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Tom Garcia has indicated he is President and Senior Consultant of Culture Dynamics, Inc.

Tom GarciaTom Garcia

Navy Fighter Pilot -22 yrsNavy Fighter Pilot -22 yrsCommercial Airline Pilot -14 yrsCommercial Airline Pilot -14 yrsNaval Safety Center Consultant Naval Safety Center Consultant

& Analyst& Analyst

MD80

757

767

F100

777

High Reliability Organization High Reliability Organization (HRO)(HRO)

Organizations which perform complex Organizations which perform complex tasks in demanding environments tasks in demanding environments

with very low rates of error.with very low rates of error.Every study done of HRO’s has Every study done of HRO’s has concluded that culture is the key concluded that culture is the key

element.element.

CultureCulture

The learned and shared assumptions, The learned and shared assumptions, beliefs, values, and behavior of an beliefs, values, and behavior of an

organization. organization.

Keys to Understanding Culture Keys to Understanding Culture

Stable – The deepest, most driving Stable – The deepest, most driving forces of your culture are the most forces of your culture are the most stable. If you want to manage them, stable. If you want to manage them, you must understand them.you must understand them.

Hidden – Based on assumptions.Hidden – Based on assumptions.

0

10

20

30

40

50

60

50 60 70 80 90 00 01 03

Angled decks

Aviation Safety Center

Naval Aviation Maintenance

Program (NAMP), 1959

RAG concept initiated

NATOPS Program, 1961

Squadron Safety program

System Safety Designated Aircraft

ACT

ORM

Naval Aviation Mishap TrendFY50-03

RateRate

776 aircraftdestroyed in

1954

28 aircraftdestroyed in

2003

Culture Workshop

Patient Safety?Patient Safety?

HRO Lessons LearnedHRO Lessons Learned

Learn from HRO’s instead of the Learn from HRO’s instead of the hard way and become an HRO hard way and become an HRO quicker.quicker.

Patient Safety and Developing a Patient Safety and Developing a Culture of SafetyCulture of Safety

HRO key to success is HRO key to success is CultureCulture HRO’s have greatHRO’s have great safety safety recordsrecords

Healthcare Healthcare HRO HRO == Culture of Safety Culture of Safety

Healthcare Transition to High Healthcare Transition to High ReliabilityReliability

Develop the cultural traits of a HRO.Develop the cultural traits of a HRO. How?How?

Maintain HRO status.Maintain HRO status. How?How?

Naval Aviation 1996Naval Aviation 1996

4 Serious and costly mishaps4 Serious and costly mishapsAll preventableAll preventableUnderlying problems were Underlying problems were

dysfunctional culturesdysfunctional cultures

Naval AviationNaval Aviation

Already has the cultural traits of a Already has the cultural traits of a HRO.HRO.

In order to maintain HRO status.In order to maintain HRO status. Prevent dysfunctional cultures from developing.Prevent dysfunctional cultures from developing. Eliminate dysfunctional cultures that do develop.Eliminate dysfunctional cultures that do develop.

Dysfunctional CulturesDysfunctional Cultures

Kotter and Heskett, Harvard Business Kotter and Heskett, Harvard Business School professors, spent 4 years studying School professors, spent 4 years studying over 200 large U.S. companies.over 200 large U.S. companies.

dysfunctional cultures “…are not rare; dysfunctional cultures “…are not rare; they develop easily, even in firms full of they develop easily, even in firms full of reasonable and intelligent people.” reasonable and intelligent people.”

Dysfunctional CulturesDysfunctional Cultures

NASA - Columbia Accident NASA - Columbia Accident Investigation Board Report Investigation Board Report

““Cultural traits and organizational Cultural traits and organizational practices detrimental to safety were practices detrimental to safety were allowed to develop.”allowed to develop.”

Dysfunctional CulturesDysfunctional Cultures

No one is immune.No one is immune. The best safety program in the world The best safety program in the world

can be undermined by a dysfunctional can be undermined by a dysfunctional culture.culture.

Great safety programs do not guarantee Great safety programs do not guarantee a culture of safety!a culture of safety!

