Transcript for:
Proactive Safety Program Development Insights

great so hello welcome um I um I decid I was trying to figure out exactly how to start this talk and and I realized I really wanted to be more of an informal discussion so uh I set some places at my kitchen table for you guys um uh virtually I suppose uh but if I suppose if someone shows up I'll have to answer the door and let you guys in um I want to talk about today is is how do we set up a pro a pragmatic proactive safety program and part of that is is for us to be able to reveal the things that are invisible so I'm going to talk a little bit about uh what it takes to see the invisible um and so uh I really do want to be kind of a conversation I've left a ton of time for questions and and conversation and and I even even in the slides where it looks like I'm actually saying something prescriptive uh I want you guys to know that this is this is just our take uh you know we see we've seen some things out in different industries that are working and I want to share those with you but uh we're this is this is early these are early days for for a you can call it a safety 2 program a proactive program uh there's lots of different ideas uh lots of different interpretations uh even if we even if we all agree on the terms like how to get those put those into action so so I just I I want this to be a conversation starter I'm hoping that uh there other folks on the phone that can share some of their story as well potentially or or ask questions to so we can get at some of those things um and that uh and that really this this helps uh us connect uh the all of the folks that we know that are doing this kind of work so we can all do it together in the future so that's the hope uh so I will get started I want to use these slides as kind of a framework for the conversation and let the conversation kind of go where it will um so with that saying with that said let's get started so I'm going to take a little bit I don't know if for those of you who read the abstract of this talk um I'm going to to take it a little bit out of order and and you can you this says so you want to build a safety a proactive safety program uh you can fill in the blank uh you with a couple different things there but um I want to start thinking about what um so I've talked actually with some of you on the phone or on the web webinar about your programs and how you're making sense of this uh and there's some differences there and I want to share with you some of the things that that we're seeing uh first though I realized that know maybe we're in different places in our journey so I'm not going to hit these some of you guys have seen these slides from me I'm not going to hit all of it but but what we're going to focus on primarily is this safety 2 view of the world there there's definitely a place for safety one but that's not what I'm going to focus on I'm going to focus on this idea of safety two I'm going to hit some of the high points here just so we get some grounding and then we're going to run into this this proactive safety idea so uh the I think the biggest difference uh in safety 1 is a safety One Professional has been trained uh to think that that we keep things safe by um by by one kind of saving people from themselves by creating more rules and regulations and and if you if you uh comply with the rules and regulations we will keep things safe and safety2 professionals uh are trained to think sometimes that's true but oftentimes and as we get more complex that's not true um simply complying with the rules simply doing everything that I'm told that will not keep us safe um and goes to the underlying difference between safety 1 and safety 2 and this comes down here our systems inherently safe safety 1 says yes except for those people and I'm oversimplifying and safety 2 is saying no they're not safe you know we need these people with their skills with their expertise to keep it safe every day um and moving forward a safety One Professional again this is this should be kind of a logical extension how do we keep how do we measure safety how do we keep people safe we count errors we count incidents we we measure compliance safety 2 is harder uh we're trying to analyze what are what are the things in our system that are that are at odds with each other we're analyzing go conflicts we're looking at workarounds we're looking at the gap between procedures and practice between work is done and work is imagined um and from there we're trying to determine potential likelihood and impact of risks so we're both looking at risk we're looking at risk in a very a very different way um so I'm going to unless there are questions about safety 1 and safety 2 which not just yet and just that's the that's the backdrop and I don't want to spend a whole lot of time on that um but we can certainly talk about it if that's what the group wants to talk about so so that's the first thing I want to talk about the second thing to talk about is how to see the invisible and and what I've realized and this is actually with some of my work with folks that that uh that do work with things like x-rays with things like um you're looking at the what what you uh what ultraviolet reveals versus what visible what our eye visible light reveals hyperspectral analysis uh you realize that um things are not nothing is truly invisible but you need you need a set of eyes you need a a a sensing mechanism to be able to see them and that's true like uh that's true both both um literally and metaphorically there's lots of things that are going on the system that we are that that go on right in front of our face that we just don't see because we're not we're not um appropriately primed to see it and what what I realize is is as you as as we all go through our journey through safety through system safety through resilience engineering through safety one and safety two um we this training this exposure to different things this gives us a new set of eyes and and these new eyes are are are hard earned it it's hard work to get this new set of eyes and so you know we're learning and mastering new Concepts we're learning new patterns so we're going to talk a lot about adaptation and edges of the system today and like what is you know how do we understand how to see adaptation what kind you know what what does that even mean in fact in one um one situation uh we went into an organization and we asked them just uh kind of openly um so Jo so tell me this is a long this is quite a while ago now uh Jo tell me where you adapt and uh the Frontline workers all looked at us like we were idiots because we're like whatat do you mean I adapt all the time that's my work that's my job that's like you're going to have to be more specific uh this is happening all the time and yet it's difficult for for us as Outsiders to to sometimes truly appreciate that and that's part of it is getting you know trying to get inside and understand that so so we want to learn these new patterns we want we want to collect uh we want to collect a set we want a toolkit we want a a utility belt of patterns uh that when we see triggers for those patterns