41dd3e08

Work School Bus with Rowdy Kids

Tue, 13 Oct 2020 14:00:30 GMT

Deference to expertise

As a school bus driver I had a route where the kids would hide rather than stand at the bus stop. My route is for the kids who are about to be dropped from the school system for behavior problems, no one wants to be seen getting on my bus. However I do not have a problem with student’s behavior. The district rule is to call dispatch if we stop more than three minutes and call the police if we stop more than five minutes. I stop for one minute then move the bus forward and stop for one minute. Then I do not have to report in. But the kids know they will be late getting home or reporting to work. They learn to control each other in a positive way.

Deference to expertise
Anonymous, Florida

Work Expanision of Credit Card Program

Tue, 13 Oct 2020 13:43:27 GMT

Preoccupation with failure

As Eastern Europe was becoming incorporated into Western Europe the credit card companies began extending credit to people. Someone quite familiar with Eastern European financial practices on a personal level I made several recommendations based on the program in my company. These were ignored. As I saw losses increase I became worried and more assertive. This led to my dismissal from the company.

Within one year losses had mounted to millions of euros. The company contacted me and brought me back in. Were able to correct this program and became a vibrant and productive credit card business.

Preoccupation with failure
Anonymous, Eastern Europe

Home Raising Children

Tue, 13 Oct 2020 13:37:13 GMT

Reluctance to simplify...

Whenever the little girl across the street came to play with my children we would end up with a fight involving my son. She would cry out for me and when I looked, sure enough, he was hitting her. But something seemed odd so I began watching more closely. Sometime during the play she would begin running up close to him and I watched her hand. She would push him or hit him. Finally, he would hit her.

Then, when she cried out for me that my son was hitting her I sent her home. She was upset because it was not her fault but I did not respond. I only sent her home. Within a few visits the fighting stopped.

Reluctance to simplify
Anonymous, California

Anxiety, Engagement, and Structure

Sun, 13 Oct 2013 18:55:18 GMT

Engagement to solve problems creates High Reliability Organizing; withdrawal from the situation toward structure (rules and principles) or authority may be an anxiety response to uncertainty and threat.

I was talking with my daughter about anxiety. I had previously discussed with Tom Mercer my ideas that people respond to uncertainty or the unexpected by engagement and problem solving vs. structure and authority. Both enact different futures but failure in the first instance is failure from action that can be corrected. Failure in the second instance is failure from inaction and failure either cannot be identified or even recognized. Here, failure is not failure; rather, it is the state of being. While talking to my daughter I realized that responding to uncertainty and unexpected by withdrawing to or creating structure and authority is actually an anxiety response.

We see structure that is not there because we do not calibrate our sensemaking or we find refuge in structure, any structure. I recall that Frank Lloyd Wright said there are two types of structures - caves and cathedrals. Caves have low ceilings; they are comfortable and secure. Children drape sheets over chairs to create the security of a cave. This is the comfort in a room with low ceilings or the cantilever design of his prairie style homes. Cathedrals create awe and can intimidate, almost be scary. When you enter a home with a high entrance it is not as comforting as one would have predicted predict. The confines of structure can be reassuring to the anxious.

Authority attracts us for a number of reasons; reassurance and passing responsibility are high on the list. And we create these authorities through operant conditioning. The authority acts in a manner that people find reassuring so they listen and give positive feedback. This increases the behavior in the authority that creates more reassurance in the people that increases this authority-seeking behavior in them. This occurs because people do not calibrate their faith in their authority with what is happening in the environment.

Rules and policies provide authority and structure to the anxious.

HRO is the means to live free and explore.

Preoccupation with failure I

Sat, 12 Oct 2013 18:53:33 GMT

Preoccupation with failure from my experience.

“Test of failure” is a term from engineers. In firefighting it is loss of life and fires and we should learn from the little failures to keep them from becoming big failures. Small failures occur commonly.

In healthcare, failure is seen as a weakness and imperfection. It is personalized and failure is seen as an individual act. Part of professionalism, in the healthcare view, is that you do not have failures.

People seem to accept talking about failures and weaknesses but they do not put them into the first person. The physician is supposed to have all the answers, when the physician does not the physician and others see that as failure.

When we discuss failure we do not include failure of how to think. We do not seem to recognize the different ways to think and how they fit different circumstances.

In preoccupation with failure, Weick and Sutcliffe were looking at preoccupation as part of the culture and failure as systems failure. Dr. Weick was looking at systemic mindfulness and failure. Preoccupation does not have an action complement in it. This all presumes that we have good communication going on. (Weick, personal communication December 21, 2012)

Weick and Sutcliffe

One problem with preoccupation with failure is people think they should focus on failure and they react negatively to that, it makes you sound negative. Also, that it makes you think “we are doing something wrong.” (Kathleen Sutcliffe, personal communication November 17, 2011).

To avoid failure you must embrace failure. The organization that does not plan for failure will fail (Todd LaPorte). Failure detection involves responding to weak signals. It is more than detection. Failure in an HRO is a systems issue, not an individual issue. Many failures have a long history of occurrence, but not at a level causing catastrophic failure. Being preoccupied with finding these failures creates HRO.

Preoccupation with failure II

Sat, 12 Oct 2013 18:51:36 GMT

Further comments on preoccupation with failure in operational terms.

I have done a fair share of night hiking, sometimes under trees where you cannot see the trail and sometimes above timberline where it is difficult to discern the trail in the gravel and rock. For safety, we pay attention closely to the feel of the trail and the ground along side of it. When you feel the ground change you know you are leaving the trail, you do not have to watch. This is particularly important on a mountainside above timberline.

During my ambulance driver drill tower for the fire department we were taught high-speed driving techniques by the police department pursuit driving instructors. One of the maneuvers we learned was to drive sideways on the skid pan so that we knew but I felt like when the car broke loose on a high-speed turn.

Both of these stories explain the importance to me to know what failure feels like as it begins. Then as long as I am within those margins I do not have to pay as close attention. This gives me more brain function to solve problems.

But that is for safety and preoccupation with failure during operations. It was quite a few years before I began to really understand preoccupation with failure to prevent failure. It started to come to me on the fire department when the grumpy old firefighter or ambulance attendant seemed to overreact to minor things. There are a few of these guys I could talk to and I explained to me of some past experience that turned out poorly, very poorly. They did not want to repeat that.

Talking to Tom Mercer, this fit into a story he was giving me about his early days of flying when he would have a bad event. "You do not want to do that again."

It seems that some that event sperm so deeply into the brain that the feeling is triggered in the current day. This and only reawakens that pass ceiling but since off alarm that things are becoming dangerous.

So these are two ways that we develop body memory for preoccupation with failure. One is to learn the feel of early failure so you can become self-aware when it begins. The other is to understand and value that reaction to a trigger. This is more than a gut feeling, because you actually feel throughout your body the failure. One method guides you in one method once you. This is preoccupation with failure to me.

Reluctance to simplify

Sat, 12 Oct 2013 18:49:23 GMT

"Reluctance to simplify" in operational terms from my experience.