Naval Aviation 1996Naval Aviation 1996

Implements culture assessment Implements culture assessment programprogram

Two parts:Two parts: Climate surveyClimate survey Culture assessmentCulture assessment

March 2002 – March 2004

93% of Class A (serious)Mishaps occurred in squadrons not participating in the SafetyCulture Assessment Program.The program is now mandatory.

Source: Naval Safety Center Approach magazine Mar-Apr 2004

Naval AviationNaval Aviation

$1.1 billion saved over $1.1 billion saved over

5 years by assessing and 5 years by assessing and improving cultureimproving cultureLtCol(Ret) Rick ‘Spike’ Boyer, former Director of Aviation Safety, U. S. Naval Safety Center

Naval AviationNaval Aviation

A HRO found that by managing A HRO found that by managing cultureculture Reduced error even furtherReduced error even further More lives savedMore lives saved More money savedMore money saved Improved operational efficiency, not just safetyImproved operational efficiency, not just safety Eliminated unnecessary training!Eliminated unnecessary training!

Unnecessary TrainingUnnecessary Training

Because culture assessments find the true Because culture assessments find the true underlying problems, they highlight the underlying problems, they highlight the effectiveness of current programs and the effectiveness of current programs and the potential of new programs.potential of new programs.

Some existing programs had no real Some existing programs had no real benefit.benefit.

New programs that initially New programs that initially lookedlooked good, good, now no longer did.now no longer did.

Naval Aviation Lessons LearnedNaval Aviation Lessons Learned 50 years of trial and error. Some 50 years of trial and error. Some

programs worked, many didn’t. But programs worked, many didn’t. But now with culture assessments they now with culture assessments they find the underlying problems and find the underlying problems and safety program trial and error is a safety program trial and error is a thing of the past.thing of the past.

Great safety programs don’t Great safety programs don’t guarantee a culture of safety. Culture guarantee a culture of safety. Culture must actively be managed.must actively be managed.

Naval Aviation Lessons LearnedNaval Aviation Lessons Learned

Technology improvements must be Technology improvements must be accompanied by cultural improvements to accompanied by cultural improvements to maximize the benefits.maximize the benefits.

It is easier to manage culture to improve It is easier to manage culture to improve it than to fight it to change it.it than to fight it to change it.

Working with and improving culture Working with and improving culture pays!pays!

Naval Aviation Culture AssessmentNaval Aviation Culture Assessment

Two parts:Two parts: Climate surveyClimate survey Culture assessmentCulture assessment

Culture vs. Climate?Culture vs. Climate?

Climate = organizational conditionsClimate = organizational conditions ObservableObservable What we see and hearWhat we see and hear Can change from day to dayCan change from day to day

Purpose of a SurveyPurpose of a Survey

A survey is a benchmarking tool used A survey is a benchmarking tool used to indicate to indicate potentialpotential problems. What problems. What it gives you are symptoms. You still it gives you are symptoms. You still need to find the problems.need to find the problems.

Healthcare Climate SurveyHealthcare Climate SurveySafety climate surveys were Safety climate surveys were conducted at 15 hospitals and conducted at 15 hospitals and from naval aviators from 226 from naval aviators from 226 squadrons. squadrons.

Differences in Safety Climate Between Hospital Personnel and Naval Aviators, Human Factors,  Volume 45, 2, Summer 2003 Stanford University & &VA Palo Alto

Survey ResultsSurvey Results

QuestionQuestion

##

QuestionQuestion NavyNavy

All All Hospital Hospital

PersonnelPersonnel

High High Hazard Hazard DomainDomain

22

Loss of experienced personnel has Loss of experienced personnel has negatively affected my ability to negatively affected my ability to provide high quality patient careprovide high quality patient care

18.518.5 55.155.1 59.459.4

1717

Staff are provided with the Staff are provided with the necessary training to safely necessary training to safely provide patient care provide patient care

2.22.2 11.311.3 12.912.9

Differences in Safety Climate Between Hospital Personnel and Naval Aviators, Human Factors,  Volume 45, 2, Summer 2003

Survey ResultsSurvey Results

QuestionQuestion

##

QuestionQuestion NavyNavy

All All Hospital Hospital

PersonnelPersonnel

High High Hazard Hazard DomainDomain

2020

Senior management has a clear Senior management has a clear picture of the risks associated with picture of the risks associated with patient care patient care

1.91.9 21.921.9 30.630.6

44

Senior management does not Senior management does not hesitate to temporarily restrict hesitate to temporarily restrict clinicians who are under high clinicians who are under high personal stress personal stress

7.87.8 37.137.1 45.445.4

Differences in Safety Climate Between Hospital Personnel and Naval Aviators, Human Factors,  Volume 45, 2, Summer 2003

Survey ResultsSurvey Results

Where do the most significant Where do the most significant problematic responses point?problematic responses point?