like oh that might be an example of this and I'm going to show you guys a couple patterns around adaptation at towards the end um but without those patterns without those kind of archetypical Notions of how things are done you may miss it entirely or you may diagnose it as something else you know just like uh just like this poor fellow down here um you know may have been diagnosed the first couple times you know with a sinus headache well no he doesn't have a sinus headache or she doesn't have a sinus headache she's got a nail in her face um so I want to think about you know how do we make in general this is how we make the invisible visible as we put a new set of eyes on it that can literally be a new person coming into the situation or that can be you know helping helping people to to develop uh a set of tactics and strategies about seeing these things all right so that's the first part you have a comment from if you look in the chat ah yes bog thank you uh yeah so bog says for sure we saw it took about six months for us safety observers to stop seeing crew performance for safety one lens excellent uh yeah and uh uh that's that's the kind of thing we would expect to see thanks bog for sharing um so here's the dark secret about the safety 2 graphics so if you guys for those of you guys are kind of in the weeds with safety 2 you've seen this graphic before and the way this graphic is usually presented is you know from a safety one perspective we're trying to figure out what's going wrong and try to to mitigate what's going wrong and we realize in these Ultra safe Industries that's this percentage roughly of the entire you know the entire body or volume of work that's going on so we we understand that for Ultra safe Industries accidents happen less than one in 10,000 opportunities that's really low and what we thought start talk about in safety 2 is that we don't want to just look at what goes wrong in fact we want to really deprioritize our effort in looking what goes wrong we want to look at what goes right and and I think that is a wonderful pneumonic for for thinking about safety 2 and getting people to to to start their Journey from safety one but I I think it's just a little too cute um because it's it's not just about what's going right it's about what's going on because in the moment we're never going to be 100% sure if what we're seeing is going right or going wrong we only know if it goes right or goes wrong after something goes wrong so retrospectively we can go back and say oh that was definitely ra wrong now some things are more clear than others but but you know it's it's very difficult so what I'd like to us to think about is that it's it's not I think safety 2 is not really about seeking out the things that are going right it's certainly not a quest for seeking out what's going right although we want to do that it's certainly not a quest for seeking out what's going wrong although there are times where we have to do that in fact they're pretty prevalent um or right not prevalent that's what we know but we spend a lot of energy on that right now what I want us to think about is that we need to understand how work is going on we need to understand all of it now that sounds lovely but there's again here's the dark secret H that's a lot of ground to cover that's a lot of ground to cover in fact if you do the quick math um you know we have it's it's 10,000 times as much work probably uh if we want to try to understand all of this work like we try to understand this little bit of work so so where are we going to recruit our new Army uh and that's how I I mean we could talk about I talk about a bunch of different ways I talk about deputizing I talk about recruiting uh when I'm with a healthcare audience I talk about us with this as possible reach as many resources um as possible we need to utilize analytics and machines wherever possible although they create some of their own problems we won't talk about today uh or uh issues unintended consequences um we need to be able to recruit and so so we have some choices now I'm going to oversimplify a lot in the next three or four slides but but more or less you have you know for people you could recruit you have you have three choices and again I and this is where if the comments want to blow up and you know there are more choices I'm I'm happy to talk about them um but but really we have you know you you can go call the external experts and there you know because safety 2 is getting more and more momentum there are a number of external experts out there some of them started the safety 2 movement um and for the purpose of this I'm GNA I'm going to talk about you know New View which is Dave Wood's uh formulation of this and uh I'm sorry new look for Dave Woods New View for Sydney Decker and safety 2 which is a formulation uh Eric hmel Bob we and a couple other people most recently for today I'm gonna talk about all those kind of the same way so either so so with all that said there are quite a few people who who understand safety to have seen it in a variety of Industries um and and can come and help you there also the what I'm call I'm going to be very I'm very kind of vague and Broad they're the internal project workers in your organization if you're if if you work for an organization who does safety critical business critical work and and these are the folks this is the this is the safety team this could be a performance team this could be an investigation team these are folks that you know they they do or they you know at least part of their work they identify they're doing it as projects I'm I'm moving from part of the organization part of organization and trying to make things safe or make things more efficient or make things something else and then there are the Frontline workers and um and they're you know and so the Frontline workers are actually doing this safety critical work we call them the sharpest of the sharp end um and so they're you know they're actually doing this work these are the nurses the Physicians the surgeons the pilots the air traffic controllers um the operators in the control center of the nuclear power plant um you know they're the ones that do the work and there's characteristics of each of these three so as we talked about with these with these new eyes um you know so so and I'm going to these are overgeneralizations but I think they they basically hold up your experts are going to be you know the most trained on on this they're going to have seen the most they're going to see it in multiple Industries um but they're the fewest there aren't that many of them the your internal project workers they're you know and I don't know I don't know if it's actually 16 to one or not I just put this on here for you know for uh for notional uh just to to demonstrate the point there are more of them um so uh in most organizations some organizations you know there they might you might have a onetoone external expert to internal project worker and the Frontline workers in most Industries are going to be you know considerably more you know arithmetically more maybe geometrically more than your internal project workers these