These are notes I’ve taken while binge listening to the last two months of the PreAccident Investigation Podcast, which you should subscribe to.
Kent Whipple – The power of the story
- When we investigate an accident, we don’t tell the story of what happened, we tell a story about what didn’t happen.
- Identifying what didn’t happen doesn’t help you fix what did happened.
Dr. Alan Frankfurt - High Reliability, Safety, and Delivering Babies
- Highly reliable teams don’t realise they’re highly reliable, they don’t set off to become highly reliable, they set off to become more stable, safer, more effective, or learn.
- Destroy vertical silos, create horizontal integrations. The silos stop us from working together and becoming as good as we can get. Horizontal integrations help people take ownership.
- Prepare for events with a pre-brief: use a template, identify what the threats are, verbalise and share concerns.
- Hold a post-action review soon after the operation, schedule around the surgeon because of time demands.
- There are rarely technical issues, but there are always communication issues that come up.
- Everyone in the team needs a role, and understand how that role fits into the goal of the team. “I’m gonna do my doctor thing, you’re gonna do your nurse thing, but I’m not any more important than you are.”
Dr Jim Joy - Critical Controls
- Risk registers end up being a list problems on paper that are useless as a management tool.
- Critical controls are a more effective management tool for dealing with risks and events.
- Controls are anything that prevents or mitigates an unwanted event, that we can use to improve our resilience when things go wrong.
- Controls can be acts, objects, and systems.
- Acts are behaviours we mandate or encourage.
- Objects are tools that work by themselves.
- Systems are combinations of acts and objects.
- Training is not a control, supervision is not a control. We can’t measure it, we can’t validate it, we can’t audit it.
- Once we have controls, we can define performance requirements (pressure valve is released at x pressure, the operator understands how to perform x task in context), measure, then validate those performance requirements are being met.
- Once we have requirements, we can set targets to assess the reliability of the controls, which is more of an objective discussion around metrics.
- We can then feed these metrics into the design of the controls based on what happens in our organisations.
- We need to move beyond thinking about risks as likelihood x consequence.
- Risk is the degree to which your controls aren’t working.
- Health and Safety Critical Control Management Good Practice Guide from ICMM publications
Dr Jim Barker - Complexity
- We don’t manage complexity, we move with it.
- Think about complexity as fluidity instead of non-linearity, because there are linear aspects to our complex systems (like time).
Martha Acosta - The 4 Things Leaders Control
- When leaders say “come to me with solutions, not problems” it seems like a great empowerment move, but they’re creating a distance between workers and management.
- If people come up with solutions, wouldn’t it be more empowering to just let them go and implement them, and only come to you when they have problems they can’t solve?
- The value leaders provide to their organisations is helping the people at the pointy end ask the right questions, and helping them create a solution at the pointy end.
- “When significant change comes up against significant culture, culture always wins” - Edgar Schein
- Culture is something that arises from behaviour. That behaviour tells us what matters, how we do things around here, what works and what doesn’t. The internalisation of that behaviour is what becomes culture.
- Outsiders see culture. Insiders have difficulty seeing it.
- Once we see culture externally, we think we can change culture externally.
- The four things leaders control are Roles (what people do), Processes (how we do work), Norms (how we interact with one another), Metrics (what we measure and incentivise).
- Anxiety in the leadership structure is contagious, and can turn into fear lower down in the org structure.
- Social anthropologists see culture as a bunch of intertwining narratives. If you add an anxiety narrative to your culture’s story, that changes the story.
- When you get people talking about their narrative in your culture’s story, that reflection produces surprises and uncovers how things work.
Dr. Eric Young – Patient Safety, Surgery
- Checklists have become overused to the point where they’re causing more harm than good (Dr Young has seen 84 items on one list), need to be kept down to a page per Checklist Manifesto.
- The best way to reduce error rates is to ensure a consistent team is working together to perform the surgeries.
- This isn’t always a possibility, so ensuring consistent skills across all team members is the next best thing.
- Dr Young is surprised more patients don’t get actively involved in their medical care by asking their doctors questions (e.g. why this brand of joint replacement over another?) and finding out more about their treatments.