Staffing Staffing Policy Policy

ManagementManagement

Theseus EquationTheseus Equation™™ for Error for Error

Error Rate =Error Rate =

ClimateClimate + Culture+ Culture

Error rate drops/increases Error rate drops/increases with the sum of with the sum of

improvement/dysfunction improvement/dysfunction of climate & cultureof climate & culture

StructureStructure

Staffing Staffing Policy Policy ManagementManagement

AssumptionsAssumptions

BeliefsBeliefs

ValuesValues

PerceptionsPerceptions

TeamworkTeamwork

MoralMoral

Survey ResultsSurvey Results

Will new safety programs and training Will new safety programs and training improve?:improve?: StaffingStaffing Policy Policy ManagementManagement

Are there actual staffing, policy and Are there actual staffing, policy and management problems or only misperceptions management problems or only misperceptions of them? And what sort of additional of them? And what sort of additional symptoms are these issues causing?symptoms are these issues causing?Diagnosis of these symptoms is needed.Diagnosis of these symptoms is needed.

Culture Assessment?Culture Assessment?

Develop the cultural traits of a HRO.Develop the cultural traits of a HRO. YesYes

Maintain HRO status.Maintain HRO status. YesYes

Culture Assessment and its Role in Culture Assessment and its Role in Developing High ReliabilityDeveloping High Reliability

The Key Element in HRO is The Key Element in HRO is CultureCulture.. Why?Why?

““Complex tasks in a demanding environment.”Complex tasks in a demanding environment.” In the case of aircraft carrier ops, the observed In the case of aircraft carrier ops, the observed

conditions and environment initially confused conditions and environment initially confused researchers as to why the error rate was not higher.researchers as to why the error rate was not higher.

Aircraft carrier staffing example.Aircraft carrier staffing example.

Culture Assessment and Developing Culture Assessment and Developing High ReliabilityHigh Reliability

Researchers discovered that it was the culture of Researchers discovered that it was the culture of the organization that overcame the “organizational the organization that overcame the “organizational climate” limitations and barriers.climate” limitations and barriers.

““We have been struck by the degree to which a set We have been struck by the degree to which a set of highly unusual formal and informal rules and of highly unusual formal and informal rules and relationships are taken for granted, implicitly and relationships are taken for granted, implicitly and almost unconsciously incorporated into the almost unconsciously incorporated into the organizational structure of the operational Navy.”organizational structure of the operational Navy.”

The Self-Designing High-Reliability Organization: Aircraft Carrier Flight The Self-Designing High-Reliability Organization: Aircraft Carrier Flight Operations at Sea Operations at Sea Gene I. Gene I. RochlinRochlin, , Todd R. La PorteTodd R. La Porte, and , and KarleneKarlene H. Roberts H. Roberts

Culture Assessment and Developing Culture Assessment and Developing High ReliabilityHigh Reliability

So, a process of accurately assessing, managing So, a process of accurately assessing, managing and improving culture will greatly improve any and improving culture will greatly improve any organization’s transition to high reliability.organization’s transition to high reliability.

BecauseBecause – Culture is so important to that – Culture is so important to that transition.transition.

Culture Assessment - Developing Culture Assessment - Developing and Maintaining a High Reliability and Maintaining a High Reliability

CultureCulture

Think of Think of cultureculture as a as a patientpatient..

How do we improve and maintain the How do we improve and maintain the health of our patient?health of our patient?

Culture as Our PatientCulture as Our Patient

First step is to First step is to Diagnose.Diagnose. We define the We define the current state of health.current state of health.

