Crew Resource Management (CRM) and the Energy Industry

If you work in the airline or healthcare industries, you are probably already familiar with Crew Resource Management (CRM) training.  CRM training was an outgrowth of evaluations of catastrophic airline crashes that were deemed to be due to “human error”.  The original idea behind CRM was to capitalize on the knowledge and observations of other crew/team members when the pilot or doctor was seen doing something that could lead to an incident.  The goal is to help crew members develop the skills necessary to successfully anticipate and recognize hazards and then correct the situation. Recently, the energy industry has begun to provide guidelines for member companies to implement CRM training in an attempt to avoid catastrophic events like the Macondo and Montara blowouts.* CRM training focuses on six non-technical areas needed to reduce the chances of “human error”.  These six areas are:

1. Situation Awareness This involves vigilance and the gathering, processing and understanding of information relative to current or future risk.
2. Decision Making This involves skills needed to evaluate information prior to determining the best course of action, selecting the best option and implementing and evaluating decisions.
3. Communication This involves skills needed to clearly communicate information, including decisions so that others understand their role in implementation.  It also involves skills for speaking up when another person is observed acting in an unsafe manner.
4. Teamwork This involves an understanding of current team roles and how each individual's performance and interaction with others (including conflict resolution) can impact results.
5. Leadership This involves the skills and attributes needed to have others follow when necessary.  It also includes the ability to plan, delegate, direct and facilitate as needed.
6. Factors that impact human performance Typically this category has focused on stress and fatigue as contributors to unsafe actions or conditions.  However, drawing from the wealth of Human Factors research, we view this category more broadly and feel that it includes the many ways in which human performance is impacted by the interaction between people and their working contexts.

We have been writing on these skill areas in our blogs and newsletters for several years and thought that some of our work on these subjects might be beneficial to our readers who are either currently working to implement CRM training or evaluating the need to do so.  If you have been following our writings, you will already know that we take a Human Factors approach to performance improvement (including safety performance), which involves an understanding of the contextual factors that impact performance deemed to be “human error”.  It is our view that, while human error is almost always a component of failure, it is seldom the sufficient cause.  We hope that this link to our archive of Crew Resource Management related posts will be useful and thought-provoking.  For ease of access, you can either click on one of the six CRM skill sets described above, or the Crew Resource Management link, which includes all related writings from the six skill sets.

*OGP: Crew Resource Management for Well Operations, Report 501, April, 2014. IOGP: Guidelines for implementing Well Operations Crew Resource Management training, Report 502, December, 2014 The EI Report: Guidance on Crew Resource Management (CRM) and non-technical skills training programmes, 1st edition, 2014.

Why It Makes Sense to Tolerate Risk

Risk-Taking and Sense-Making Risk tolerance is a real challenge for nearly all of us, whether we are managing a team in a high-risk environment or trying to get a teenager to refrain from using his cellphone while driving.  It is also, unfortunately, a somewhat complicated matter.  There are plenty of moving parts.  Personalities, past experiences, fatigue and mood have all been shown to affect a person’s tolerance for risk.  Apart from trying to change individuals’ “predispositions” toward risk-taking, there is a lot that we can do to help minimize risk tolerance in any given context.  The key, as it turns out, is to focus our efforts on the context itself.

If you have followed our blog, you are by now familiar with the idea of “local rationality,” which goes something like this: Our actions and decisions are heavily influenced by the factors that are most obvious, pressing and significant (or, “salient”) in our immediate context.  In other words, what we do makes sense to us in the moment.  When was the last time you did something that, in retrospect, had you mumbling to yourself, “What was I thinking?”  When you look back on a previous decision, it doesn’t always make sense because you are no longer under the influence of the context in which you originally made that decision.

What does local rationality have to do with risk tolerance?  It’s simple.  When someone makes a decision to do something that he knows is risky, it makes sense to him given the factors that are most salient in his immediate context.

If we want to help others be less tolerant of risk, we should start by understanding which factors in a person’s context are likely to lead him to think that it makes sense to do risky things.  There are many factors, ranging from the layout of the physical space to the structure of incentive systems.  Some are obvious; others are not.  Here are a couple of significant but often overlooked factors.

Being in a Position of Relative Power

If you have a chemistry set and a few willing test subjects, give this experiment a shot.  Have two people sit in submissive positions (heads downcast, backs slouched) and one person stand over them in a power position (arms crossed, towering and glaring down at the others).  After only 60 seconds in these positions, something surprising happens to the brain chemistry of the person in the power position.  Testosterone (risk tolerance) and cortisol (risk-aversion) levels change, and this person is now more inclined to do risky things.  That’s right; when you are in a position of power relative to others in your context, you are more risk tolerant.

There is an important limiting factor here, though.  If the person in power also feels a sense of responsibility for the wellbeing of others in that context, the brain chemistry changes and he or she becomes more risk averse.  Parents are a great example.  They are clearly in a power-position relative to their children, but because parents are profoundly aware of their role in protecting their children, they are less likely to do risky things.

If you want to limit the effects of relative power-positioning on certain individuals’ risk tolerance - think supervisors, team leads, mentors and veteran employees - help them gain a clear sense of responsibility for the wellbeing of others around them.

Authority Pressure

On a remote job site in West Texas, a young laborer stepped over a pressurized hose on his way to get a tool from his truck.  Moments later, the hose erupted and he narrowly avoided a life-changing catastrophe.  This young employee was fully aware of the risk of stepping over a pressurized hose, and under normal circumstances, he would never have done something so risky; but in that moment it made sense because his supervisor had just instructed him with a tone of urgency to fetch the tool.