When I first applied to medical school I was still working on the fire department. The senior engineer (the one who drove the fire engine) reviewed my application and advised me “There are a thousand things going on and only a few things you can do. Pick some and do them, then do as many as you can and see what works.” Well, it did not get into medical school that time but his advice, fire house wisdom, guided me for any confusing situation. An incident is complex, do not simplify it and think you know what to do.

However, we must simplify to gain a grasp of things and also to teach. But we must also accept that there is more in these events than we can understand. How do we balance simplifying so we can think and talk about it while accepting the complexity of events?

In situation awareness, the situation changes, you remain aware of these changes, and you alter the task.

In confirmation bias, we look for information that confirms our conclusion. It is challenging to recognize this bias in ourselves. Also in confirmation bias you start to see things that confirm your belief, it is not only selective seeing by choice. Our ingrained nature is to be optimistic. You want to find you are successful and see it working.

I would teach shortcuts by first breaking the process into as many steps as necessary. The purpose of reducing to many steps was to make each step have a reason for it. Then we can discuss the reason. I let the student amalgamate the steps on his or her own. Someone may combine the first two, some the last two, and some the middle two. It made no difference to me because it was only important for it to make sense to the student. (I taught this to a dance teacher who then used it to teach multiple steps to his students. He let the student decide how to combine steps for a smoother dance.) Amalgamating in this way created more meaningful short cuts, as the shortcuts included all the steps.

Dr. Weick emphasizes “reluctance to.” (Personal communication, January 18, 2013.) It is not a rule that we do not simplify, only that we are reluctant to simplify. Simplification is not bad in itself. In responding to a situation you have seen this before and you have not seen this before. It is old and new at the same time. You are reluctant to simplify but you will do it.

There is intentional simplification and unintentional simplification. If you have intuitive impressions, are you backing them with facts? Fact-check your intuitive feelings. Intentional simplification may have ulterior motives. For example, the manager may want to increase productivity at the expense of safety.

We tend to make it a simple problem with a simple solution. How you shape and define the problem helps you understand the solution. But some times we have a solution in search for a problem. Simplifying the problem and the solution can be dangerous.

Weick and Sutcliffe

When we lump details together or name things we lose information. Simplification, in an HRO, is done slowly and purposely. It is something we would rather not do. Having team members with different backgrounds reduces simplification as they see things differently than other team members will.

Sensitivity to operations II

Sat, 12 Oct 2013 18:45:50 GMT

Further comments from operational experience with "Sensitivity to operations."

In the hospital I would sometimes ask a resident physician to contact the hospital administrator-on-call or a medical consultant. The person often responds with "What can they do?" My counter response was, "If I knew, I would do it myself." This is part of a complex system. It suppresses the drive to ask for assistance. Is this the antithesis of sensitivity to operations?

The following is an example of such a query:

The Emergency Department physician caring for a child critically ill and deteriorating requested transfer of the child to the pediatric intensive care unit. The parents were Jehovah’s Witnesses and refused to grant permission to transfer unless we could guarantee no blood transfusion. By law physicians could have transfused in life-threatening situations without a parent’s permission (in fact, for minors they have a legal duty to transfuse). Sometimes the wisest use of power is the decision not to use it. I called the hospital administrator on call who calmed the family, explaining procedures. The parents then allowed transfer of the child. I had no idea how the administrator would fix the problem when I made the request but I knew that my involvement, as treating physician, would become sidetracked with administrative and legal issues regarding transfusion. In this particular case there was little likelihood of a transfusion but it was a major concern of the parents. The administrator was very sensitive to the complexity of the situation, calming and reassuring the parents. We made the transfer and the hospital stay went smoothly.

For information flow, what kind of assistance do you have to escalate information flow? How do you create a system that allows escalation of information flow without overtaxing the system? Information cannot get to the CEO for every issue. We cannot communicate linearly for everything. Sometimes you have to skip layers, but how do you manage this without breaking down the system? We need a workable system that works when you need it.

If I have a question, I have to be sensitive that the resources I am drawing are not available to the rest of the organization.

In the ICU, people are going to try to make sense out what is going on in an alien environment experiencing things they never thought possible. If I did not guide sensemaking, the family will create their own, often with assistance from people having even less knowledge and experience. The sensemaking I guided them toward had to take into account the ICU, the healthcare team, extended family and friends, and other issues specific to the parents.

How do we give feedback during the operation when things are not working? My experience in healthcare is that superiors do not like to receive disconfirming evidence – bad news. For those operating at a high level of sensitivity to operations they wanted bad news, as that was their guide for further operations.

Sensitivity to operations should be compared to planning and strategy making (not always the key activities). We need to be in contact with what is going on right now rather than how far we have deviated from the plan.

Deference to expertise

Sat, 12 Oct 2013 18:43:25 GMT

"Deference to expertise" from my operational experience.

Expert, expertise, local knowledge, knowledge of the circumstances - what do we mean when we defer to expertise? It is not so simple as it sounds. If you believe in it and use it then, yes, it works. But many people cannot make the leap of faith and believe we allow "freelancing," that is, we let the patients run the hospital. So ... what is it? What are the benefits of deference? How do we do defer safely?

Physicians have difficulty the concept of deference to expertise, as they believe it is their responsibility to manage all aspects of patient care (Paul Schyve, MD, Joint Commission, personal communication, December 2011). We also have the idea that means people can do what they like. They do not see it as local knowledge or specialty knowledge in a field other than medical care.

The main challenge in medicine is that physicians feel autonomous; they feel they have to be infallible. The system encourages this as the governance in the hospital is the physician and it is the physician who is ultimately accountable for patient care. This leads to rejection of suggestions and physicians appear to have a large ego. The commander of ship analogy is deleterious to patient care in medicine. This makes the physicians feel they have to be in control and they become emotionally defensive and protective from suggestions by fellow caregivers.

Sensemaking makes for a better approach, as there are no objections, rather suggestions, to improve sensemaking. We must break down the need for autonomy and infallibility in physicians and encourage system responsibility for patient care.

We independently use expertise in different manners. To teach endotracheal intubation, I brought together a medical expert from the hospital, a paramedic with field experience, and an educator who writes teaching objectives. Each one has an expertise component.

We have two ways of viewing ourselves- positive and negative. The negative tell us "I am not smart," "I am not correct," or “I cannot do this.” It takes time to train this out of people. We need the positive such as self-awareness, courage, and transcendence (the part of ourselves that helps each other). The positive will help people more freely say, "This is what I think." We need to listen to them because they are seeing things we have not seen before.

To assist in this I not allow people to introduce themselves as "just a student." I will comment, “She is ‘just the resident physician,” and “He is ‘just’ the nurse.” I close with, “I am ‘just’ the attending.” The adjective “just” is a low reliability word. I do not allow the word "just."

When you empower the little guy you will be surprised at what they bring. When someone with no power gives their opinion you learn more and that benefits the whole program.