are the folks that do that work um now the one thing I did not put on here and I guess it would be over here on the right side are our Bots analytics uh machine learning AI that kind of stuff as well that could have we're not going to talk about that today but we could also you know we have these you know we have software that could be helping us do this as well and basically what does our army need to do and and with this one I and I didn't have a good slide for it in fact I did have a good slide and I forgot to put it in what I what I think we need to think about as safety 2 is we're not talking about investigating we're not we're not talking about C primarily creating a plan we're not talking about responding that's not the the primary part of safety to although it includes those things it's surveillance it's the now if you think about the the H H hles cornerstones which became potentials you know I think we're what I'm going to focus in on is the monitor uh and anticipate you know parts of it so how how am I monitoring what's going on in the world so that I can anticipate um not again not at a sharp end level but literally at the at the blunt end as an organization how can I monitor what's going on in the organization so that I can intervene that's the respond so that I can learn so that I can uh redirect resources um so what do we need to do we need to get data you know if we're going to do surveillance we need to be able to be collecting data of some form of flavor that could be surveys interviews organizational data stuff in databases observations we can also look at artifacts uh that the people are creating we can have people keep Diaries like there's all kinds of stuff we can do then we need to analyze the data figure out what's meaningful that could be a statistical analysis some kind of advanced analytic AI that can be um you know more qualitative methods like constant comparative grounded Theory um you know kind of more generally a pattern analysis we need to report or escalate the findings as necessary and we need to intervene and respond and basically the way I'm thinking about it is is we need to kind of do this kind of light surveillance that helps us understand the world and we need to you know we need to have resources ready to go do a more intense surveillance in areas where we think that's necessary now going back to our graphic we can't do it everywhere you know if this is all of work I can't be intense everywhere but but hopefully with my light surveillance whatever I choose to do is my light surveillance it can help me understand Pockets where I need to redirect resources now and those resources are probably coming in the flavor of this this project work you you know these These are the resources that can move around Frontline workers probably can't as much or bringing in external experts so again what are our you know what can our new Army do and what's are you know what are things that are interesting about our new Army I talked about this already a little bit I I tend to do that I tend to go out of order okay just checking to see if there's chatter not yet um so again those external experts we can expect to have the most extensive training see it in the most um in most places and and for the right price they can invest 100% of their time you know on your problem or or your place to go uh to go look further the internal project workers um again on average on balance are goingon to have less training than external experts they can invest a portion of their time their time is a little bit more tied up in the day-to-day um and they're closer to the system um and the Frontline workers often have little to no training in these kind of analyst skills or relevant Concepts um and they can invest really pretty little of their own time because they've got day jobs and those day jobs primarily don't have to do with safety except everything has to do with safety um they have to do with something else you know patient care keeping planes in the air uh you know you know producing energy whatever that you know primary focus of that organization is um however those Frontline workers are best at describing their real work so these are some of the characteristics I think we that are relevant in figuring out how we can utilize dynamically each of these different groups so this probably should say a sweet spot for our new Army but I was feeling Grand uh when I wrote it so I put the sweet spot for our new Army um so I think that there are roles for all these these different groups the Frontline workers they can record data about their work if it's if we have it targeted if it doesn't take too much time and it's still meaningful both to them and the organization so so what I realized is um a lot of times our so I'm GNA kind of go out of order here too our external experts have the ability to parachute in and and wildly improvise like they go to go see that they can see it they can they can compare it to things that they've seen the other place and create this kind of custom plan um they can they can you know pretty address l or ad depthly pull from all the patterns in their pattern book they can you know put it together know maybe some of you guys have seen this in action um it's uh and it all looks very fluid what we realized is that the the As you move to folks that that are that are trying to do this work in the organization so say a safety management organization safety managers in that organization um and and the Frontline workers especially don't have those skills yet don't have that that kind of conceptual knowledge to be able to to pull those patterns and and uh and adapt them quite as readily so so as we move down so Frontline workers yes they can collect data but um we found that if I ask them to you know collect open-ended data about you know what's what's the problem or when do you adapt or anything that's that's that open um what I get is you know what I get is um not what I expected and um it's also you know frustrating for them it's frustrating for us so these things have to be much more targeted um and that's also true if we're going to ask the the the internal project workers to take a significant role in data collection and Analysis we have to if we're going to rely on them for the majority of it and by the way my note at the bottom says you go you know as as as an organization you need to rely on your people to do this analysis not the external experts it has to be a little bit more tailored uh now hopefully everybody increases you know and as they move on their Journey they get a little bit better at all these things so we have we can be we can improvise a little bit more um uh we can adapt a little bit more we can uh you know but but this is what we're seeing and then the external experts um we really want to use them very sparingly now um and and I hopefully that's you know that's not Troublesome to the other external experts that are on this call or not are hearing this recorded when they hear it but what we're realizing is ex as external experts we are external which means one we we can't we can't keep Pace with what the organization is doing and and we don't