It is well documented that people will do wildly uncharacteristic things when instructed to do so by an authority figure.  (See Stanley Milgram’s “Study of Obedience”.)  The troubling part is that people will do uncharacteristically dangerous things - risking life and limb - under the influence of minor and even unintentional pressure from an authority figure.  Leaders need to be made aware of their influence and unceasingly demonstrate that, for them, working safely trumps other commands.

A Parting Thought

There is certainly more to be said about minimizing risk tolerance, but a critical first step is to recognize that the contexts in which people find themselves, which are the very same contexts that managers, supervisors and parents have substantial control over, directly affect people’s risk tolerance.

So, with that “trouble” employee / relative / friend / child in mind, think to yourself, how might their context lead them to think that it makes sense to do risky things?

A Personal Perspective on Context and Risk Taking

Most of our blog posts focus on current thinking about various aspects of safety and human performance and are an attempt to not only contribute to that discussion but to generate further discussion as well. I can’t think of an instance when we took a personal perspective on the subject, but an experience that I had a couple of weeks ago got me thinking about willingness to take risk and how context really does play a crucial role in that decision. I was attending a weekend long family reunion in the Texas hill country where we had 25 family members all staying together in a lodge that we had rented. It was a terrific weekend with a lot of food, fun, reminiscing and watching young cousins really get to know each other for the first time. My nephew brought his boat so that the adventuresome could try their hand at tubing on the river that ran by the property. I decided that since I had engaged in this activity many times in the past that I would simply act as a spotter for my nephew and watch my kids and their kids enjoy the fun. (Actually I was thinking that the rough water and bouncing of the tube would probably have my body hurting for the next week. This, I contend was a good evaluation of risk followed by good decision making).

There was also a rope swing attached to a tree next to the water allowing for high flight followed by a dip in the rather cold river water that attracted everyone to watch the young try their hand at this activity. There were actually two levels from which to begin the adventure over the water, one at the level of the river and one from a wall about 10-feet higher. All of the really young and really old (i.e. my brother-in-law) tried their hand at the rope from the level of the water and all were successful including my older brother-in-law. I arrived at the rope swing shortly after he had made his plunge only to have him and his supporting cast challenge me to take part. I told them that I would think about it and this is where “context” really impacted my decision to take a risk. The last time I had swung on a rope and dropped into water was probably 20 years ago. At that time I would swing out and complete a flip before I entered the water. No reason not to do the same thing now….right? No way I could accomplish this feat in front of my wife, sister, children, grandchildren, nieces and nephews, not to mention my brother-in-law, by starting from the waters edge. It would have to be from the 10-foot launching point. In my mind, at that moment this all sounded completely reasonable, not to mention fun! As I took my position on the wall I was thinking to myself that all I needed to do was perform like I did last time (20 years ago) and everything would be great. I was successful in getting out over the water before letting go, (needless to say that I didn’t perform the flip that I had imagined…..seems that upper body strength at 65 is less than at 45). I’m not sure how it happened, but I ended up injuring the knuckle on one of my fingers and I woke up the next morning with a stiff left shoulder. By the way, two weeks later I am feeling much better as the swelling in my finger and stiffness in my shoulder are almost gone.

As I reflect on the event, I am amazed at how the context (peer pressure, past success, cheering from my grandchildren, failure to assess my physical condition, etc) led to a decision that was completely rational to me in the moment. I am pretty sure that the memory of the pain for the next several days afterwards will impact my decision making should such an opportunity arise again. Next time I will enter from the waters edge!

Hardwired Inhibitions: Hidden Forces that Keep Us Silent in the Face of Disaster

Employees’ willingness and ability to stop unsafe operations is one of the most critical parts of any safety management system, and here’s why: Safety managers cannot be everywhere at once.  They cannot write rules for every possible situation.  They cannot engineer the environment to remove every possible risk, and when the big events occur, it is usually because of a complex and unexpected interaction of many different elements in the work environment.  In many cases, employees working at the front line are not only the first line of defense, they are quite possibly the most important line of defense against these emergent hazards. Our 2010 study of safety interventions found that employees intervene in only about 39% of the unsafe operations that they recognize while at work.  In other words, employees’ silence is a critical gap in safety management systems, and it is a gap that needs to be honestly explored and resolved.

An initial effort to resolve this problem - Stop Work Authority - has been beneficial, but it is insufficient.  In fact, 97% of the people who participated in the 2010 study said that their company has given them the authority to stop unsafe operations.  Stop Work Authority’s value is in assuring employees that they will not be formally punished for insubordination or slowing productivity.  While fear of formal retaliation inhibits intervention, there are other, perhaps more significant forces that keep people silent.

Some might assume that the real issue is that employees lack sufficient motivation to speak up.  This belief is unfortunately common among leadership, represented in a common refrain - “We communicated that it is their responsibility to intervene in unsafe operations; but they still don’t do it.  They just don’t take it seriously.”  Contrary to this common belief, we have spoken one-on-one with thousands of frontline employees and nearly all of them, regardless of industry, culture, age or other demographic category, genuinely believe that they have the fundamental, moral responsibility to watch out for and help to protect their coworkers.  Employees’ silence is not simply a matter of poor motivation.