It is a necessary balance, depending upon the amount of time you have, to draw out from people their own expertise but in the end you must put their words into proper terms and make a decision. Then interpret for all in the broader context. This takes knowledge and experience to translate their words into the terms needed for the team.

With deference to expertise you are not making a decision solely on the basis of your power and authority. You defer to a person on ground with knowledge and skill appropriate for the circumstances. But what happens when life or death situations occur? The authority gradient is so great the person with expertise may not be forthcoming.

The leader can make decisions and build barriers that people cannot speak through. In an educational system, one person had to have preapproval from the superintendent an area that the person was an expert in. This is because there is a rule. When a person makes their first decision things can go wrong. That will kill future initiatives not only for that student but everyone involved or who hears about it.

There must be willingness in the leader to give up control and defer to expertise. You must do this to defer to expertise. After you have deferred expertise, made a decision, and have given responsibility to the junior officer been the leader still maintains accountability and should not shoot the messenger if it does not work out.

Weick and Sutcliffe

HROs allow decisions to migrate up and down (Karlene Roberts, personal communication frequently). Migrating decisions up is not as much to keep authority central but to allow the operator the freedom to think unencumbered. Migrating decisions down gives responsiveness to the operator. Also, expertise is situational, not always related to the position in the organization’s hierarchy.

Enactment Creates High Reliability Organizing

Sat, 12 Oct 2013 18:39:29 GMT

Enactment, the process of engaging the situation and changing circumstances, is the basis for High Reliability Organizing.

How you respond to uncertainty or threat determines whether you or your organization attains resilience and adaptable to contain the situation or whether the situation decomposes into disorder and runs its course naturally.

A structural approach with principles, rules, or use of authority values obedience and conformity and looks to past experience for strength. It offers the security of what is known and what is known to work. However, the resulting structural inflexibility can lead to potentially preventable failure when circumstances overmaster the ability of the person or organization to respond. Engaging the situation (enactment, Weick) with real-time interactions (Bea) values initiative and creativity and looks toward the future for novel solutions. It offers security from the ability to match complexity of response to the complexity of the situation. Structural approaches risk self-interest or self-protection while enactment encourages collaboration toward enacting a new future.

The choice of a structural approach vs. enactment will influence attitudes, behaviors, beliefs, and values in people to create the culture of an organization. It will also influence emphasis on the type of education used, teaching (design or structural approaches) vs. learning (enactment) and whether training is directed toward skills to do the job (“Do it right”) or is directed toward conditioning to manage the unexpected (“Get it right”). Most important, the choice will decide on reasoning and epistemology, that is, does one collect facts that will guarantee the hypothesis (deductive reasoning) or strengthen evidence to support an adaptive conclusion (inductive reasoning)? How does opinion become fact and belief become knowledge (epistemology)? In structural approaches, given two opposing opinions, only one can be correct though both may be wrong. With enactment, opposing opinions may both be correct or both wrong yet both will work.

Enactment is both taught and learned. Conditioning can produce enactment when the person experiences a threat, rather than the person reverting to fear responses and situational cognitive distortions the person will choose to engage and persevere. Enactment can produce a High Reliability Organization that has high performing individuals building a stronger organization.

People will make sense out of the circumstances they find themselves in, what they will call their “situation.” We can educate and train them but, in the final analysis, they will make sense for themselves and use this sensemaking later to justify their actions.

This sensemaking occurs in different brain regions depending whether it is fear, uncertainty, a complex problem, or challenging problem. Uncertainty can be processed in the area of the brain where the Executive Functions lie, the prefrontal cortex, and people will analyze the situation using known principles and concepts and make decisions in an “either/or” mode (binary decision making). If uncertainty poses a threat, because of time demands, pressure to not be wrong, or effects on one’s image, the brain will involuntarily process perceptions in the more primitive reptilian brain as the emotion fear, this is the amygdala. Threat is also processed in the amygdala.

The problem we encounter is that we cannot tell someone how to process threat; it is an involuntary, reflexive response as perception moves directly to action. In the prefrontal cortex perception goes to thought and can occupy the brain and take an inordinately long time to process to action. So, there is a long period to well thought out action, in the prefrontal cortex, or immediate, action without thought, in the amygdala.

The brain has an alternative area for processing perceptions and creating action, the anterior cingulate cortex, which can modulate the amygdala (control the fear response), identify error, and make adaptive decisions (what works vs. what is right). This requires conditioning to use routinely and preferentially when enacting situations of uncertainty or threat.

Sensitivity to Operations I

Sat, 12 Oct 2013 17:40:52 GMT

I advised a resident physician that, once she mastered a procedure, she should teach it because in life she will be teaching her subordinates while she is performing the procedure.

Later, she came to me excited; she never knew all the things that went on while placing a tube into a patient's windpipe (endotracheal intubation). During dynamic events we easily cone our attention to what we are doing, shutting out other activities as we concentrate. One of the first things we must teach a rookie is to be aware of all that is around him or her.

Sensitivity to operations, the awareness of and interaction with the activity of others, is not customary for people, they have to learn how to do it, learn how to actively monitor. But we cannot do things on automatic.

Can we distinguish between sensitivity to operations and situation awareness? (Situational awareness is to be aware depending on the situation, hence situational.) To me, sensitivity to operations describes how other operations bot influence your and are influenced by your operations while situation awareness is more passive, it is more related to perception and mental processing.

Is there scaling with sensitivity to operations, that is, can we distinguish between sensitivity to operations at a personal level and between organizational levels? At an operations level we share the same primary problem and work in the same environment. As we move up in the organization we begin to interact with others outside of our problem environment. These people may not see what we see. At this point we must begin looking through their eyes, as what they see, from their specific operational environment, will not be what we see from our operational environment.

Weick and Sutcliffe

Organizations must respond to the reality within their system, leaders cannot respond to what they believe is the system. For this, the leader will monitor within the system and respond as an organization to the unexpected. In this discussion, Weick and Sutcliffe present operations within the organization.

Leaders in an organization may overestimate the soundness of the system, particularly from both confirmation bias (the see only what is favorable), an indifferent environment did not test the system, or near misses were misinterpreted as successes do to the qualities of the program.

Weick states that, in sensitivity to operations, he was comparing it to sensitivity to planning. This was to get people out of the mindset of planning and missing what was going on "right now.” Sensitivity to operations was done to counter sensitivity to planning. (Personal communication, February 1, 2013)

What I did: Pediatric Intensive Care Unit (PICU) 1989-1995

Fri, 11 Oct 2013 18:37:12 GMT

Before I had heard of HRO, Dr. Ron Perkin and I created one in a Pediatric Intensive Care Unit

A few years after we had created the PICU I noticed that the pediatric residents had returned to their higher performing level after day 11. (This was odd, as it was consistently day 11 regardless of the day of the week or when our coverage as attendings. Dr. Perkin noticed it to; it was not day 10 or day 12, but on day 11 the residents picked up on things earlier, responded more effectively, their stress and anxiety dropped, and they came together as a team. On day 11.) The residents have a one-month rotation beginning on the first day of the month with two-to-three months in the PICU during their last two years of residency training.

