greenstreet berman

Organisational DriftOrganisational Drift

Jonathan BermanGreenstreet Berman LtdGreenstreet Berman Ltd

Fulcrum House, 5 Southern Court, South Street, Reading RG1 4QS

www greenstreet co ukwww.greenstreet.co.ukjonathan.berman@greenstreet.co.uk

0118 938 7703

1

greenstreet berman

Major accidents�…Major accidents�…

2

greenstreet berman

�‘Minor�’ accidents�…Minor accidents�…

3

greenstreet berman

Imminent accidents�…Imminent accidents�…

4

greenstreet berman

Route Mapp

�• Setting the Scene �– what is Organisational g gDrift?

�• Why is it significant?�• Characteristics of Organisational Drift�• Compliance �– its importance for OD

Implications and recommendations�• Implications and recommendations

5

greenstreet berman Conceptual model for Ergonomics (Carayon et al, 2006)(Carayon et al, 2006)

greenstreet berman

Wh t i O i ti l D ift?What is Organisational Drift?

�• Columbia�• Davis Besse�• Tokai-Mura�• Costa Concordia�• Deepwater Horizon�• Alder Hey�• Bristol Royal Infirmary

�– What are the common threads?�– What are the common threads?

7

greenstreet berman

ColumbiaColumbia

�“So ingrained was the agency�’s belief that foam d b i t th t t fli ht f t th t idebris was not a threat to flight safety that in press briefings after the accident, [the Program Manager] still discounted the foam as a probable cause�”

�“In contrast, foam debris and eroding O-rings were defined as nagging issues of seeminglywere defined as nagging issues of seemingly little consequence�”

�“Each time an incident occurred, the Flight Readiness process declared it safe to continue flying. Taken one at a time, each decision seemed correct�”seemed correct

8

greenstreet berman

Why does it matter?Why does it matter?

�• Nuclear industry study/Regulatory concerny y g y�– Is it inevitable? �– Can you detect and prevent Drift?

R ili i ti l h d t it?�• Resilience is essential �– how do we create it?

�• 2 necessary conditions for Drift:�• 2 necessary conditions for Drift:�– Degradation of key aspects of operational processes�– Failure of oversight processes

�• Its about whether you�’re doing what you think you�’re doing...you re doing...

9

greenstreet berman

ExamplesExamples�• Water industry �– control of processes�• Nuclear �– failure strictly to complete paperwork during

fmovement of material�• Rail �– failure to undertake maintenance correctly�• Driving �– speed, mobile phones, rest breaks�• Finance�…�• Healthcare:

�– Reduce nursing staff in high-dependency ward due to t ff h t th th tti th t li tstaff shortages rather than cutting theatre list �–

becomes the norm�– Accepting confusing packaging or equipment

A ti i l t t�– Accepting incomplete notes

10

greenstreet berman

Packaging�…Packaging�…

11

greenstreet berman

Drift�…Drift�…

12

greenstreet berman

Attributes of Organisational DriftAttributes of Organisational Drift

T i llTypically:�• It occurs in high-performing organisations

It i d l�• It is a gradual process�• It comprises shortcomings that are detectable�• There is a failure to detect those shortcomings�• There is a failure to detect those shortcomings�• The organisation becomes �‘comfortable�’ with a

level of performance that is less than padequate.

greenstreet berman

Defences?Defences?

�• Focus on operational standards �– and criteriaWhat are you doing?�– What are you doing?

�– How are you actually doing it?

�• Early, effective detection of change�• Proactive identification/review of �‘threatening�’

changesEff ti i ht�• Effective oversight:�– Can detect deterioration in �‘technical�’ standards�– Can identify deterioration in commitment and focus�– Is independent of/resists degradation influences�– Is compelling�– Is externally anchored�– Is externally anchored

�• Indicators include �‘compensating behaviours�’14

greenstreet berman

15

greenstreet berman

A definition of complianceA definition of compliance

�• Rule compliance: the extent to which people p p pchoose to follow a rule or procedure or, knowingly or unintentionally, choose not to do soso.