At the heart this issue is the “context effect.”  What employees think about, remember and care about at any given moment is heavily influenced by the specific context in which they find themselves.  People literally see the world differently from one moment to the next as a result of the social, physical, mental and emotional factors that are most salient at the time.  The key question becomes, “What factors in employees’ production contexts play the most significant role in inhibiting intervention?”  While there are many, and they vary from one company to the next, I would like to introduce four common factors in employees’ production contexts:

THE UNIT BIAS

Think about a time when you were focused on something and realized that you should stop to deal with a different, more significant problem, but decided to stick with the original task anyway?  That is the unit bias.  It is a distortion in the way we view reality.  In the moment, we perceive that completing the task at hand is more important than it really is, and so we end up putting off things that, outside of the moment, we would recognize as far more important.  Now imagine that an employee is focused on a task and sees a coworker doing something unsafe.  “I’ll get to it in a minute,” he thinks to himself.

BYSTANDER EFFECT

This is a a well documented phenomenon, whereby we are much less likely to intervene or help others when we are in a group.  In fact, the more people there are, the less likely we are to be the ones who speak up.

DEFERENCE TO AUTHORITY

When we are around people with more authority than us, we are much less likely to be the ones who take initiative to deal with a safety issue.  We refrain from doing what we believe we should, because we subtly perceive such action to be the responsibility of the “leader.”  It is a deeply-embedded and often non-conscious aversion to insubordination: When a non-routine decision needs to be made, it is to be made by the person with the highest position power.

PRODUCTION PRESSURE 

When we are under pressure to produce something in a limited amount of time, it does more than make us feel rushed.  It literally changes the way we perceive our own surroundings.  Things that might otherwise be perceived as risks that need to be stopped are either not noticed at all or are perceived as insignificant compared to the importance of getting things done. In addition to these four, there are other forces in employees’ production contexts that inhibit them when they should speak up.  If we're are going to get people to speak up more often, we need to move beyond “Stop Work Authority” and get over the assumption that motivating them will be enough.  We need to help employees understand what is inhibiting them in the moment, and then give them the skills to overcome these inhibitors so that they can do what they already believe is right - speak up to keep people safe.

Human Error and Complexity: Why your “safety world view” matters

Have you ever thought about or looked at pictures of your ancestors and realized, “I have that trait too!” Just like your traits are in large part determined by random combinations of genes from your ancestry, the history behind your safety world view is probably largely the product of chance - for example, whether you studied Behavioral Psychology or Human Factors in college, which influential authors’ views you were exposed to, who your first supervisor was, or whether you worked in the petroleum, construction or aeronautical industry. Our “Safety World View” is built over time and dramatically impacts how we think about, analyze and strive to prevent accidents.

Linear View - Human Error

Let’s briefly look at two views - Linear and Systemic - not because they are the only possible ones, but because they have had and are currently having the greatest impact on the world of safety. The Linear View is integral in what is sometimes referred to as the “Person Approach,” exemplified by traditional Behavior Based Safety (BBS) that grew out of the work of B.F. Skinner and the application of his research to Applied Behavioral Analysis and Behavior Modification. Whether we have thought of it or not, much of the industrial world is operating on this “linear” theoretical framework. We attempt to understand events by identifying and addressing a single cause (antecedent) or distinct set of causes, which elicit unsafe actions (behaviors) that lead to an incident (consequences). This view impacts both how we try to change unwanted behavior and how we go about investigating incidents. This behaviorally focused view naturally leads us to conclude in many cases that Human Error is, or can be, THE root cause of the incident. In fact, it is routinely touted that, “research shows that human error is the cause of more than 90 percent of incidents.” We are also conditioned and “cognitively biased” to find this linear model so appealing. I use the word “conditioned” because it explains a lot of what happens in our daily lives, where situations are relatively clean and simple…..so we naturally extend this way of thinking to more complex worlds/situations where it is perhaps less appropriate. Additionally, because we view accidents after the fact, the well documented phenomenon of “hindsight bias” leads us to linearly trace the cause back to an individual, and since behavior is the core of our model, we have a strong tendency to stop there. The assumption is that human error (unsafe act) is a conscious, “free will” decision and is therefore driven by psychological functions such as complacency, lack of motivation, carelessness or other negative attributes. This leads to the also well-documented phenomenon of the Fundamental Attribution Error, whereby we have a tendency to attribute failure on the part of others to negative personal qualities such as inattention, lack of motivation, etc., thus leading to the assignment of causation and blame. This assignment of blame may feel warranted and even satisfying, but does not necessarily deal with the real “antecedents” that triggered the unsafe behavior in the first place. As Sidney Dekker stated, “If your explanation of an accident still relies on unmotivated people, you have more work to do."

Systemic View - Complexity

In reality, most of us work in complex environments which involve multiple interacting factors and systems, and the linear view has a difficult time dealing with this complexity. James Reason (1997) convincingly argued for the complex nature of work environments with his “Swiss Cheese” model of complexity. In his view, accidents are the result of active failures at the “sharp end” (where the work is actually done) and “latent conditions,” which include many organizational decisions at the “blunt end” (higher management) of the work process. Because barriers fail, there are times when the active failures and latent conditions align, allowing for an incident to occur. More recently Hollnagel (2004) has argued that active failures are a normal part of complex workplaces because of the requirement for individuals to adapt their performance to the constantly changing environment and the pressure to balance production and safety. As a result, accidents “emerge” as this adaptation occurs (Hollnagel refers to this adaptive process as the “Efficiency Thoroughness Trade Off”) . Dekker (2006) has recently added to this view the idea that this adaptation is normal and even “locally rational” to the individual committing the active failure because he/she is responding to a context that may not be apparent to those observing performance in the moment or investigating a resulting incident. Focusing only on the active failure as the result of “human error” is missing the real reasons that it occurs at all. Rather, understanding the complex context that is eliciting the decision to behave in an “unsafe” manner will provide more meaningful information. It is much easier to engineer the context than it is to engineer the person. While a person is involved in almost all incidents in some manner, human error is seldom the “sufficient” cause of the incident because of the complexity of the environment in which it occurs. Attempting to explain and prevent incidents from a simple linear viewpoint will almost always leave out contributory (and often non-obvious) factors that drove the decision in the first place and thus led to the incident.

