Managing the Unexpected: Resilient Performance in an Age of Uncertainty

by Karl E. Weick and Kathleen M. Sutcliffe (2009)

In some organizations, such as hospital emergency rooms and firefighting units, slight errors have major consequences like the loss of property or even the loss of life. These organizations develop systems and ways of learning that reduce the incidence of error and allow the organization to recovery quickly from errors that do occur. Weick and Sutcliffe call these High Reliability Organizations (HRO) and they have studied them to decipher what makes them so reliable. In the process, they have identified lessons for other businesses that want to learn to recognize threats early, respond to them appropriately, recover from them quickly and reduce their negative impact.

When the authors compared several business disasters, they found a pattern of company behavior and corporate culture that differed from that of the HRO's. They found that the reliable companies managed their expectations differently and developed a level of mindfulness that continually updated expectations based on unexpected events. Rather than seeing the unexpected as a blip on the screen, the HRO's saw them as an early signal of possible failure and then predict what could go wrong.

Weick and Sutcliffe have developed a set of five principles that characterized the HRO's.
Principle 1: Preoccupation with Failure
The HRO's "...treat any lapse as a symptom that something may be wrong with the system, something that could have severe consequences if several separate small errors happened to coincide." (Page 9)

These organizations create an environment that encourages people to report errors; the organizations come to mistrust complacency and drifting into automatic processing. They consider a small discrepancy to be the symptom of a larger failure evolving.

To identify the point of potential failures, the HRO's ask three questions:

1. What activities involve the most direct human contact with the system?
2. What activities, if performed less that adequately, pose the greatest risks to the well-being of the system?
3. How often are these activities performed in the day-to-day operations of the system as a whole? (Page 48)

The highest potential for failure is the points with the most frequent human contact, performed the most often.

Principle 2: Reluctance to Simplify
When we simplify our understanding of a system, we lose the details and along with them, the early warning signs. The HRO's are reluctant to cluster events into just a few categories. When an event doesn't fit an existing category, they recognize it as an unusual occurrence that signals a potential failure and requires a different response.

Inter-disciplinary and inter-departmental teams, actively questioning each other's interpretations of events, add to the understanding of the system's operation. "That's why HRO's simplify slowly, reluctantly and mindfully." (Page 54)

Principle 3: Sensitivity to Operations
HRO's are responsive to the messy reality inside the systems, ready to act promptly when the unexpected occurs. This is the process of seeing what is actually being done, not what is supposed to be done.

A sensitivity to operations includes qualitative as well as quantitative information, neither standing higher than the other in the value hierarchy. These companies pay close attention to real-time information through frequent operations meetings, widely disseminated measures of performance and nearly continuous face-to-face interactions.

Principle 4: Commitment to Resilience
Errors are inevitable and managers need to be as concerned with recovering from them as they are with preventing them in the first place. "To be resilient is to be mindful about errors that have already occurred and to correct them before they worsen and cause more serious harm." (Page 68)

"Resilience involves three abilities: (1) the ability to absorb strain and preserve functioning despite the presence of adversity...; (2) an ability to recover or bounce back from untoward events-as the system becomes better able to absorb a surprise and stretch rather than collapse... and (3) an ability to learn and grow from previous episodes of resilient action." (Page 71) A commitment to resilience shows in these three components.

Principle 5: Deference to Expertise
The first people to know a system is failing tend to be those closest to the work, often lower in rank, perhaps invisible to the leadership and often reluctant to speak up. An organization that defers to authority and hierarchy is less informed by this critical front-line expertise and takes longer to address failures and correct them.

In HRO's, it is a sign of strength to recognize when you have exceeded the limits of your knowledge and know enough to ask for help, whether that help is higher or lower in the organizational hierarchy.

Weick and Sutcliffe offer audit questions to help the reader assess their organizations' capabilities on the five principles of mindful infrastructure that enable HRO's to be aware of their own capabilities. They conclude with recommendations for managing mindfully; here are two:

• Remember that mindfulness takes effort...you're asking people to pay more attention to their failures than their successes.
• Offer support to people who are making an effort to become more mindful...make it safe for them to try it on.

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