Ron Perkin would teach:

Support the bedside caregiver even when they are wrong. There are ways to do this without making people the wrong this was fine to do.

Never criticize anyone. They had a good reason for their action or a justification for their ideas. We can learn from them.

When someone gives an explanation with cogent reasoning, we must find a way to make it work, or at least to make sense of it, even when the reasoning is wrong. This can be circuitous but we must remember it made sense to the person for a reason.

Use simple principles to explain the situation and to guide interventions. In complex situations or under time pressure we can process our thoughts more effectively if we use simple principles.

Develop five or six causes of what you saw and five or six ways to treat it. The first one is the easiest to think of, not necessarily the correct one.

Always say yes, volunteer to help. Often, no one else would come forward to help. Because of the broad nature of our work and the diverse groups we work with we could often assist in unique or unexpected ways. If we did have to withdraw, people are less inclined to criticize you if you have a reputation and practice for helping and volunteering.

I gave four lectures:

Monday was organizing complexity.

Tuesday was unrecognized stress and fear.

Wednesday we discussed decision-making.

Thursday morning we watched Weird Al Yankovic music videos.

Organizing complexity: The first day I came on service in the PICU we would usually have a patient on a ventilator with multiple medication infusions and a large number of problems. The child may have several diagnoses. The usual format of presenting a patient is the most serious problem first but typically the residents would present the problem list with the first item being one they knew about and used routinely, which was fluids, electrolytes, and nutrition (“FEN” in their words).

We would first list all the problems coming up with about 20-30 items. I would then group them as common causes or diseases. Invariably we would have 3-5 major issues to deal with. One would be life-threatening (for example, septic shock), one would keep the child in the intensive care unit (for example, being on a mechanical ventilator to support lung function), and the other two or three would resolve over time with straightforward treatments (for example, infection or wound healing). From over 20 things they needed to monitor and respond to we now had basically one and if we could address that one the child would more likely survive and the rest will follow. It became easier now to develop strategies for treatment and they would spend less time on the minor but easier issues and more on the critical matters

Unrecognized stress and fear: I used Ray Novaco’s model of stress that he adapted from Lazarus. We would list the demands and expectations placed upon his in an review our attributes (what we have as individuals) and resources (what others, particularly our organization, can help us with). If demands and expectations exceeded our activism resources we needed to reevaluate. If we do not reevaluate we stay in an increased state of arousal that, if unidentified within ourselves, would lead to a stress reaction. This is a matter of self-awareness.

We also discussed unrecognized fear in those around us that was usually manifested as anger (fight), avoidance (flight), or freeze (the freeze response of prey species). We also discussed maneuvers for ourselves and when interacting with others having these responses.

Surprisingly, this was a rather popular lecture and there were times when a senior resident would ask me to repeat it for the junior residents or an individual would pull me aside and ask for a repeat presentation.

Decision-making: This had several parts. I taught decision making based on John Boyd's OODA Loop that I learned from Lt. Col. George Orr's book C3I: Combat Operations (US Air Force Press). We also discussed how to develop multiple ways to intervene and how to decompose an objective to allow us a stepwise approach to reach our final objective. Our goal was to increase our chance of success while simultaneously decreasing her chance of failure.

We looked at conflicted decision-making as described by Irving Janis with our focus on vigilance where we violate each new approach and if it is not work we go back to what we originally were doing. We did not want to fall into hypervigilance where we try methods and, if they do not work, we try more methods and continue trying things. When this happens, we end up treating her treatment.

Finally, we learned useful biases and heuristics. Specifically, I found availability, representativeness, confirmation bias, over-conservative revision, and cognitive dissonance most useful.

Take a break with Weird Al Yankovich (a rock parodist), one thing I noticed early on for medical school was that if a medical student took a break people thought he or she was disinterested. For residents to take a break was almost considered abandonment of their job. For my public safety background I knew we needed the occasional break to perform at peak function when an unexpected demand occurred. We had all operated at intense levels of fatigue and knew the dangers. It was difficult to have my residents and medical students take a breather now and then.

Another contributing factor to this refusal to take a break is a lack of trust that others will help or would pick up the load, or even could pick up the load. To demonstrate this I realize I need to force them into a break situation we did not discuss medical care and we had to rely on the team to let us know when an emergency occurred.

I brought in my Weird Al Yankovic music video and we listened to it together. In all the time I did this only two residents refused to participate. They left the room to continue seeing patients. The goal here was to demonstrate the ability to rest, the competence of a team they can trust, and the reliance on others to let them know when an emergency occurred.

What I did: Pediatric Critical Care Transport 1989-1994

Fri, 11 Oct 2013 18:34:16 GMT

With the intent to give better service to referring Emergency Departments, we created a High Reliability Critical Care Transport Service

When I became the medical director for the pediatric critical care transfer program it was a small program serving an area approximately three times the size of the state of Vermont. Transports by ambulance could take over an hour to drive and by helicopter 45 minutes. The team consisted of one pediatric resident taking a call rotation and one transport-experienced nurse and respiratory care practitioner.

The major problem they encountered was friction in the Emergency Department (ED) when they arrived to pick up the child. The ED staff desired a rapid removal of the child and believed that their stabilization was sufficient. The transport team, experienced in working in the constrained environment of the vehicle and responsible for the extended period of time in the medically austere environment, referred to become better acquainted with the child's condition and ensure the stability would last during the transport. Also, many physicians believed it was better to transport the child rapidly using a paramedic vehicle and not have a higher level of team.

To remedy this, I drew upon my fire department Rescue Ambulance experience working in South Los Angeles. It was not uncommon to have hostile bystanders and, depending on the engine company, uncooperative firefighters to assist. I advised them to enter the ED as if it was a hostile scene.

They would enter the ED and greet the caregiving team, ask about the patient's condition, and complement them on the care rendered. Further, they would identify something specific they could complement an individual on. They were to make no comment until they had physically examined the child. (I learned this from another medic who told me to never make a diagnosis until I had taken a blood pressure reading. No matter what the patient's problem, no one would listen to me unless I had taken an action to examine the patient and a blood pressure reading was the most obvious. This was a matter of demonstrating interest in the patient's condition and building trust.)

After a few visits like this, I predicted the people would begin watching them. The team was to stand in a position that people could see what they were doing and, if the person stood by or walked close enough, they would talk openly about the actions they were taking. If anybody asked the question they would answer it simply with a very short answer and conversational tone. They were to pay close attention so they do not sound condescending.

This is exactly what happened and after about six months our relations improved dramatically. ED staff began contacting me to complement us on our team.

Then another problem arose, we were called out and we began to have more severe illness in our patients. Our transport team began to request laboratory evaluations and radiologic examinations. This not only delayed transport but also caused confusion as to who had the hospital privileges to order these studies. While the patient was in the ED under our care it was considered an admission to our hospital. However, our staff did not have the authority to order the studies. But the most serious problem was the delay in care and the question whether it was necessary.