Why Does it Matter?

Thinking of human error as a normal and adaptive component of complex workplace environments leads to a different approach to preventing the incidents that can emerge out of those environments. It requies that we gain an understanding of the many and often surprising contextual factors that can lead to the active failure in the first place. If we are going to engineer safer workplaces, we must start with something that does not look like engineering at all - namely, candid, informed and skillful conversations with and among people throughout the organization. These conversations should focus on determining the contextual factors that are driving the unsafe actions in the first place. It is only with this information that we can effectively eliminate what James Reason called “latent conditions” that are creating the contexts that elicit the unsafe action in the first place. Additionally, this information should be used in the moment to eliminate active failures and also allowed to flow to decision makers at the “blunt end”, so that the system can be engineered to maximize safety. Your safety world view really does matter.

Safety Culture Shift: Three Basic Steps

In the world of safety, culture is a big deal. In one way or another, culture helps to shape nearly everything that happens within an organization - from shortcuts taken by shift workers to budget cuts made by managers. As important as it is, though, it seems equally as confusing and intractable. Culture appears to emerge as an unexpected by-product of organizational minutia: A brief comment made by a manager, misunderstood by direct-reports, propagated during water cooler conversations, and compounded with otherwise unrelated management decisions to downsize, outsource, reassign, promote, terminate… Safety culture can either grow wild and unmanaged - unpredictably influencing employee performance and elevating risk - or it can be understood and deliberately shaped to ensure that employees uphold the organization’s safety values.

Pin it Down

The trick is to pin it down. A conveniently simple way of capturing the idea of culture is to say that it is the “taken-for-granted way of doing things around here;” but even this is not enough. If we can understand the mechanics that drive culture, we will be better positioned to shift it in support of safety. The good news is that, while presenting itself as extraordinarily complicated, culture is remarkably ordinary at its core. It is just the collective result of our brains doing what they always do.

Our Brains at Work

Recall the first time that you drove a car. While you might have found it exhilarating, it was also stressful and exhausting. Recall how unfamiliar everything felt and how fast everything seemed to move around you. Coming to a four-way stop for the first time, your mind was racing to figure out when and how hard to press the brake pedal, where the front of the car should stop relative to the stop sign, how long you should wait before accelerating, which cars at the intersection had the right-of-way, etc. While we might make mistakes in situations like this, we should not overlook just how amazing it is that our brains can take in such a vast amount of unfamiliar information and, in a near flash, come up with an appropriate course of action. We can give credit to the brain’s “executive system” for this.

Executive or Automatic?

But this is not all that our brains do. Because the executive system has its limitations - it can only handle a small number of challenges at a time, and appears to consume an inordinate amount of our body’s energy in doing so - we would be in bad shape if we had to go through the same elaborate and stressful mental process for the rest of our lives while driving. Fortunately, our brains also “automate” the efforts that work for us. Now, when you approach a four-way-stop, your brain is free to continue thinking about what you need to pick up from the store before going home. When we come up with a way of doing something that works - even elaborate processes - our brains hand it over to an “automatic system.” This automatic system drives our future actions and decisions when we find ourselves in similar circumstances, without pestering the executive system to come up with an appropriate course of action.

Why it Matters

What does driving have to do with culture? Whatever context we find ourselves in - whether it is a four-way-stop or a pre-job planning meeting - our brains take in the range of relevant information, come up with an effective course of action, try it out and, when it works, automate it as “the way to do things in this situation.”

For Example

Let’s imagine that a young employee leaves new-hire orientation with a clear understanding of the organization’s safety policies and operating procedures. At that moment, assuming that he wants to succeed within the organization, he believes that proactively contributing during a pre-job planning meeting will lead to recognition and professional success.

Unfortunately, at many companies, the actual ‘production’ context is quite different than the ‘new-hire orientation’ context. There are hurried supervisors, disinterested ‘old timers’, impending deadlines and too little time, and what seemed like the right course of action during orientation now looks like a sure-fire way to get ostracized and opposed. His brain’s “executive system” quickly determines that staying quiet and “pencil whipping” the pre-job planning form like everyone else is a better course of action; and in no time, our hapless new hire is doing so automatically - without thinking twice about whether it is the right thing to do.

Changing Culture

If culture is the collective result of brains figuring out how to thrive in a given context, then changing culture comes down to changing context - changing the “rules for success.” If you learned to drive in the United States but find yourself at an intersection in England, your automated way of driving will likely get you into an accident. When the context changes, the executive system has to wake up, find a new way to succeed given the details of the new context, and then automate that for the future.

How does this translate to changing a safety culture? It means that, to change safety culture, we need to change the context that employees work in so that working safely and prioritizing safety when making decisions leads to success.