Second step is to treat as necessary.Second step is to treat as necessary.

You can’t improve or treat an unknown You can’t improve or treat an unknown therefore a thorough and accurate therefore a thorough and accurate

diagnosis leads to accurate treatment.diagnosis leads to accurate treatment.

Keys Elements That Exist and Must Keys Elements That Exist and Must be Developed in a HRObe Developed in a HRO

Vision/MissionVision/Mission

Decision Making ProcessDecision Making Process

Learning OrganizationLearning Organization

RedundancyRedundancy

Culture Assessment & HRO KeysCulture Assessment & HRO Keys Vision/MissionVision/Mission

Are they understood, shared and realistic?Are they understood, shared and realistic? Decision Making ProcessDecision Making Process

What Barriers exist? Standardization?What Barriers exist? Standardization? Learning OrganizationLearning Organization

Is error reporting working?Is error reporting working? RedundancyRedundancy

Is it being utilized properly?Is it being utilized properly?

Culture of SafetyCulture of Safety

What are the keys?What are the keys? Can CA help?Can CA help?

Culture of Safety Key Culture of Safety Key CharacteristicsCharacteristics

StandardizationStandardization Leadership CommitmentLeadership Commitment Open CommunicationOpen Communication Absence of FearAbsence of Fear Best PracticesBest Practices

Culture Assessment & Culture of Culture Assessment & Culture of SafetySafety

StandardizationStandardization

Define and solicit for improvementDefine and solicit for improvement Leadership CommitmentLeadership Commitment

Must be real and Must be real and in touchin touch with org with org Open CommunicationOpen Communication

CA is an open communication processCA is an open communication process

Culture Assessment & Culture of Culture Assessment & Culture of SafetySafety

Absence of FearAbsence of Fear

CA defines the level of confidence CA defines the level of confidence and is an excellent forum for and is an excellent forum for anonymous real time feedback.anonymous real time feedback.

Best PracticesBest Practices

Lessons learned andLessons learned and FeedbackFeedback

Keys to Assessing CultureKeys to Assessing Culture

Culture is a group phenomenon. You Culture is a group phenomenon. You won’t get it from surveys, won’t get it from surveys, observation, or individuals. observation, or individuals. It is It is hidden.hidden.

Self diagnosis is flawed. Self diagnosis is flawed.

How Do We Assess/Diagnose?How Do We Assess/Diagnose?

Logical Peer GroupLogical Peer Group Brings assumptions to the conscious levelBrings assumptions to the conscious level Exposes and defines the current culture of safety .Exposes and defines the current culture of safety . Exposes the underlying problems to observed Exposes the underlying problems to observed

symptoms. symptoms.

How Do We Then Manage and How Do We Then Manage and Improve Culture?Improve Culture?

Beauty of CA is that it greatly Beauty of CA is that it greatly simplifies this process.simplifies this process. CA fixes ½ your problemsCA fixes ½ your problems

As much as 50% of problems are related to As much as 50% of problems are related to miscommunication and misperceptions.miscommunication and misperceptions.

Clearly define your cultural strengths.Clearly define your cultural strengths.

It is easier to build upon cultural strengths than to It is easier to build upon cultural strengths than to fight the constraints of your weaknesses.fight the constraints of your weaknesses.

How Do We Then Manage and How Do We Then Manage and Improve Culture?Improve Culture?

Clearly defined weaknessesClearly defined weaknesses

When you understand the true underlying causes When you understand the true underlying causes of your weakness, solutions are much easier.of your weakness, solutions are much easier.

Example – your car is running poorly.Example – your car is running poorly.

Culture of SafetyCulture of Safety Too many historical examples of great Too many historical examples of great

safety programs that did not create a safety programs that did not create a culture of safety. Relying on safety culture of safety. Relying on safety programs alone to shift culture is trial and programs alone to shift culture is trial and error. error.

Treat culture like a patient – work Treat culture like a patient – work directly with that culture to thoroughly directly with that culture to thoroughly define the current state and then manage define the current state and then manage it to improve it. You will get better it to improve it. You will get better results.results.

Culture of SafetyCulture of Safety

Diagnose, then Treat!Diagnose, then Treat!