At this point I focused on clinical evaluation at the bedside and decision-making based on response to therapy. The team had to rely on their senses and perception. Unfortunately, people are taught that their senses can fool them. I developed several lectures to demonstrate that our senses are quite sensitive and that if we are aware of how we can be full we can navigate to the environment quite successfully.

This worked quite successfully except for three deaths in a six-month period because of airway problems. We began use of a five-point respiratory exam that did not require chest x-ray studies or evaluation of the blood gas. We also focused on airway stabilization prior to moving the child. We never experienced another death during transport.

What I did: Pediatric subacute to chronic critical care 1997-2003

Fri, 11 Oct 2013 18:25:03 GMT

The application of 1970s EMS to a troubled pediatric subacute care facility also created an HRO. This program was presented at a safety culture conference for NASA.

A local nursing home expanded its care to include more complex children, some dependent on a mechanical ventilator. Following this, there came problems with state regulators regarding very quality level of care offered. The facility requested the medical director from the Department of Pediatrics. Because of the complexity and the use of mechanical ventilators there was little interest in this position. I had become interested in the needs children while I was caring for them in the Home Mechanical Ventilator Clinic so I accepted the position.

When I began working there I observed that the staff did not recognize the fragile physiology of these children. To help them understand the risk and their role in helping the children I invited everyone to a barbecue in the parking lot. We would have the picnic for 2-3 hours and all would come.

I heard everybody dividing up the time so that somebody would always be in the facility. Because there was no risk of death and it was fairly safe, at least that is what they had told me, I told them nobody would be in the facility during our picnic, we would all have fun together. Individually or in small groups they came to me and said they could not do that, at least one of the children might die during the picnic and someone needed to stay nearby.

After a number of people shared this same concern with me I pointed out to them that, yes, these children can die but none had. If a child could die in the next three hours if we all left, then that means a child did not die in the last 3 hours because of the care they gave. They had saved the life of one of the children, and had even saved the lives of at least six children that day.

Now we could discuss how these children die and the things they do that save a life on a routine basis. Everyone at the facility is a lifesaver.

It now became easier to discuss care for these children. Over time I presented this work at a NASA safety conference, an Institute of Medicine committee on patient safety, and a Joint Commission special study group. I will write about hat we did in later blogs. It involved the OODA Loop, studies of expertise and who you compare yourself to, clinical evaluation, refined objectives for care, how to effectively describe your observations and experience, and how to work in a world where you and your patients are not respected.

Most important, our over-arching goal for these profoundly handicapped children became “make each child smile.” Each caregiver had smile as their responsibility … and pleasure.

Change and Resistance to Change

Fri, 11 Oct 2013 18:23:07 GMT

Change meets resistance when we focus on what we do wrong but for the athlete change is the path to better performance. What philosophy do your leaders use?

“Do you think he changed?” This was the question my acute psychiatry attending asked me after a presentation. My first rotation in medical school was psychiatry, first in an alcohol rehabilitation facility then an acute psychiatry ward. My patient professed to having had a horrible criminal past and was now admitted for an acute psychiatric episode. My task was to develop a therapeutic relationship with him and generate information necessary to help with the diagnosis.

As I spoke with this man and received some advice from my attending psychiatrist the patient became very happy that I helped him understand his problem and he was going to get better. The flaw in my thinking can with the question "Do you think you changed?" My tinny pointed out that he was too happy and this is a manipulation. If he were going to change then he would have to recognize the seriousness of his behaviors and how he had hurt people. If he felt this, we would expect him to be sad. I had been fooled.

We may change when we recognize that what we are doing is wrong, that our belief system is not working. This has resistance. Resistance may also come from the bad feeling we feel when realizing the things you have done wrong and who you have hurt.

There is another method of change. I ran track and cross-country in high school and my coach would watch me run, and then give me methods to improve. He wanted to better everyday and run faster every race. The more tips he gave me more valued I felt.

We can interpret the information outsiders give us in different ways. From my experience in psychiatry, more suggestions marks me as performing more poorly. However, from my experience in running, the more suggestions I receive the more I am valued and the better I will become. The difference depends upon relationship I have with those around me. And is a leader, I must pursue the relationship of a coach being watchful that my students cannot take these coaching remarks as negative criticisms.

Change can also come from moving toward a goal – becoming better. This is the change from a coach. While we may think of the coach yelling at the team, in reality the coach works to maintain a bond with the athlete for trust. The athlete trusts the coach and changes because he or she wants to perform better.

Coaching to do better is the change of HRO and what I wanted in my staff. It works from the top down but not upward. This places a ceiling on introducing HRO – it can only go down. That is, downward.

Create High Reliability

Thu, 10 Oct 2013 21:55:34 GMT

by Thomas A. Mercer, RAdm, USN (retired)

RAdm Mercer initiated the studies of High Reliability when he invited academicians from the University of California, Berkeley, to study his crew with the goal of improving their performance. At the time (July 1983-March 1986) he was Captain of the USS Carl Vinson (CVN 70). Rather than offer methods to improve, the academicians codified RAdm Mercer’s command philosophy and methods as a High Reliability Organization (HRO). He flew 255 Vietnam Combat Missions, has 970 carrier arrested landings, and has 3,700 hours in the A-4C and A-7E. His awards include the Defense Distinguished Medal, Distinguished Service Medal (two awards), Defense Superior Service Medal, Legion of Merit (two awards), Distinguished Flying Cross (three awards), four individual Air Medals, 25 Strike Flight Air Medals, and six Navy Commendation Medals.

What does HRO do?

Thu, 10 Oct 2013 18:21:21 GMT

Some people wonder why we need HRO or whether HRO is only for safety.

Marc Flitter, MD, was questioning me about why I did HRO in the pediatric intensive care unit (PICU). We were writing an article on physician sensemaking and he wanted to know if I was looking for reliability or safety. This frustrated me because I was doing neither and I had never really thought about my initial reasons.

During my medical education I observed behaviors in many healthcare providers that I recognized from my experiences on the rescue ambulance as fear and stress responses. As a physician in the PICU I now had the opportunity to address this. I worked to reduce the effect of fear on my staff.

Also during my medical education I paid attention to the criticisms of paramedics made by healthcare providers and the criticisms given me for how I made decisions. I wanted to understand better the differences between how public safety professionals made decisions under time pressure in the face of grave threat compared to healthcare providers, particularly physicians.

So my goal was to reduce the effect of unrecognized fear in the hospital and to improve decision-making with imperfect information under time pressure.

Ron Perkin, MD, my partner and director of the PICU, wanted to support the bedside caregiver and simplify for staff the objectives and decisions necessary for medical treatment.

After this discussion with Dr. Flitter, I asked Thomas A. Mercer, RAdm, USN (retired), why he “did” HRO. He was Captain of the USS Carl Vinson where Dr. Karlene Roberts conducted her early studies when she codified HRO. He told me that he wanted to improve the crew's performance and make the ship stronger.