have we'll never have enough time no matter how much you you pay us no matter you know how many of you you try to clone us we just don't have enough time for for a true proactive safety program um so so we want to educate on Concepts we want to assist on difficult analyses we want to direct where the large scale safety efforts are going um like you know what would a Frontline worker data collection practice look like what would your your safety organization data collection look like um and then the big one is how do we create and share these generic patterns how do we help everybody else um you know uh uh practice and and test their new set of eyes and again if and this is this is a caution if if you find in this program is you're having your external experts actually do you know the blocking and tackling work that's not sustainable it can work for a while but it's not sustainable so you you you know the ultimately your internal organization has to be self-sustaining because that's the only way you're going to keep pace so we have comment oh great question from Bogue um how do we get Frontline worker by and that this will be valuable and show them positive feedback with their efforts also please expand on the note about external experts um yeah so I'll answer the second one first uh yes uh external experts are the individuals outside of your organization like me um we have a role we want to play a role um but what I'm saying is our role has to be um guiding not leading um and listening and that's what I'm going to get to the next slide is listening to see what's working and you know providing feedback about what other things could work um but but the engine of this thing um what I'm proposing here the engine of this thing has to be internal uh so now the first one how do you get Frontline work or Buy in uh so so there's a chicken and an egg here um you need to ask you need to ask your Frontline workers to do something that's small enough so that they'll do it um you need to have enough trust with them to know that you are on their team so because what you're ask them to do is probably sensitive information in one way or another you're going to ask them so what we're going to talk about is is adaptation and adaptation means I'm I'm having to decide between these two rules or I'm not following the rules in this particular situation or I've had to do something on my own I didn't ask for permission first I had to do something on my own that's sensitive and it happens all the time so part of it is you have to you have to get that trust you have to assure them and you have to back it up that that they will not get in trouble um for sharing and and then you need to be able and again it's got to be lightweight enough so that um they'll give it a shot for some amount of time and the smaller it is I think the longer they'll give it a shot and then you need to be able to back it up to say now you know even if it doesn't benefit you in this six month or nine month period that you're doing it in um here's what we're tracking and here's why we're doing it um and and so if we're seeing this thing not just for you but across you know in uh in in your case bog you know across you know all of our Pilots if we're starting to see these things across all of our Pilots um you know we will start you know if I start seeing that we're starting to relax certain certain goals or certain rules more readily starting to see more chronic workarounds um that can potentially be a vulnerability to the system and we're going to you know that's how we're going to send these extra resources to try to address it um you can also and we're doing this in in a couple different cases where um literally just sharing back what we're seeing um so in the case we're doing some work in the uh in the emergency room of Ohio State's Medical Center and you know part of the way that we ensure um part of the way we ensure future participation is to keep them involved and engaged about what we're doing now so what we found is that uh there's definitely a a power gradient you know between physic Ians and nurses and Pharmacists and we're finding uh different uh configurations of those of those three roles that uh that keep the system safe um and and keep you know keep multiple of those perspectives together and we're just about to share that back with them um even though I haven't told my lab that we're just about to share that back with them to say that you guys each have a role in the safety you you you know please keep doing these things um and I'm going to share that across the different roles to say this is what all of you guys are doing together um same thing we we saw with um gosh where else did we see that oh I've lost it but I'll get it back um so so you know we we oh sorry we also did a study two years ago um and again I'm breaking my rule we the external folks did it um but we want to start training the internal folks to do it um where we revealed to a set of surgeons and nurs nurses that they actually were seeing the patient very differently um you know nurses were looking at um at symptoms and Physicians were looking at diagnosis and how the symptoms were uh were aligned with diagnosis or not and that Rift was actually keeping them from uh from being able to communicate on on a large number of patients and so um and so uh so just showing them feeding that back to them to say look we we saw this that you were not aware of we made something invisible visible um has been very valuable to them um and not only valuable to Ohio State but that's actually you know that's been sent to a number of surgery conferences to say this is something we need to be looking out for so that's been seen as the larger Community is being valuable um so um and I want to Echo a point that Thomas uh Tom just sent to all of us to say this this idea of of uh we not we we can't just be neutral about this idea of of blaming blaming the folks that did something different we have to understand they have to understand that we will be their Advocate that this is something that this is something that is crucial and necessary to the system um and and they need to understand that we're gonna we're going to have their back we're not just going to sit silently and you know so there's there's one and this has happened to me before when I've talked about some of the adaptations that we've seen um in the organization you know management so many management comes with you know red in the face and we'll say well who did that and I'll have to look not only am I going to say not only going to remain silent which is the very least I could do but I'm Al I'm going to say I I'm not going to tell you because because that was you know because because one I don't I'm not entirely trusting that you're going to see it for the the critical adaptation that it was um so until you prove to me that that the organization has made that complete shift I I am not going to um you know I'm going to protect the people that are helping create safety every day I don't think I use those exact words um but pretty close so so we we all need to have an active part in you know in order to reveal these things