Three Basic Steps:

Step 1

Identify the “taken-for-granted” behaviors that you want employees to adopt. Do you want employees to report all incidents and near-misses? Do you want managers to approve budget for safety-critical expenditures?

This exercise amounts to defining your safety culture. Avoid the common mistake of falling back on vague, safety-oriented value statements. If you aren’t specific here, you will not have a solid foundation for the next two steps.

Step 2

Analyze employees’ contexts to see what is currently inhibiting or competing against these targeted, taken-for-granted behaviors. Are shift workers criticized or blamed by their supervisors for near-misses? Are the managers who cut cost by cutting corners also the ones being promoted?

Be sure to look at the entire context. Often times, factors like physical layout, reporting structure or incentive programs play a critical role in inhibiting these desired, taken-for-granted behaviors.

Step 3

Change the context so that, when employees exhibit the desired behaviors that you identified in Step 1, they are more likely to thrive within the organization.

“Thriving” means that employees receive recognition, satisfy the expectations of their superiors, avoid resistance and alienation, achieve their professional goals, and avoid conflicting demands for their time and energy, among other things.

Give It a Try

Shifting culture comes down to strategically changing the context that people find themselves in.  Give it a try and you might find that it is easier than you expected. You might even consider trying it at home. Start at Step 1; pick one simple "taken-for-granted" behavior and see if you can get people to automate this behavior by changing their context. If you continue the experiment and create a stable working context that consistently encourages safe performance, working safely will eventually become "how people do things around here."

Effective Organizations Identify Meaningful Measures and Provide Timely Feedback

There is an old saying in management circles that “you won’t predictably get what you don’t predictably measure”. Likewise, “you can’t measure what you don’t define.” Effective organizations do both.....they define and measure. In Effective Organization Characteristic #1, we discussed how effective organizations communicate not only mission, goals and values, but also performance and results expectations as a means of providing a clear definition of what results are expected. This definition and communication of expectations occurs throughout the organization, from top management down through the front lines.

Individuals must understand how their performance fits into the overall performance of the organization and what specific results are required for that to occur. This requires that managers and supervisors make sure that their employees understand those expectations through regular and effective dialogue. While definition of expectations is absolutely required for effectiveness, measurement of and feedback concerning performance is also critical for success of both the individual and the organization.

Measurement

Measurements can be either qualitative (no numerical value) or quantitative (based on numerical value). Most organizations use both, but those that are highly effective focus decision making on quantitative measurements of performance. They identify particular measurements that are associated with achievement of their objectives and monitor those measurements over time. These measurements are often referred to as “Key Performance Indicators (KPI)” because they are central (Key) to evaluating the effectiveness of various efforts, both at the individual and organizational levels.

Leading & Lagging Indicators

Performance measurement can, and should focus not only on the output (results), but also on the process of achieving that output. Effective organizations actually focus more on what are referred to as “Leading Indicators” associated with the process than they do on “Lagging Indicators” associated with the output. They are obviously interested in final results but they understand that the success of the process is directly related to the success of the output.

For example, when attempting to impact safety performance, effective organizations measure Leading Indicators such as frequency of engaging in specific unsafe behaviors and frequency of intervention by another person when observing a person engage in an unsafe action. These Leading Indicators are related to Lagging Indicators such as Total Recordable Incident Rate (TRIR).

These effective organizations find that reducing unsafe behavior through intervention by another person leads to the desired reduction of TRIR and thus are better measurements of safety performance than TRIR. The key is to evaluate the result desired and the process for achieving that result with the use of KPI’s that are meaningfully associated with that result from both a leading and lagging perspective.

Feedback

If no one knows the results of the measurement, then the measurement will have no effect on future performance. It would be like trying to adjust your speed in an automobile to the legal posted speed without looking at the speedometer. You might get close but you would probably not be as close (effective) in driving the speed limit as you would if you monitored your speed quantitatively.

Effective organizations identify methods for allowing employees to get regular and predictable feedback on performance (KPI’s) for both personal and organizational performance. In Effective Organization Characteristic #4, we discussed how effective organizations hold people accountable for results in the sense of “accounting” for and understanding why those results were achieved. This accounting requires both measurement of performance and feedback about the results of that measurement.

Feedback, as with accountability, does not require the application of a consequence (either positive or negative), however a consequence may be associated with the feedback as appropriate. For example, when you monitor your speedometer while driving there is not always a consequence unless you happen to be speeding and a police officer is also monitoring your speed. Your measurement (monitoring) may, however, result in a correction to the legal speed prior to a ticket.

What's the point?

This is what effective organizations do. They monitor performance at all levels and provide appropriate, quantitative, predictable feedback that will lead to the best performance and results possible.

Why Rule Breaking Makes Sense

Complexity & Rationality Why do employees decide to break the rules?  Do it their way?  Resist change?  It doesn’t make any sense!

It can be frustrating, and often perplexing, when employees fail to adhere to company policies and procedures, especially when those policies and procedures are in their best interest. There is a useful way to think about this issue: What employees do makes sense...to them; but the complexity of work environments makes it hard to understand why it makes sense to them.

We live and work in complex environments. It helps to think of our environments as systems with overlapping and interacting components - including people, things, rules, values, etc. - which are, in turn, complex sub-systems. One of the principles of complex systems is that the “people” component tends to respond only to the limited information that they are presented with locally. We make decisions based on our knowledge of what makes sense at the local level, which is called “local rationality”.

