Of heroes, villains, error traps and accidents

Another from the Reason files (I have a few more of these).

The image below explores the maturity cycle organisations go through regarding the role of people.

First, problematically, people are seen as hazards. And according to management logics, hazards should be controlled and the variability damped.

This focus separates people and behaviour from the necessary context; concealing the error traps and systemic factors for performance.

As organisations mature, they come to see and leverage more of people as the heroes [* an archetype]; providing more autonomy to workers. And this involves “capitalizing and exploiting the heroic features of the willingness “to go the extra mile.” (p61).

In this case, people adjust, compensate and improvise to ensure work occurs and thus inadvertently conceal some underlying systemic weaknesses and error traps.

That is, people make crappy systems work and look more functional than they are.

So eventually another serious event occurs and “there is a backlash when the layers and the patients and the managers say … let’s get rid of all this autonomy … and get more automation and more rules” (p61) – the cycle moves back to people as a hazard.

Systemic issues are still concealed.

Importantly, Reason notes that, hopefully, variability is reduced each time the cycle repeats. People are seen as *less* of a hazard over time and “more and more the notion of person and system comes into increasing harmony” (p61).

Finally, it’s argued that as an organisation “learns and matures, the variability will diminish, tensions and transitions implicit the cycle, but the perturbations are less disruptive” (p61).

Source: Peltomaa, K. (2012). James Reason Patient Safety, Human Error, and Swiss Cheese. Quality Management in Health Care: January/March 2012 – Volume 21 – Issue 1 – p 59-63.