�• Non-compliance: the failure to follow a rule �–Non compliance: the failure to follow a rule may occur deliberately (but with good intent), or unintentionally (eg through ignorance, misunderstanding task difficulty etc)misunderstanding, task difficulty, etc).

16

greenstreet berman

Why focus on compliance?Why focus on compliance?

�• Organisational Drift is partly defined by aOrganisational Drift is partly defined by a gradual deviation from �‘accepted�’ performance

�• It tends to be associated with increasing levels f d t t d liof undetected non-compliance

�• Incentives for non-compliance can be indicators�• Compliance can be influenced directly�• Compliance can be influenced directly�• Improvement in compliance leads to greater

resilience �– it allows the organisation to recognise and address the factors that degrade performance

17

greenstreet berman

What is the challenge?What is the challenge?

�• Do we know the extent of non-compliance?p�• Do we condone non-compliance?�• Has non-compliance become easy?�• Has non-compliance become �‘normal�’?�• Are we clear what constitutes non-compliance?

Wh t l i ki l d�• What claims are we making on people and are they reasonable and clear?

�• Do we understand the �‘contract�’ between theDo we understand the contract between the organisation and the employee

�• Shared goals?�• Feasibility of role?

18

�• Feasibility of role?�• Support?�• Development?

greenstreet berman

How is it manifest?How is it manifest?

�• Indication of problem or cause?Indication of problem or cause?�– Culture: inadvertent reward? �– Goals: communication?

I t f l ki f h tf ll ?�– Interfaces: looking for shortfalls?�– Procedures: compensating behaviours?�– Training: training needs update?�– Job Aids: ad-hoc aids to compensate?

�• Do people perceive that they are non-compliant?compliant?

�• Do people consider that what they are doing has management approval?

19

greenstreet berman

Factors affecting complianceFactors affecting compliance

�• Procedures �– are they clear, available, relevant?relevant?

�• Objectives �– do people understand what they are being asked to achieve and why?

�• Competence �– are people suitably trained and experienced?T k d i i it t l d�• Task design �– is it easy to comply and are necessary tools/systems/equipment/PPE available?

�• Do we listen adequately?�• What do we reward?

20

�• Do we adequately manage the process?

greenstreet berman

Potential SolutionsPotential Solutions

Make compliance easier / remove

Apply discipline / sanctions /

rewards

easier / remove problems

Make rule better/correct

I d li

Involve staff in rules and

i l i

Set clear standards

Improved compliance

Educate/

implementationIntroduce a behavioural modification

approachexplain

Make rule and compliance importantMake non-

compliance difficult / pimpossible

21

Supervise / monitor

greenstreet berman

ResilienceResilience�• Compliance exists within a dynamic

environmentenvironment�• Combat the gradual erosion of management

controls �– organisational driftN li i b th f d ift d�• Non-compliance is both a cause of drift, and also an indicator

�• Need controls to remain robust over time�• Use compliance management to detect and

respond to �‘compensating behaviours�’�• Remain alert to degradation�• Remain alert to degradation�• Retain clarity of staff autonomy �– what they are

permitted to do, particularly when faced with abnormal conditions

22

abnormal conditions.

greenstreet berman Conceptual model for Ergonomics (Carayon et al, 2006)(Carayon et al, 2006)

greenstreet berman

ConclusionsConclusions

�• Organisational Drift is both pervasive and g pcontrollable

�• Compliance needs constant effort�• Ergonomics is at the heart of what needs to

happen�• The benefits are significant �– productivity and�• The benefits are significant �– productivity and

organisational resilience�• Any intervention that can highlight actual or

potential non-compliance needs to be explored and addressed

�• The organisation needs to earn compliance�• The organisation needs to earn compliance24

greenstreet berman

The challenge�…The challenge�…

An organisation not only must strive for excellence but also must put in placeexcellence, but also must put in place arrangements that give confidence that such performance is sustainable�…