The policies and procedures contained in the corporate manual are only influential if they are brought to bear on the daily lives of people in the workplace. If those policies and procedures only exist in the manual and are not made a part of the local workplace, then they don’t exist in reality and will not have an impact on performance. They will lack influence.

Companies have policies and procedures for a reason - to create good, reliable results; so it is the responsibility of supervisors to bring those policies and procedures to life in the workplace. By intentionally incorporating formal policies and procedures into the “local” work environments of employees - through conversation, feedback, modeling, etc. - supervisors make it “rational” to follow the rules.

Effective Organizations Tolerate Acceptable Risk and Learn from Success & Failure in an Attempt to Be Innovative

Risk is a natural part of life. Just about every decision that we make has some level of risk associated with it. Some risk is inconsequential, such as the decision regarding the color of the shirt that you decided to wear this morning. On the other hand, some risk can have significant impact on you and those with whom you associate, e.g., whether you ask a specific person to marry you or not. We start taking risks from a very early age and if we didn’t, we would probably never learn how to walk! Without some level of risk, things would never change or improve and effective leaders understand this.

Do You Value Initiative?

We often ask our Performance Management course participants whether they would rather have employees who show initiative or those who just do what they were told to do. They always respond with “I want employees who show initiative”.

But initiative is a form of risk-taking because the decision that the employee makes could be wrong and negatively impact desired results.

Clarify "Appropriate Risk"

Effective leaders are careful to clarify what they mean by “appropriate” risk taking and consistently encourage both initiative and innovative thinking while helping employees understand what is appropriate by helping them understand the potential results of both failure and success.

Understanding Context

We work with many organizations to help them improve performance and especially safety related performance. We know that the decisions that people make, both safety and non-safety related are driven by their understanding of contextual factors including themselves, others, the environment and the organizational systems.

Local Rationality

We have discussed before in other newsletters and articles the concept of “local rationality” in that our decisions make sense to us given our interpretation of the context and the associated risk. For example, we may make a decision to forego wearing safety glasses because we are being rushed by our supervisor to get the job done quickly and safety glasses are not readily available. We accept the risk of possible injury because the risk of displeasing the boss is seen as greater in the moment (local rationality).

Creating a New Context

Effective leaders attempt to create contexts that control factors (pressure to rush) that can lead to poor decision making (not wearing safety glasses) while increasing the chances of effective and even innovative decision making (coming up with a plan to both wear safety glasses and get the job done quickly).

They do this by encouraging active dialogue about the workplace (context) and ways to improve that context to encourage employees to take initiative (appropriate risk taking).

Contextual Analysis

Effective Leaders evaluate why both success and failure occur within the organizational context and do so without assuming poor motivation as a starting point. (See May newsletter for further discussion of contextual analysis and accountability).

What's the point?

Effective Organizations are filled with individuals who make good decisions about acceptable risk (initiative) because their leaders have created an organizational environment (context) that assists in that decision making.

A Best Boss Is a Good Decision Maker & Deals Effectively with Conflict

Over the course of 2012, the world-wide media has interviewed, polled, analyzed, and dissected countless opinions and agendas with respect to the characteristics and qualifications, both desired from and previously demonstrated by, the various candidates for global leadership from Cairo to Washington and Athens to Beijing.During this same time, we, here at The RAD Group, have been broadcasting our own analysis of the characteristics we hope to see in today's leaders. Our Best Boss series has had one simple agenda and we hope you have found it valuable.

Our analysis will impact the results you are seeing wether you are a newly elected Prime Minister, a CEO, a night shift supervisor, or mom or dad. We believe that you and the other leaders in your organization can improve performance by listening to what your employees have been telling us over the last 20+ years. We asked thousands of participants in our performance management classes to describe the best boss they ever had. Though our polls are not closed, we feel confident to announce the results.

A "Best Boss":

#1 -- is a good communicator #2 -- holds himself and others accountable for results #3 -- enables success #4 -- motivates others #5 -- cares about the success of others #6 -- is honest and trustworthy #7 -- shows trust by delegating effectively #8 -- is fair and consistent #9 -- competent and knowledgeable #10 -- rewards / recognizes success #11 -- leads by example #12 -- is loyal to employees #13 -- is friendly #14 -- is a good problem solver #15 -- is a team builder #16 -- is flexible and willing to change when necessary #17 -- is a good planner / organizer and #18 -- shows respect to others.

This month we close out the series with a look at how a Best Boss:

#19 -- is a good decision maker and #20 -- deals effectively with conflict.

A Good Decision Maker

Scores of books and articles have been written on the best way to make decisions and many of the processes described include valuable assistance for decision makers. In actuality, we are all decision makers and make decisions many times each day. Some decisions are just more important than others, in that they can lead to more significant (both positive and negative) consequences.

Understand the Facts The key to good decision making is a complete (or as complete as time and information allow) understanding of the facts and potential consequences of each possible decision. Without question it involves an examination of any and all ethical consequences of the decision. For simple decisions, little or no input from others may be needed. These are the routine daily decisions that don’t require a lot of “buy-in” for execution to occur. But complex, high impact decisions are different.

As we have said several times before in previous newsletters, getting input from team members and other experts is invaluable when gathering facts, understanding consequences and making the final decision.

Recruit Help Best Bosses understand that they can’t have all of the information, knowledge and experience needed to make all important decisions, so they recruit help. They treat important decision making as a team-based problem solving exercise. Once they have gathered the relevant information, they then “pull the trigger”, make the decision and then stand behind both the decision and the team.