None of us had the focus of reliability or safety, as we believe that was a part of our work.

The focus of HRO as a means to achieve safety is misplaced. We cannot have operations in a hazardous environment without the possibility of injury to somebody. To do nothing will increase the amount of injury to workers and the community. The goal is more of achieving safety through good operations and having good operations through safe actions.

We accomplish this by reducing the effect of fear, making better decisions with imperfect information, supporting those at the point of impact, and directing our efforts to improve the performance of our teams. When we do this we have a strong organization. HRO describes those organizations that maintain productivity despite time pressures, hazards, and uncertainty.

HRO makes the organization stronger through better crew performance. That is what it does.

Grand vision or roadmap, our only choices?

Thu, 10 Oct 2013 18:19:20 GMT

How do we develop a plan to reach HRO?

Our bosses come to us and ask for a program that ensures safety, reliability, and productivity. Do they want a grand vision we can discuss philosophically or are they asking for a practical roadmap that details how we move from where we are to where we want to be?

Grand visions sell and make people feel good. Great advertising. On the bad side you are telling them what they are not. Roadmaps are reassuring, we know where we have been, where we are, and can pick a route where to go. Part of my decision making lecture in the PICU was just that - if I tell you to go from your house to the store, how would you go? Trick question as I then give them obstructions and problems. Roadmaps don't work then. Have several ways (routes and mechanisms and others) to go to the same place, and then you do something in an emergency because you choose to, not because you have to. Jim Denney, EMS Captain, LAFD [person], a friend of mine, had two tours in Viet Nam and worked in South LA as a medic with me. He would say, "When faced with a void, move forward.”

Choose the void.

In thinking about it, if it is all a grand non-specific vision, from 60,000 feet, it ends up going nowhere with a group of people who are seeing patients every day. Ahh, the 60,000 ft or 30,000 ft view. Remind people (this is why I do not use clichés) that you are traveling at that level to go from one point to your destination. Everything below you is incidental to your travel and you are not involved. What frustrates you, if I could be that bold, is that they move to a new destination bypassing the work and problems, if you can even see them. Nothing changes as you choose passive observation, easy to criticize. The bosses are passing overhead while you want them engaged.

Choose engagement.

If it is too granular, then everyone only sees their own few feet of space. Then we have territoriality - get off my space! Granular, reductionism, how can we break things into parts we can discuss? Super, either we have our own space, which we believe we understand, or we have a great set of intricately laced nodes and linkages that only we can understand, and which frustrate us when others do not see what we see. Or, we believe quality comes through interactions and interactions produce complexity to the point of looking smooth, no edges. The first, granularity, the one you fear, is an object, a noun. The second, interaction, is a verb and produces smoothness without edges or borders ... and it is scary. Our anxiety makes us see structure where none exists; our anxiety drives us to choose structure.

Choose the verb.

So, we enact our program. There is failure from not acting and failure from acting. The first one stagnates us but the second one we can correct.

We go for small wins. We do better each time. Everyone can do better. That is the coach's mantra and the athlete's goal. Make better decisions. We prepare for failure. We identify where can we fail and we bolster those areas. Our goals will be verbs. We are actively engaged to achieve our goals. Quality is to do it better. We search for how to do it better.

Communication is information flow. Failure comes from impeded information, we search for and identify anything that interferes with information flow ... starting with our own behavior and attitudes.

Ask people where they are. If we are a best-kept secret (or well-kept) then ask what makes it so secret? Then, ask where they want to be if they only had one small win. One small change, what would it be? Think of something that would initiate an action rather than a result.

Not a vision or a road map, attitudes are a means to the action, or verbs, we want.

I choose attitudes.

Isolation

Thu, 10 Oct 2013 18:17:22 GMT

Working isolated harms high reliability.

Febra, my wife, and I visited Mann Gulch in Montana, a lonely gulch where we were the only visitors that day. Mann Gulch was where 15 smoke jumpers died (MacLean, N 1992, Weick K 1993). This tragedy led to major changes in firefighting and fire management.

She and I talked about how the response by the wildland fire community to such tragedies differs from other industries such as healthcare. Could it be that it is more publicized as wildland firefighters die in groups? Or that the mishaps come to themselves and their officers know the dead? The last question came to me as I recalled a conversation with a petroleum executive in charge of safety and reliability internationally for his organization. As head of a refinery he was in charge when an explosion put some of his men into the intensive care unit. He advised corporate headquarters he would visit them in the morning. Corporate told him no, not to visit the men. He told me that he had to, as it was his decisions that put the men in the ICU. He made the visit and, as a consequence, was then transferred to a backwater refinery.

This is also Dan Kleinman's story, but in the prospective. While directing operations against the largest fire in Arizona's recorded history he was given the forest headquarters for his command site. After a short bit of time, he noticed the firefighters could not relax despite the solid walls, hot water, and air conditioning. He found out that was the place they were called to for discipline. He moved himself and his operations out to tents to make them feel more comfortable. Our tour of his Incident Command Center at another fire showed us the significance of his decision; he supports his team first.

When talking to people about safety, reliability, and leadership, I want to learn how they feel about their subordinates. I especially am sensitive to those who use isolation as a behavior control method. Standing at the markers where the men at Mann Gulch died, Feb and I could look straight up the ridge and see the specific low point in the ridge that each man was running toward. Their death markers were scattered along the side of the ridge. No one should die alone.

Working in high risk, dynamic circumstances, no one should work alone.

What is HRO?

Thu, 10 Oct 2013 18:11:53 GMT

When I was first told I had created an HRO, I did not know what an HRO was.

When I first began learning about HRO I read that it was a description of organizations that operated in high intensity, high-risk environments but had fewer than expected serious incidents. Karlene Roberts, from the University of California, Berkeley, told me that our PICU was operating as an HRO. She heard about our program from Pete Sarna, Chief of Public Safety for Alameda County Parks and Recreation, who came across me from comments I made on emergency decision-making at a California state EMS conference. He was talking to an EMS physician who attended this conference and heard about my use of John Boyd's OODA Loop to teach pediatric residents how to make decisions in emergencies.

This is a bit circuitous to get to the definition but it helps to understand that those of us who grew up in an HRO before Dr. Roberts codified it did not necessarily learn the program for purposes of safety or reliability. We learned it as a means of doing our job. If you were hurt you could not do your job, and if you did your job well you were less likely to be hurt.

The definition given above is the academic definition and whether it matters or is important to a line worker facing danger is probably not so important. The definition, to me, is more of an epiphenomenon of the work we do at the interface with the problem or environment we work in. This blog will focus on the small bits and pieces that will come together to form an HRO, or whatever the academic researchers will call it.

When I was faced with a situation I did not want to make a mistake so I constantly watched to see if my efforts were moving in the right direction. If the mistake hurt my patient, my partner, or me it was a safety issue. If the mistake damagd Fire Department issued equipment it was a quality problem. If the mistake used up resources or tied my unit up for an extended period of time it was a productivity issue. I did not focus on safety, quality, or productivity. I focused on identifying my mistakes and correcting them as soon as possible. Since I was not perfect at this (it is hard to identify your own mistake as it seems so right at the time or you would not have done it), I relied on my partner to watch for my mistakes just as I watched for his.