uh we we need to uh again advocate for them it's not just being silent in the face of the of a safety 2 kind of blame Fest or safety one blame Fest sorry um but how are we actively doing this so that we can engender that trust that's critical hopefully that that was a little bit longer of a soap box than I thought I was going to go on but uh hopefully that helps okay so I think that gets us through the sweet spot for our new Army at least a sweet spot for our new Army uh and I just wanted to recap it real quick and again like I I when I see these these kinds of Recaps are nice but um you know take it with a grain of salt as well um so but just just to recap you know front line we have we've there are lots of people that we could tap to help with the work the project team maybe have tens of people or maybe a couple people external they're one to few um availability to to help per person you know is very low from the front line project team you know has moderate external could have high training is often Low Project team is moderate external is high and The Sweet Spot is this kind of lightweight data collection describing real work project team is moderate data collection lightweight to moderate analysis and then externals kind of educate sparingly use everywhere else bring in patterns kind of you know help and advise that way um so I wrote this and I was really excited with myself and I read it again I'm like uh it's not perfect um that's awfully prescriptive so I wanted to really think about what again what we really care about here is if you have you put an organization that has this kind of lightweight cheap analysis that can in that with the interactions between these various groups that are working together we can shift perspective and shift resources so some examples of that is you know in doing this work with it the Frontline workers get a sense of something that's changing that triggers some kind of ad hoc analysis or the project team and the Frontline workers together create a new lightweight kind of probe because maybe the other one's not working very well uh or external experts working with all the company employees to understand anchors and new probes and analyses and I I didn't touch that point exact uh explicitly in the beginning with my graphic of safety 2 um we we can't study everything we can't analyze everything we have to pick what we're going to look at and that's going to be really important what we pick um and then last and again these are just examples um we get some feedback from a front line that helps the project team and the external experts that a current probe's not working isn't collect what intended requires a change um you know all of those things were working together across these different groups so I wanted to talk about what what we're doing in Cecil in the cogni systems engineering in Laboratory um and how we're we're we're focusing on adaptations we think that's a good anchor uh to get started and and why are adaptations important adaptations are important because those adaptations occur when your system is challenged in ways that the the normal stuffed isn't working anymore and those are really important things for us to St understand as resilience Engineers as cognitive systems Engineers as safety 2 Personnel um like when are we outside of perform our our original performance boundaries those edges we know that outside those edges some combination of your policies and procedures will be inadequate to deal with it the B the book inverse of your training will be insufficient you're going to have to do something else something new it might be a little bit of something new and it could be a lot of something new and what we want to understand is when when your when your people do that thing that's new is that indicative of of future brittleness or future resilience so are they and we have to understand the nature of today's adaptations in the face of these challenges to try to predict or extrapolate to try to anticipate when those challenges get a little bit more or a little bit different or combined in different ways uh do we think that the the system has the right capabilities uh meta capabilities generic capabilities to be able to deal with those new challenges so why we like you know adaptation and stretches and edges um we can look at different uh adaptation patterns and again we see these as you know we stretch to to deal with these you know these new strains you know as we get to the edge and past it these new edges and strains help us understand something more about our stretches and it keeps moving through here and we're going to hit uh all of these different uh types of stretches that we're looking at or or or characteristics of stretches that we're looking at uh we're not going to not going to talk about the edges too much today although we could now what we're doing is we're we're building off of our tool called the systemic contributor man I still have the wrong words this is systemic contributor and adaptations diagramming Someday I'm gonna get all the right words here in the right slides and and where we started was this is a way this is a response to the root cause analysis methodology um in thinking about you know previous accidents so but that's not what we're talking about today we're talking about proactive so we created an innovation I want you to you really pay attention to this slide it's this shift is really important if you guys if you blink you're going to miss it so here's the Innovation the proactive we removed the event do it again guys missed it and so so we again we started with this big event some accident that happened and started working back to understand the pressures and the conflicts that led to that set of adaptations that that uh resulted in the event the contributed to the event and what we realized is that we could take the event away still look at the adaptations the day-to-day adaptations uh and the Not So day-to-day adaptations and and we can still come back and see how those adaptations are the result of conflicts of multiple pressures or expectations on the system so how these uh how these workers are are dealing with the conflicts or tradeoffs between these different pressures um and still works so um so again why we started with this in you know for retrospective is it's lightweight we found it to be productive in a number of different settings and and it's sustainable there are um there are a couple organizations right now that are using this without us uh in fact they started one of them in St Louis started this without us uh got a little bit of advice along the way and is now doing this without us um and it doesn't require extensive training um this is the one we're working on right now where either the the Frontline workers themselves or a safety professional can work with them um to start understanding you know first um give us some background about this this situation that precipitated an adaptation tell us about the textbook behavior um that that should guide your behavior or your your actions now tell us what you did and how it's different than textbook um and then from this thing that you did let's