Prepare for the Next Decision If success follows a decision, Best Bosses share the “glory” with the team and if “failure” follows, they accept responsibility and go to work determining why the failure occurred so that it won’t happen again. In other words, they engage in team-based problem solving to correct the failure. Regardless of the outcome, how the boss responds to the results of a decision making process will dramatically impact the ability to recruit help next time, the willingness of recruits to communicate facts and consequences, and the confidence with which future decisions will be executed.

Deals Effectively with Conflict

Conflict is a naturally occurring issue anytime you have people working or living together. We define conflict as unresolved differences of opinion or perceptions regarding some issue. Conflict by definition is required for improvement and innovation to occur and is completely healthy if managed correctly.

Foster Positive Conflict Best Bosses understand the value of conflict and foster opportunities for conflict-based conversation that leads to creative improvement. Best Bosses also know that conflict can lead to reduced productivity, quality, safety, etc. and work to keep unhealthy conflict to a minimum.

Collaboration and Communication Best Bosses keep unhealthy conflict to a minimum by understanding that the best way to resolve conflict is through collaboration. Collaboration requires an understanding of the problem solving process and how to communicate by listening effectively before any decision concerning action is taken. All parties must have the opportunity to “state their positions”, but must also be “respectful” enough to listen to the other person to gain a complete understanding of their position. Best Bosses create an environment of respectful openness where disagreement is encouraged and the skills to collaboratively resolve conflict are learned by every team member.

Best Boss Bottom Line - Series Finale

We have created a name for best bosses; we call them “Facilitative Relational Leaders”. Facilitation is defined as the accomplishment of results by making it easier for other people to express their views and achieve their objectives. Relational is demonstrating respect and care for others. The skills and characteristics identified in our research are the same skills needed to facilitate and build relationships. You may have noticed that the Best Boss skills/characteristics tend to tie together and demonstration of one involves application of others. Best Bosses understand this and continuously attempt to improve in the use of each of the skills that we have been discussing. Maybe it is time for you to evaluate or re-evaluate where you stand.

A Best Boss Is a Good Problem Solver & Team Builder

Through the first nine installments of this series, we have seen that a 'Best Boss': #1 -- is a good communicator #2 -- holds himself and others accountable for results #3 -- enables success #4 -- motivates others #5 -- cares about the success of others #6 -- is honest and trustworthy #7 -- shows trust by delegating effectively #8 -- is fair and consistent #9 -- competent and knowledgeable #10 -- rewards / recognizes success #11 -- leads by example #12 -- is loyal to employees and #13 -- is friendly.

This month we will examine how a Best Boss:

#14 -- is a good problem solver and

#15 -- is a team builder.

You may have heard it said that “if this job was easy, everyone would be doing it.” It’s true. In reality, supervision, management, leadership and other roles defined by the ability to produce desired results through the efforts of others is genuinely difficult. The job of supervision is a minefield full of problems and people. The corporate battlefield is littered with human resource casualties and lost productivity and profits from the scores of “supervisors” that just weren’t Best Bosses.

The best bosses, the ones described in our research, thrive in complex and challenging environments and are often described by those they have influenced over their careers as good problem solvers and good team builders. These two characteristics clearly work in tandem. A problem solved by “Throwing the team under the bus” does not qualify for best boss status. Nor does building a great team of lifelong friends that consistently fail to solve the problems they face. These two characteristics go together.

Good Problem Solver

Best Bosses are not only good at solving problems, but they are good at teaching their employees how to solve problems. They understand that employee’s who can recognize problems and then bring thought-out solutions to the table are much more likely to take initiative and exhibit creativity in other ways.

While not all supervisors use/teach the same problem solving techniques, most keep it simple and focus on no more that 5-steps.

These 5-steps usually include:

Problem Identification

Knowing that you have a problem is the first step and this involves the monitoring of results relative to standards, listening to coworkers, clients, etc. In other words, it involves the identification of “pain”.

Problem Exploration

Best Bosses know that problems can arise for a multitude of reasons and make sure that they have evaluated each possibility before deciding on a solution. They also involve their team members in this evaluation because it both teaches and increases the chances that the “real reason(s)” will be identified.

Objective Setting

Best bosses know that well stated objectives will increase the chances that an effective plan will be created. They therefore ensure that every objective is Specific, Measurable, Achievable, Relevant and Time-bound (SMART).

Action Plan Development

As important as development of a workable plans is, ownership of the plan is equally important. Best bosses involve the appropriate team members in plan development to both create the best plan possible and to increase the willingness of the team to implement the plan effectively.

Measurement and Correction (as necessary)

If the objective is stated correctly, then measurement is simply the evaluation of the results against the stated objective.

If failure occurs, then best bosses avoid blame and begin the problem solving process all over again to make sure that each step was completed successfully.

While best bosses are skillful at solving problems, they are equally skillful at involving team members in the solution process.

Team Builder

Best bosses know that success is more a function of team work than it is individual skill, so they work just as hard to develop team work as they do to develop individual skills.

Team building first requires bosses to assess their team’s interaction so that they can determine what if anything is creating less than desired teamwork. There are five critical issues related to teamwork that all best bosses evaluate on a regular basis. The specific team building plan will be driven by this evaluation.

How well do the team members get along on an interpersonal level?

• It is not necessary that team member become best friends, but civility and courtesy are a requirement for having a successful team.
• Best bosses are quick to identify any conflict within the team, determine the cause(s) of that conflict, and address those causes effectively.

