Human experience shows that people, not organizations or management systems, get things done.
– Admiral Hyman G. Rickover
Major industrial accidents in the 1980s led to a focus on management systems to understand and control risks. The focus was on the work processes needed to control risks and the effectiveness of those processes. Explicitly, expectations were set that those processes be followed. Implicitly they constrained behaviors and limited critical thinking.
After twenty-five years of practice, these systems are showing their age. They have become complex and bureaucratic with time. Leading companies are beginning to ask, “How can we get the benefits of a procedural structure while stimulating innovation, creativity, and critical thinking?”
A further complicating factor is that these systems were designed with a heavy dose of audits. As time has gone by, the audits have focused increasingly on the bureaucracy of the system. They simply do not address the effectiveness of critical thinking within the organization. Major operational events continue despite the systems. Why?
Work processes as part of a structured approach will continue to be important. It is time to address two critical barriers: growing complexity and the failure to unlock human potential. The next generation of management systems will focus less on constraining people and more on enabling people. Simply put, the goal is recognizing a company’s strength in the talents of its people and focus on a simple and structured way to unlock and expand those talents.
Most recent major incidents could have been prevented with more robust critical thinking and not one more procedure! Upwards of 95% of all critical decisions are made deep in the organization at “2 AM” when few are around. Most of those decisions are sound and appropriate. You have good people with good intentions and skills.
The public expectation that bad things never happen is a high bar. What can be done to further increase the number of good decisions being made? An organization must have the right behaviors, which lead to the right habits, and ultimately become engrained as a culture. People are hired and rewarded for these behaviors. It becomes the essence of the organization and leads to very effective critical thinking.
The human behaviors you seek need to have the following attributes:
- Simple – They need to be intuitive, fundamental, and easily described at any organizational level.
- Aligned – They apply at every level of the organization without exception.
- Alive – They cannot be a slogan or poster. They are driven by leadership, and modeled by and expected from all.
- Integrated – They are part of goals, performance reviews, pay, hiring, promotion, development, strategic HR commitment, investment and technology strategies, engineering, design, and roles and responsibilities. Simply put, they are the “way we work.”
With a focus on these five behaviors, critical thinking improves in work planning, situational awareness, and post-operation reviews.
The key is creating a simple model of what appropriate critical thinking looks like and giving the human aspects attention akin to how management systems address processes. Let’s first look at some of the flawed approaches:
These are characterized by a campaign to get everyone to buy into zero as a goal or target. They are often supplemented with a bonus or reward system for performance. If the reward system is significant enough, performance defects are driven underground. Investment is made to train everyone in the zero initiative. While some benefit is gained in the short term, zero initiatives almost always have a shelf life and they wane in importance with time. The focus centers on the target rather than what the target is trying to achieve. This is a subtle but important difference.
Production versus Safety
This mindset is based on the premise that nothing is risk-free and therefore a set of trade-offs always exists. An example is that e-coli is dangerous but manageable. The cost of elimination in the food supply is very high. Other lower cost solutions exist.
Many lobbying efforts exist to sustain the false “production vs. safety mindset” and protect from higher costs. The mindset gets in the way of critical thinking and problem solving built around a “safe production mindset.” Production vs. Safety also actually gets in the way of getting to better solutions.
Many will suggest that the audit process is a key component of an organization’s approach. Too often we see that current audit processes are flawed and give a false sense of confidence. Audit processes are expensive and time-consuming and are subject to being gamed by both the auditor and the group being audited. They focus on whether a process is in place and whether it is being followed. They seldom address critical thinking, behaviors, and the key human factors that are essential for business success.
Auditors tend to follow implicit or explicit expected outcomes. “Every audit will have a certain number of major findings” is a typical expectation. The background and makeup of the audit team introduces its own inevitable bias. People with a deep understanding of the business are a precious resource and will not often be seen in audit groups.
Those being audited have the incentive to receive an “excellent audit.” The game to play then is to be cooperative, emphasize the great things going on, and downplay or gloss over the defects that may exist. In some cases, it goes so far as to hide defects and attempt to steer the auditor away from them. The closing audit meeting becomes a “justification” or “defensive” session with few real opportunities for growth and improvement. The objective becomes to get the audit done with a little damage as possible, minimize the follow-up actions, and get back to business as quickly as possible.
Not all audit processes are flawed, but you should look to these potential flaws if you are putting your faith in traditional audits to uncover and prevent potential incidents. Audits will always be required by regulation but the key is to recognize their limitations and change the tenor from finding defects to generating change and improvement.
Rules, punishments, discipline, and consequences are all variations on fear-based approaches. Even accountability, which is an important positive trait in any organization, can become fear-based. This happens when accountability in the lower levels of the organization is used as a tool to fix blame and avoid attention to systemic problems that should have accountability higher in the organization.
Fear-based approaches are time consuming, viewed as unfair, distract from critical thinking and the willingness to speak up, and create a wall between the enforcer and the target of enforcement. As such they should be used judiciously. Despite best intentions, the worker blames punishment on the punisher and takes little or no ownership for the “offense.” For example, an employee gets a letter of reprimand in his file and three days off work for some infraction. What does their spouse hear? “My no-good boss is just picking on me…I’d just like to know why the rules only apply to me!” While rules are necessary, an overemphasis moves you away from a critical thinking culture.
Operational excellence and incident avoidance is not just about processes or systems. It’s not just about statistics or metrics. It’s actually about people and attitudes. It is a mindset. It must be built from the top and be a long-lasting state of existence. It must compel people to observe, think, and act. Organizations should have well-engrained pillar behaviors that translate into the following characteristics:
- We all come to work every day with the intent to learn something new and ready to share something we have learned with someone else
- Incident avoidance is a race against time to learn something new. We cannot fix what we do not know—we drive ourselves to discover
- We have a healthy sense of vulnerability
- We slow down and think what could go wrong—think twice, act once
- We are never complacent about the routine
- We seek to understand deviations from normal and act to eliminate causes
- Everyone feels empowered to and obligated to ask the hard questions, even when it might seemingly slow down work
As a leader, building the right culture requires your personal time and energy. Avoid slogans and programs. Invest sufficient time in communicating with people and enabling their success. Put in place a long-lasting way that the company works that turns “people are our most important asset” from a cliché to a reality.