work backwards and start see you know what you know you did it differently than textbook what are the pressures and expectations that lead to textbook or that that helped craft the textbook how are those things conflicting with each other how did you manage those conflicts or what are the important parts about those tradeoffs um and then how do we get to how do we get to the adaptation itself so this is something that we're working with again a couple organizations right now on and we're finding that this you we absolutely can have safety professionals without without the external EXP experts um they can deliver they can uh implement this um we haven't had a whole we we think that Frontline workers can can do this as well I there's no reason why they couldn't um we just haven't seen it there there's some we haven't had an organization like really test it yet um but we think that can happen as well and so so we see this as serving maybe two purposes the first purpose is just to get a lay of the land what are the types of adaptations we're seeing let's get a catalog of the different pressures and expectations that are on the system and let's get a catalog of how they how they tend to conflict um now this is a little bit more involved at first because we want to understand you know we don't know what we need to understand so we're g to you know we have to go a little bit deeper we've got to use uh you know more qualitative techniques we don't know enough to start you know excuse me start like counting things or getting rates but that's where we want to go so where we're going so now now the obstacles um with this um we found that um we need to we need to work really hard with the safety team to be able to there's a script you can work from but then there's being able to see things that could potentially be interesting and and I'm not going to tell you that uh that the experts have cornered the market on finding things that are interesting but I've noticed in going through these interviews uh you know pouring over the data that there are a lot of times where I see something really interesting because of my eyes and my conceptual framework that that interviewer didn't think was important and so we missed it and that's that's that's a fact of life it's going to happen but uh what we're trying to understand is is how can we how can we minimize that as much as possible so then we when they see something interesting when was something like that that doesn't seem quite right how do we help them dig into it further um and that's that again that's kind of part of the journey with that skill Mike you have a question from s okay does there have to be an incident no so sorry s um sorry I would make that more clear with this one um so the question from sadp is does there have to be an incident or some flash point for the scad or can you trace adaptations without necessarily having an event involved the the purpose of this that you guys are seeing right now and I'll or uh Marine I will get you your question as well it's a great one um the purpose of this if you see there's no accident or incident here uh the we're not ever asking them about an accident or an incident or a flas point or even like a major Junction Point juncture point we're saying tell us about a time where you did something differently now so that could be you this could be a workaround story this could be what we call a contingent adaptation to say there was this time on a Thursday and and let me tell you about it so so absolutely you do not have to have in fact we do not want proactive scad which I think scad is going to become uh the proactive side and we'll talk about reactive scad as the one with the event but with that the dust isn't settled yet on that um but yes absolutely this Canon should be used to understand real work as it's going on uh without an without an accident or incident I have another question uh do you apply scad with individuals or teams or cross functional teams the answer is yes so these in these interviews um right now tend to be uh individual because it's about what one person did but they could easily be what did your team do um you could start getting a team together to to talk about this together and how they did it together um and and so you could use it as I think it should be able to scale up or down as much as you want to and then Ivonne asks will this be a good understanding of improvisations now let's talk about the word improvisation for a second because I don't I can't tell you around around the planet all the different connotations of improvisation but in in the United States improvisation in industrial communities has a negative connotation it's not seen positively um but yes so if we think about improvisation as the ability to do something different to adapt um and and and you know the you know and the and the kinds of and the the intensity of that adaptation which I'll talk about in a second yes we would expect um so this we think is this is a good way to understand improvisations not only for the individual which is the individuals are idiosyncratic but how does that improvisation reflect the goals and conflicts and trade-offs and the pressures and expectations that that individual was under and as well um what are the you know what is the inherent ability of this system to be able to improvise you know some systems are going to be able for a variety of reasons to improvise better they're able to go further with the same uh the same kind of raw ingredients um than others okay and then the question what are the dots what are the lines and how do you actually create the catalog of pressures so we put these in the cartoon if you notice um let's go back if you notice there are no lines on this one and and we can deliver it this way um that we have a series of you know you put your adaptation or maybe one adaptation was actually um the result of other adaptations up here and then you can put as many conflicts as you want as many pressures as you want and then you want to connect them the reason there are dots and lines here is we we think again from the from where we've delivered this we think that having some having some blanks to fill in um are helpful so I would consider all of these these dots um these are places where I I put a conflict or a tradeoff and that and actually what when we actually see one and I didn't think to share one um when we see a real one we have like there's a pressure up here so let's say this pressure is throughput or production pressure and then we have another pressure that is service or collegiality and interestingly in some Industries this is a we find this is a really invisible pressure but it's a really really strong pressure collegiality across organizations collegiality within a team uh some call this professionalism like what are the professional rules when you know when is it okay to ask for help when is it not really kind of not okay to ask for help um and so you hopefully you could quickly see that when you have throughput pressure and collegiality pressure and some safety pressure those you know in a given situation on a Thursday those could absolutely conflict