Organizations lessons hard to learn, organization design hard to change

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Organizational lessons hard to learn,
organizational design hard to change Mathilde
BourrierWorld Social Science ForumBergen, May
11, 2009
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My perspective is based on

• Ethnographic studies (90s- 2003) in nuclear
  power plants (US and France)
• Collaborative work on railway safety
• New work on skills transmission in Anaesthesia
  during ambulatory procedures

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Initial questions

• What are the recurrent difficulties such
  high-hazard organizations face?
• What do we know about their organizational
  responses to these challenges?
• How to assess their micropolitics of safety?
• Where are they heading ?

AZFs explosion Sept. 21, 2001 (Toulouse,
France 1/3 of the town impacted) No cause
determined to date
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Studying High-Hazard Organizations

• A well established field (seminal controversy
  HRO, La Porte Consolini, 1991 vs NA theory,
  Perrow, 1984 JCCM, 1994 Rochlin, 1996), making
  use of the classic heritage of work on
  bureaucracies, complex organizations and their
  dysfunction...along with organizational
  anthropology, ergonomics, social psychology.
• Ever growing number of organizations members of
  the club
• - Nuclear Power Plants, Chemical plants,
  Aviation
• Hospitals now considered High-Risk Organizations
  (To err is human, 1999 Gaba, 2000)
• The financial system a High-Risk System?

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The face of a High-Risk Organization

• Uncertainties in the process are always present,
  yet kept minimal by intense surveillance,
  controls, mitigation strategies both technical
  and organizational (famous  defense in depth )
• 2. Staff can only fill their own slot (a
  characteristic already noted long ago by Perrow,
  still current) Allow for top skills and
  knowledge to be maintained
• - e.g Hardly any possibility to move from
  maintenance to ops or from ops to maintenance
• 3. Detailed proceduralisation of work and
  activities (?)
• 4. Work and activities are strictly planned (?)
• 5. More and more subcontracting practices (e.g
  maintenance ?)
• 6. A detailed supervision of work and activities
  (?)
• 7. Production sites heavily regulated

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Consequences

• 1. Risks keep changing
• 2. Silos,  structural secrecy  (Vaughan, 1996)
  develop knowledge does not travel easily
  within the organization
• 3. Procedures need to be created (Whos in
  charge, How? Is Taylor still alive and well ?),
  up-dated endlessly ( principle of
  correctedness , Stinchcombe, 2001), or else they
  are potentially breached

• 4. Where do the Planning folks fit in the
  organization?
• 5. Subcontracting requires reorganization by the
  Principals, seldom carried through
• 6. Too much supervision and control potentially
  create a lack of autonomy, resentment, lack of
  ownership, dilution of responsibilities (too
  little has also its drawbacks of course!)
• 7. ditto regulation i.e., nuclear regulators
  in France are considered the true bosses of EDF
  NPP, How does it affect safety?

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Recurrent organizational challenges

• Organizing constant assessment
• Constantly battling against ghettos
• Organizing the  classic  dilemma between
  Prescription and Autonomy
• Resort to a separate planning section (US) or
  deciding planning is not a specific activity
  (France)
• Organizing contracting work How? For which
  activities? Under what conditions?
• Organizing control On which basis? Who are the
  controllers?
• Organizing the relationships between regulators
  and regulatees?

• Uncertainty of risk
• Rigid division of labor
• Ultra-prescription
• Planning each every activity
• More more subcontractors
• Mandatory control of activities
• Regulation of the production process

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• These questions cannot be solved once and for
  all.
• The concrete and contingent organizational
  answers given to these problems by and large
  determine the social construction of safety
• By the way, what are these  contingent
  answers ? What do we know about the strategies
  that organizations have taken to confront these
  recurrent problems?
• Do we face a uniform response?

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3 possible regimes
Where is it heading?
?
 Opaque Autonomy 
 Empowerment 
? Entering the micropolitics of safety which
model would you choose?
 Logistic 
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• Strict separation between those who design the
  work and those who execute
• Preparation of work not a priority, leading to
  numerous surprises in the field
• Rather informal control of activities in the
  field
• No formal delegation of power to modify
  procedures when needed at the workers level
• Workers and foremen have the tendency to solve
  problems by themselves
• Safety authorities seldom on site distant
  oversight

The  Opaque autonomy  regime
?A lot of informal adjustments to rules,
do-it-yourself, prevail
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Balance

• Strengths
• Kingdom of  superheros , (firemen type)
• lots of creativity
• Lots of adaptability
• Great pleasure in troubleshooting activities

• Vulnerabilities
• Lots of tacit knowledge
• Lack of transparency
• Low level of organizational learning
• Difficult for newcomers (or subcontractors) to
  get onboard

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• Strict separation between those who design the
  work those who execute
• Unlimited resources allocated to the people in
  the field (helpers, engineers, tools)
• Detailed planning preparation (drills)
• When procedures need modification, a dedicated
  engineering section helps the workers to update
  them rapidly
• The control of activities entirely subcontracted
• Heavy handed safety authorities (on site)
• Deliberate opposition to  unplanned 
  initiatives