For us, the academics can focus on the definitions of reliability and safety and they can define all the concepts that we use. I will focus in this blog on error identification and correction, modulating emotions in emergencies, making decisions, forming a team, and leading people. Defining terms is important and I will make operational definitions that are clear and concise with each word having one meaning.

HRO, to me, is a way of acting in uncertainty or when faced with threat and under time pressure. HRO will not prevent bad outcomes but will help you work through them. In fact, that may be what HRO is, the ability to perform in the confusion of uncertainty and threat when other people have lost their way.

About me, Dave

Thu, 10 Oct 2013 18:09:58 GMT

A little about me and how this blog came about.

Walking through the emergency department (ED) at the end of my second year of medical school I saw a trauma resuscitation going on. Because of my experience working on the Rescue Ambulance for the Los Angeles Fire Department (LAFD) I was interested in how it was done in the hospital. What I saw, I simply could not understand. We would have been disciplined had we acted on the streets like what I saw. Yet, here they were not only acting in that manner, they were proud of it and happily criticizing others after the resuscitation ended.

I did not know at that time the problems my Rescue Ambulance past would cause me. I was one of the first career fire paramedics to enter medical school. Witnessing these behaviors started my pursuit to understand the science that made the beliefs and behaviors of 1970s ambulance men and firefighters correct, what made the beliefs and behaviors of certain physicians wrong, and what was it that made them believe they were right

When I became a physician in the Pediatric Intensive Care Unit (PICU) I had a chance to apply my mountaineering and LAFD Rescue Ambulance experiences to medical care and teaching. Ron Perkin, M.D., a former U.S. Navy aviator with aerial combat experience from the Vietnam War, and I used our experiences to create a new PICU. Within three years we were the second largest PICU in the state and had the second largest pediatric critical care transport program. We also had half the expected mortality for a unit of our size and for an academic center. We used this approach in in our regional EMS program and an investigative reporter spent three months looking for problems in our pediatric EMS program. He found none.

These results gained the notice of Karlene Roberts, PhD, from the University of California, Berkeley, who told me that we were performing in a manner she called High Reliability and that we had created a High Reliability Organization (HRO). This started our collaboration with the Berkeley group of HRO academics and our series of HRO articles. To share this information and our experience I started the series of International HRO Conferences and the website.

Early on I was taught that people are our best assets, particularly when a problem must be solved immediately because of high risk. This philosophy worked well in the PICU and we could see change in the performance of the PICU staff, or any of the programs where I worked, within months. The interventions are generally straightforward and we worked from middle management downward to the line worker. As Dr. Roberts pointed out, the executives and organization must allow this to happen.

I started this blog to focus on what the individual can do. My experiences, and what I learned from other practitioners, will be my guide here. What I write has been used by me or taught to me by people I work with

Please read this material and see what you can use immediately. Tell me what works or if you had a problem with it. Let us continue the discussion of how HRO is a normal behavior we can implement immediately.

My bona fides

Thu, 10 Oct 2013 18:07:01 GMT

Where I learned about the processes now called HRO.

I am a pediatrician with fellowship training in Pediatric Critical Care. As a pediatrician I used these methods to help develop a PICU, critical care transport program, Emergency Medical Care bachelor's degree program for paramedics, nurses, and Respiratory Care Practitioners, two pediatric chronic intensive care facilities, and several EMS programs. Currently I am the medical director for REMSA, the Riverside EMS Agency (Riverside County, California) and an Assistant Professor of Pediatrics, Loma Linda University School of Medicine. My publications are listed in the reference section of this blog.

My academic background includes two bachelor’s degrees from the University of California, Irvine, My degrees are in Social Ecology and Biological Science. I was a chemistry major for a while at California State University, Long Beach. My medical degree (1984) is from the University of California, Irvine, where I also did my pediatric residency. My Pediatric Critical Care Fellowship was in Dallas at the Children's Medical Center and Parkland Memorial Hospital.

My ambulance work started in 1972 for a private ambulance company while I worked my way through Cerritos Community College. In 1974 the opportunity came to work as a Rescue Ambulance (RA) Driver for the LAFD which I took as I was having problems affording college. Most of my time was spent assigned to Fire Station 66 in South Los Angeles during the period when the street gangs Crips and Pirus (later called the Bloods) were moving into the area and an Angel Dust epidemic came through. This is where I not only learned what is now called HRO it is where I practiced it and learned refinements I have used later.

On the RA we worked with two men assigned to the RA unit and responded alone. A fire company or the police responded only when we made the request from the scene. There is one exception, if the caller used the word “gun” or said it was a shooting we waited for law enforcement, otherwise we responded alone to all crimes of violence including stabbings. This gave me experience in forming a team on the run while treating a patient and keeping everyone safe.

My station commander at FS 66, William J. Corr, counseled me to consider medical school. He was my model and mentor for how I would later practice medical care in emergencies and the basis for what is HRO in my use.

While working with the LAFD I took my paramedic training at the Paramedic Training Institute of the University of Southern California under Ronald Stewart, MD. Dr. Stewart was an early pioneer in teaching paramedics using high level concepts such as use of the measures of cardiac output (how much the heart pumps each minute) to understand medical emergencies and guide treatment. He also focused on supporting the paramedics as a means to improve care. He encouraged me to apply to medical school and it is his philosophy of medical care, how to treat patients, and how to work with paramedics that I continue to use today.

The men who taught me during this period were combat veterans from World War II, the Korean Conflict, and the Vietnam War and they were also veterans of major fires, crime scenes, and the Watts Riots. The Central Receiving Hospital ambulance men had been transferred to the LAFD to create the Rescue Ambulance. These men worked in the Central Receiving Hospital Emergency Department with doctors and nurses, and responded to the field where they worked closely with LAPD. They had a wealth of information of both emergency medical care and law enforcement activity.

My mountaineering experience had become a part of my daily life both as belief and metaphor. I began climbing in high school in the Sierra Nevada Mountains both winter and summer climbing and saw my first death in the mountains before I graduated from high school. It was at this death that I began to wonder about decision-making under stress. I have since made solo climbs in winter and have trekked in the Himalaya including an attempt to ascend Mt. Pharchomo in the Rolwaling Himal. I aborted that climb when I developed pulmonary edema below the 20,000 ft. summit and made a solo descent to high camp.

Random things you may not know about me

Thu, 10 Oct 2013 18:04:51 GMT

Though random here, as you read this blog there significance will develop.

1. I was one of first career fire paramedics to attend medical school.

2. I went around the world … twice.

3. I trekked and climbed in the Himalaya.

4. I taught cooking Mexican food to a restaurant in Kathmandu.

5. I started the first clinical academic Bachelor’s Degree program for paramedics.

6. I knew Tom Wheeldon who lived in Forge Cottage, UK.

7. I fell down a mountain very fast.

8. I had pulmonary edema at high altitude.

9. I sailed on a felucca down the Nile River, developed dysentery, hospitalized in Amsterdam with reactive arthritis from the dysentery, and started medical school in a wheel chair weighing 125 pounds (I am 6 ft. tall).