so these are the starter lines but we would actually abely expect people to say okay oh sorry here I went the wrong I went the wrong way I got lost um that these we actually connect say these two pressures come together and they conflict and then this is the trade-off that we're seeing or the trade you know how people are dealing with the tradeoff this tradeoff um plus this trade-off plus this tradeoff all come together and that's how I see this decision was made for this adaptation so that's what the dots and the lines are the dots are expected to be places where I would Mark the trade-off or the pressure or in this case the adaptation the lines are how we connect those things together so that you can start to see the the the the um the contribution of each of them coming into the the downstream effects so hopefully that helps and again this is the tool we're using now uh we certainly could could improve it I'm sure um oh we got one more ah so and you says oh wow there's more sorry okay so great question in complex organizations there'll be multiple perspectives on any topic whose perspective do you prioritize um and I would say it depends and I would say you you probably don't prioritize you need to understand all of those different perspectives and start to um start to reveal and this should happen so so one story doesn't give you a picture one story from multiple perspectives doesn't give you a system picture what you need to start seeing is patterns so if in this story a pattern comes out about these two kinds of pressures conflicting and then you see lots of stories with those two pressures conflicting that's something that's a pattern you start to see see that pattern say this is an important thing for me to understand these two goals are in Conflict uh um reliably and frequently that could be a problem um the details of the story they kind of fall away quickly so so yeah and that's also data if the perspectives are so wildly different and their perspectives are wildly different consistently that's a pattern and so that's something you need to work with so uh for example the the St Louis group they actually realize that two of their clinical groups that come together in this case it was intensivist and surgery um they were literally they were not just seeing the patient differently they were seeing the stories about the patient differently they were retelling the stories differently and thankfully they were in the room to do it so they could start saying oh this is this is interesting this is data we need to resolve this and that's important so so what you're doing there is actually that that's data too so it's not I don't think it's whose perspective you prioritize although that could be important at times it's oh we we have a gap in our organization and is that idiosyncratic um that that can be you know that's a glitch that's a that's a blip or is that data that we need to track to say we we reliably have multiple perspectives that are in Conflict they are not complimentary um they're not the kind of multiple perspectives we want to get to some kind of consensus or some kind of bigger picture they are fraction or fractionary or fractured and then Andy brings up so this is a Swiss Cheese model it's a little bit well that's a whole other conversation um now one of the one of the tenets of the Swiss Cheese model is this idea of latent factors or latent vulnerabilities that can lead us a stray so what we're saying is these pressures exist and these pressures exist so that the system can run now they have unintended consequences but they but they exist for a reason if those pressures didn't exist the organization wouldn't exist what we're trying to understand is how are these pressures coming together um how are they being perceived how are they affecting um how are they affecting the uh the capabilities and how we're building those capabilities how we're refreshing those capabilities um in order to stay resilient so the way I look at swiss cheese and again the only thing that can lead us astray and I don't know it's it's not about the Swiss cheese itself but it's about the common and typical perceptions and perspectives on Swiss cheese and how they're implemented is most organizations and Andy I don't know you uh in particular but most organizations that Implement swiss cheese they send the team out to go look for their latent vulnerabilities let's look for my latent factors and let's fix them so if I fix so if I so if I if I rejigger the holes which are vulnerabilities then I'm then I've solved this this is different what what we're saying here is what are the capabilities so it's it's in some ways it's the other side of the coin in some ways it really is a kind of a different way of looking at it what are the capabilities that these people are bringing to bear in order to deal with uh the realities of their system so I'm looking at the capabilities that I need to support and understand uh I'm not looking at these these um inter interdependent latent vulnerabilities or holes in the system H more good questions where do constraints fit into this Tool uh constraints are pressures so I am under time if I'm under time pressure if I'm under resource pressure and again seeing that resource pressure uh or constraint um once is a blip if I see in my stories and we can dig out my stories that we are resource constraint all the time that's a pressure that so so that is providing pressure and so you know the the so as we think about the the portfolio of adaptations that are available to our frontend uh our frontend workers um they are constrained so I would put those constraints out here and pressures and expectations all right time is it getting close I may finish um so right now so what we've what we've realized is that we we asked in where the organization is working with right now we have asked um those Frontline workers and those project teams in this case a safety organization to um to learn too much too quickly that's what we've figured out um and so what our current focus is is to try to simplify into thinking how are these adaptation because we really need to get to if if we're going to implement this proactive safeties we end we're going to focus on how changes or adaptations are changing over time so we're not going to look at States we're not going to look at behaviors that are good or bad because I said before it's really difficult in most in enough cases to understand is this a good behavior or a bad behavior what I know is that when I take all of the behaviors uh in total the system is running the system is running right now so what we're looking at is how are their how are their adaptations how are they changing over time and to get a change over time to get a rate to understand the triggers to understand the frequency um that requires a lot of data points uh because if I if I test you know every nine months then and and it looks like it's a little bit higher like I don't know if that's really higher or not I don't know what happened in the middle if it went down and up or if this is you know if if this is a a noisy indicator or if this is a a pretty quiet indicator so this