The  logistic regime 
?Hardly any informal adjustments, a go-by-the
book attitude prevails
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Balance

• Strengths
• Very explicit organization
• Constant dedication to upgrading procedures and
  policies
• Critical attention to planning

• Vulnerabilities
• Rigid organization, not reactive
• Costly
• Apathy and complacency easily develop

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The  empowerment  regime

• The execution teams participate in creating and
  have the formal responsibility to up-date working
  rules, procedures and safety policies
• These modifications are approved (or not) by top
  management 24/7 (allowing for a timely resolution
  of problems in the field)
• Control and surveillance are delegated to a
  member of the workteam, acting under the quality
  and safety department chief, for a week at a
  time.
• Safety authorities stay at a distance

?Workers play by the rules as long as they are
involved in their drafting
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Balance

• Vulnerabilities
• Constant bypass of middle management
• Punitive and blame culture
• People tend to over-defend their turf

• Strengths
• Kingdom of journeymen 
• The expertise closest to the field is highly
  valued
• Workers are empowered and look after any aspect
  of their working environment (from procedures to
  subcontracting)

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• Each model has its strengths and weaknesses
• No regime is perfect, yet each of them is
  offering an answer to the dilemmas detailed above
• These regimes are the kind of things one might
  expect from our organizations

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What is ahead? 3 possible choices

• The technocrats choice More of the same
• - More separation between those who design
  technology, organizations, procedures and those
  who execute plans, work, activities
• Fewer in-house staff/more and more contractors
• Increase of the proceduralization
• Automation whenever possible
• Will eventually continue to be an option if large
  resources are allocated (Cf.  logistic model )
  for this model to work

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The  Human-centered  choice

• Organization is seen as a waste of time, great
  contributor to events, accidents(after  human
  error ,  organizational failure  is to blame
  for everything)
• The emphasis is put on  first line actors ,
  their training, skills and resources
• Reliance on simulators, decision-making tools and
  software
• Might apply to specific populations or segments
  of an organization (hospital-doctors/surgeons,
  aviation-pilots)

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The  Organization-centered  choice

• Breaks the bureaucratic model
• Favors collective negociation of options prior to
  the set-up of organization
• Directly addresses the challenges they face
  (prescription versus autonomy control versus
  ownership)

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References

• Institute of Medicine 1999, To Err is Human
  Building a safer health system, Washington, D.C
  National Academy Press.
• La Porte, Todd Paula Consolini 1991, Working
  in Practice But Not in Theory Theoretical
  Challenges of  High-Reliability Organizations ,
  Journal of Public Administration Research and
  Theory, 1 (1), 19-47.
• Journal of Contingencies and Crisis Management
  1994, Volume 2 (4).
• Rochlin, Gene 1996 (special editor) of Journal
  of Contingencies and Crisis Management,  New
  Directions in Reliable Organization Research , 4
  (2).
• Perrow, Charles 1984, Normal Accidents, Living
  with High-Risk Technology, New York, NJ, Basic
  Books, 1984.
• Perrow, Charles 2007, The next catastrophe,
  Reducing Our Vulnerabilities to Natural,
  Industrial, and Terrorist Disaster, Princeton
  University Press.
• Gaba, D.M 2000, Structural and Organizational
  issues in Patient Safety A comparison of Health
  Care to Other High-Hazard Industries, California
  Management Review, 43 (1), 83-102, 2000.
• Vaughan, D. 1996, The Challenger Launch
  Disaster, Chicago, IL, The University of Chicago
  Press.
• Stinchcombe, A. 2001, When Formality Works,
  Authority and Abstraction in Law and
  Organizations, The University of Chicago Press,
  Il.
• _____________
• Bourrier, M. 2002, Bridging Research
  Practice The Challenge of Normal Operations
  Studies, Journal of Contingencies and Crisis
  Management, Vol.10, N 4, 173-180.
• Bourrier, M. 2005, The Contribution of
  Organizational Design to Safety, European
  Management Journal, Vol. 23, N1, 98-104.
• Bourrier, M. 2007. Risques et Organisations, in
  Face au Risque, Claudine Burton-Jeangros,
  Christian Grosse et Valérie November (Eds.),
  LEquinoxe, Collection de sciences humaines,
  Genève, Georg Editeur, 159-182.
• Bourrier, M. 2009, Das Vermächtnis der High
  Reliability Theorie. In Johannes Weyer Ingo
  Schulz-Schaeffer (Hrsg.), Management Komplexer
  Systeme, Konzepte für die Bewältigung von
  Intransparenz. Unsicherheit Chaos, Oldenbourg,
  München, 119-146.
• Bourrier, M. Coll, S. submitted, Apprendre et
  transmettre à lhôpital Le cas de lAnesthésie.