About this blog

Thu, 10 Oct 2013 18:02:25 GMT

Information about the purpose of this blog for your used.

Everybody wants to do better. The problem is how to learn and who do we learn from. With the increasing complexity of industry today there is also a focus on improving safety. This has brought in academics who observe operators but, during the observation, knowledge is lost. It has also created an industry of consultants who can bring safety and reliability to your program. We need the academics who can bring science to our experience. We need the consultants who can act as coaches, observing us and giving us methods to improve. I will not take away from them. I will offer methods to begin creating an HRO immediately. These come from my personal experience and from those whom I have worked with closely over the years.

I have taken my experiences and formed them into a list of topics. Over time my goal is to link experience with science and fill out the list of topics for you. It is important to maintain this linkage between experience and science to avoid the urban myth, the appeal of authority, and the loss of “street” knowledge during research.

What I discuss in my blog posts must be immediately useful to you. It must also be useful to anyone in the work column, from line worker through the middle manager to the executive. Some of it may be applicable to a few industries but it is my experience that the more industries a concept covers the more valid it is.

Please let me know what works for you and what you have problems understanding. I must also apply the principles of HRO to my blog, improving it, making it better every day. Thank you for your attention and spending your valuable time reviewing this material.

About the science I use

Thu, 10 Oct 2013 18:00:13 GMT

I once thought science was standard. Now I see there are different ways to use science - basic immutable principles and concepts, theories and models, and methods of investigation. Science is developing knowledge, epistemology is giving value to belief. Though close, they are quite distinct in HRO.

Dr. Jules Crane, Professor of Zoology, Cerritos Community College, Norwalk, CA, taught that science is a self-correcting body of knowledge and, wherever possible, we should both use the most basic science we can and learn as much about a topic as we can. While not perfect, I will do my best to correct my knowledge quickly, stick to the basic sciences, and stay as broad as I can.

There are many theories in the field of HRO, safety, and reliability so I must use some kind of guideline to identify theories for this blog. The theory must explain how an 18-year-old can function in a manner consistent with HRO and must also be easily understood by the novice. Whenever possible I would like to see more than one researcher using a theory (this does not include colleagues and students of the theory’s creator). I like to stay as close as possible to the basic sciences and use concepts, definitions, and principles from the basic sciences. The perfect example of this is the concept of culture that, in HRO, safety, business, and education, strays mightily from the definition and usage of sociologists and anthropologists.

A word about statistics. I am not opposed to statistical analysis and probability calculations. But the data and system must be random and independent. In the environment of processes, entrainment, and cascading failure, the initiating event may be random and independent but consequent events are not. One increases the probability (or is it possibility?) of the next.

As much as possible I like to combine multiple fields of science such as physics and neuroanatomy or chemistry and psychology. If a concept is true in more than one field of science it is more reliable to me for use in this blog.

I hope this will make the blog useful to people from novice to expert and keep the blog from becoming a battleground of theories. After all, what you read here must explain yesterday or be used tomorrow and not change at the whim of a new theory. Lives depend upon it.

About the slogan

Thu, 10 Oct 2013 17:57:04 GMT

"You do in an emergency what you do everyday," Jim Denney, Capt, LAFD (deceased). It must be useful to be used everyday. If used everyday it will be used in an emergency.

“What I teach today must explain yesterday or be used tomorrow”

"I know that is what they told you, but let me tell you what we really do." Comforting words when I first began working in the ambulance because now I would know what to do in real time, in real life. As my experience grew I begin to learn a wide spectrum of practical things that people could not put into words clearly or street knowledge from people who did not have the education or opportunity to write it down. But this phrase also came from people who made shortcuts, acted on ignorance, or worked in self-interest.

When I began teaching in the PICU I wanted to help students, residents, respiratory care practitioners (RCP), and nurses by teaching them what we really do. I wanted teaching in a way that would overcome the "I know what they told you…" comments from the wrong people.

I also came to recognize that some of my students did not want to be there, did not want to learn, and did not believe this information would be of any use to them. This is in a unit where one or two children died each week. I basically had 10 minutes to catch their attention, teach it to them, and show its usefulness. (Sometimes I stood under the television set in the patient's room while lecturing. When I saw too many eyes looking above me I would end the lecture and move on.)

Jim Holbrook, my education guru or go-to-guy, was discussing Bloom’s Domains of Knowledge with me and we focused on the Affective Domain. This, he told me, is the knowledge of "How this will help me." I decided to focus here.

This seemed limiting at first but I found that people would fill in the space between my how-this-will-help bits of knowledge. Fairly quickly, they began telling me how it worked and I used this feedback to grow my lectures. This feedback comes the same day of my lecture, next day, and even 20-25 years later.

This also helped me avoid the problem of "buy-in." When I introduced a new concept managers would tell me I would have to obtain buy-in from the staff. I asked them, "Why do I need buy-in to provide good care?" Instead, I use the Affective Domain of Knowledge to teach what will help.

"What I teach today must explain yesterday or be used tomorrow," became my teaching philosophy. Some have called it my 72-hour rule. I build on recent events or experiences the students have had, finding the greatest opportunity in everyday life such as hobbies, cooking, car maintenance and driving, normal human behavior, and dating. I wouldß prepare them for events they are likely to encounter but from the point of view of a novice facing an uncertain situation without support. These are the practical problems that experts gloss over because they seem too simple, yet in the confusion of a new event these simple problems block all further action.

About me, Dave

Thu, 10 Oct 2013 17:52:36 GMT

Why I started this blog, to share my experiences creating High Reliability from within the organization.

EMS & High-Reliability Organizing by Daved van Stralen & Thomas A. Mercer

Thu, 20 Jun 2013 17:45:30 GMT

Systems today, particularly those like EMS that are tightly linked between human actions and technology, have become complex to the level that “accidents” are not only predictable, but they can be expected.

Systems today, particularly those like EMS that are tightly linked between human actions and technology, have become complex to the level that “accidents” are not only predictable, but they can be expected. Charles Perrow described this as Normal Accident Theory after he studied the Three Mile Island nuclear power plant incident.

A few years later, academics from the University of California, Berkeley were studying the notion that “accidents” in high-risk environments can be considered “normal.” They came across the aircraft carrier USS Carl Vinson. Thomas A. Mercer, who was the carrier’s captain, invited the Berkeley researchers to study his crew for methods to improve their performance.

According to a personal communication by Karlene Roberts, PhD, the Berkeley team found an efficient team of operators who solved problems before they became significant; the team was unable to identify areas requiring significant improvement. Therefore, they codified the methods as indicative of a high-reliability organization (HRO) and found an exception to the idea that it was normal for consequential errors to occur in high-risk environments. From their studies, they codified the ship as an HRO due to its organization.