little change at the end is really meaningful so we need more data and if we need more data we need more people and if we need more people we need more uh as I said before more participation from the the project workers and the Frontline workers so this is what we're trying to go after this is the way we're thinking about doing it we're actually going to lighten our story elicitation so instead of asking to tell whole stories we're going to focus them so we're either going to theme them around a noted or notable type of adaptation um so that and I have a couple patterns of that down below um or it could be one that we just want to know more about um and they're going to collect these targeted variables which again I will talk about in a second um but so it's basically trying to you know we'll we'll do a more open-ended session but with each of them we'll say okay with this adaptation um how does that how does that rank or rate um or or or how do you qualify it on these different dimensions I'm gonna go through the dimensions in a second so as opposed to this big open-ended thing that we do a more open-ended analysis on which again is something that a number of the the if you're trained to do it that's fine if you're not trained to do it that's hard to just kind of jam into an organization um that but instead of that we're we're trying to do a much more targeted analysis that can be analyzed more readily the second thing we're doing um is or thinking about doing is call I'm thinking about this kind of inprocess Frontline data collection so I don't know how far ways goes uh but in the United States it's pretty popular um what weighs is is an app that it's a it's kind of like a Google Maps app or a GPS app but people out on the road are um are actually plugging in different traffic hazards uh different uh places where there are police stops places where there's construction and they're doing it as they're driving which I never do because I think that's I I can't imagine being able to do that in drive but people do it um but I we're thinking about what could we do while either during shift or on shift that that Frontline folks can collect about the work that they're doing so that could again we could Target a certain number of adaptations like if you do this let me know about it um and again that could be H in real time at the end of the shift looks like I have a comment or question oh that's just Avon you have three minutes fine I think I can make it so here are example variables that we're tracking right now so again with the pressures like we create that catalog of pressures that are in the system from those initial interviews we say in this story this pressure was was a contributor these pressures in Conflict are happening and this pressure is being relaxed or that pressure is being relaxed and in what order so we're trying to understand it from that perspective and then from the adaptation perspective we're saying what's the kind of adaptive capacity and that's we could call we could call that slack in our community as well that is in this adaptation is either being injected or increased or removed or decreased we could also look at the intensity and that's something I'm starting to get better language around are these lower intensity um adaptations like just like slight adjustments or using a different process or is it repurposing U like I'm using this for a way in a way that it wasn't meant to be used but now I have to use it that way or I choose to use it that way or improvising where I'm using I'm I'm really kind of going out on in a new way using uh you you really you're putting things together in very new and novel ways to do this adaptation we think it's important to think about whether this person whether this agent or team tried to take this whole thing on by themselves or if they try to recruit additional resources gets to your question about constraints you know what resources are able to be recruited and then this idea of workaround versus contingent adaptation we're trying to track that as well um the kinds of questions we're asking is again how often what's the Frequency what's the rate of these patterns occurring What's the magnitude of the challenge that triggers them like you know is this you know what how you know is this is this you know for example more traffic or more patience than usual more uncertainty than usual um you know what is the the magnitude of that challenge and how's that change over time and I want to end with just a couple of generic patterns that we found and again I think this is um this is the sweet spot for these patterns is the is the experts bringing those to the community um but it could be brought by anybody um so this is what one of the things we're talking about so so so one of these patterns is stretching the corners and that's when with increased overall workload or asymmetric workload meaning one worker has more than another with the expectation or pressures that we have smooth operation and maintaining throughput that we see this adaptation we see them taking control of processes or areas outside their responsibility relaxing one or more procedures or coordinating outside of normal practices um and then the benefits we see a reduced cost of coordination in this case potential downside is taking actions with incomplete data so that's one of the generic patterns we see and the other generic pattern that I want to share with you is this idea of increasing worker complexity now for reduced complexity or expanded options later so that could look like really risky behavior and it is it's increasing risk now to to alleviate risk later and we see this you know when you know when certain aspects of a challenge present themselves we see this pattern so I will finish to's see if there's one more awesome so I don't know by my watch I have two minutes if there are other questions or Ivon if there's something you wanted to announce we can use the last minute or so that way uh I will leave it up to you Avon yes I think we have one minute now and uh I think we can continue the discussions and uh we will put the webinar is in the website and thank you very much Mike for sharing this knowledge I think that people have the contacts with the Ohio State University and to have maybe they will be groups trying to explore this patterns of adaptation so so let's uh let's start the disc discussion in a broader community and I would like to announce the next webinar that will be will be from Brazil that is Ed Ericson so he it will he will talking about the exploration of challenges and opportunities on implementing resilience in practice in the in the oil and gas industry so it will be the 30 of March all the previous webinar and this webinar will be um available on our website so so you can you can check for the people that cannot attend and you can inform your colleagues so thank you very much Mike and with that we close the session excellent thanks everybody and just you please sad wants to scone so uh please uh feel free uh in fact don't hesitate to email me ray3 u.edu I'm also on Twitter Doo so love to hear from you this I close the session great thanks everybody