards achieving a measurable goal, but a well-intentioned amateur in the psychology and physiology of human behavior.
High Reliability has great potential beyond the fields of patient safety and risk management. It brings new thinking and approaches to solving the fundamental problem facing all serious improvement professionals…how do we sustain and scale our improvement work? It provides confidence to executive leaders that the Christmas Tree problem is solvable…it is possible to achieve and sustain green status for our dashboard indicators. And most importantly, it provides front line teams with confidence in dealing with the ambiguity they face every day. “I may not know what is happening, but I know what to do.” It involves engaging the problem from within the problem state and applying sense making and decision making to achieve a desired outcome.
The purpose of High Reliability Organization Professional Certification is to teach the principles, and more importantly, the application of a High Reliability mindset in performing skills-based, rules-based and knowledge-based work. Our goal is to create a professional practice for High Reliability practitioners with formal certification as proficiency advances from Novice to Mastery. The foundation of High Reliability is a strong Lean Production System and/or Business Process Management structure. Problem solving involves identifying a performance gap between what we observe and what we expect to see. Sense making, decision making and what HRO’s refer to as the OODA Loop…Observe, Orient, Decide, Act…provide powerful new techniques to sustain improvements once the project or initiative has concluded.
“You don’t know what you don’t know.” My hope is you will take the time to learn and understand High Reliability. Then you can decide if it provides practical knowledge you can use to deliver value to your customers, your employees, your business, and your ongoing professional development. I welcome you to join our new and growing practice of Certified High Reliability Professionals.
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