Do team members work together to accomplish tasks or do they compete with one another?

• While competition is appropriate at some levels, it is never appropriate within a team.
• Competition leads to someone winning at the expense of another team member and this almost always leads to the desire to get even.
• Best bosses know this and create an environment where teamwork is recognized and competition is eliminated or at least minimized.
• Best bosses also know that their attention or lack of it can lead to competition, so they make sure that attention and recognition is provided equally within the team and is not contingent on being better than each other.

Do they share information with each other?

• Failure to share information within a team can be the result of several issues, only one of which is keeping information to increase power or position.
• Much of the time failure to share information is simply due to forgetting to do so, not realizing that the information is needed by others, or not having the opportunity to do so.
• Best bosses make sure that all team members understand their role in information sharing and create an environment where information hoarding is not allowed and certainly not reinforced.

Do they provide support for one another when under pressure to get the job done?

• Best bosses know that high levels of stress negatively impacts an individual’s ability to perform and also reduces the desire to work together on issues.
• They also know that they have a lot of influence on the stress level within the team by the way that they manage time and stress for both themselves and for their team members.
• Best bosses also know that increasing skills through training can help reduce the negative impact of stress on a team, therefore they spend time helping employees develop the skills needed to respond more effectively when stress increases.

Do they focus on solving problems or on blaming each other when problems arise?

• While blame seems to be a natural human response when problems arise, it is really a response to the prediction that the person will receive blame him/herself.
• Best Bosses understand that if they focus on “why” the failure occurred rather than “who” failed they will then avoid contributing to the development of a blame culture within the team.
• Best bosses understand that if they don’t pass blame, they will reduce the need for blame to occur within the team and this will lead to the development of better problem solutions.

Best bosses know that failure in one or more of the areas above can lead to decreased teamwork, decreased productivity and failure to achieve results.

Best Boss Bottom Line

Problems don’t solve themselves nor do teams build themselves, rather it takes someone in charge to see to these efforts. Even more so, it takes a Best Boss to see to these efforts sustainably. Fail to both deliberately solve problems and intentionally build your team and you might have a short life on the corporate battlefield. Strive instead to build a team capable of tackling obstacles effectively using all of the resources they collectively bring to the fight.

Complexity and Local Rationality

Why do people - like employees and children - decide to break the rules?  Do it their way?  Resist change?  It doesn’t make any sense!  Or does it? It can be frustrating and often perplexing when employees fail to adhere to company policies and procedures, especially when those policies and procedures are in the employees’ best interest. Filing a required document can legally protect managers, but they don’t file it.  Locking out a machine that is being serviced can keep a technician safe from pain, injury and even death, but he regularly services the machine without locking it out.  Your children “know” the rules, but sometimes break them anyway. There is a useful way to think about this issue:  What employees and children do makes sense...to them.

We live, work, play and make decisions in complex environments. It helps to think of our environments as systems with overlapping and interacting components - including people, things, rules, values, knowledge, etc. - which are, in turn, complex sub-systems. One of the principles of complex systems is that the “people” component tends to be driven by the limited information that is available to and impressed upon those people within their local contexts. We make decisions based on our knowledge of what makes sense at the local level, at any given moment.  We call this the principle of “local rationality.”  In other words, our decisions are rational to us because they are based on the information available within the local context (which includes knowledge residing in our brains) at a particular point in time.

As supervisors and parents, we observe behavior that is driven by the principle of local rationality, but we only have limited information about what factors the individual is using to make their decision.  Why did it make sense to the employee to do such a dangerous thing?  Why did it make sense to the child to break the curfew rule?  After all, they know the rules and we have rules to make it clear how they should behave, don’t we?

Rules are only one component of the complex environments that we live and work in.  There are also pressures from other people - including superiors, peers and even you - to make a decision to act in a certain way.  Knowledge of past successes and failures, availability of resources needed to be successful, time pressures, workplace layout and numerous other kinds of factors make it ‘make sense’ for the person. Consider for a moment the last thing you saw a person do that “irked” you.  What kinds of factors could have led the person to do what he or she did?  Why would it have made sense...or did you assume it was because the person was lazy, rude, selfish, or in some other way had poor personal motivation?

As humans, we have a tendency to assume that people do what they do because of personal motivation , and then we treat their “failures” as an opportunity to motivate them to change and make better decisions in the future.  Research shows, however, that actions are often the result of the person’s evaluation of complex input from the environment and may have nothing to do with personal motivation.  For example, we tell employees to work safely, but at the same time push them for productivity, sometimes beyond their ability. The trade-off for the employee is to “cut corners” to be productive because he thinks in the moment that safety is really not at risk and showing you how productive he can be is what is really important.  Your teenager decides to come home late because her date had a couple of drinks and she didn’t trust him to drive safely...and her cell phone was dead, so she didn’t call. It makes sense in the moment, given the information that she had at her disposal.  It doesn’t make sense to you while you sit at home worried sick and imagining all kinds of terrible things.  It doesn’t make sense because you aren’t making decisions in her context!

As parents and supervisors, we need to ask a simple question before we punish undesired behavior: “Why did making that decision make sense to the person making it?”  Why was the decision “locally rational”? If we find out it was motivation, then we can deal with that; but if it is some other factor or combination of factors, then simply motivating won’t work. Look for which contextual factors actually are at play in the decision before you try to change the person’s behavior, and you will be much more successful at creating sustained change.