Safety Leadership: Safety Leadership: Lessons from healthcare and - PDF document

Safety Leadership: Safety Leadership: Lessons from healthcare and other industries Rhona Flin Industrial Psychology Research Centre Scottish Patient Safety Research Network Scottish Patient Safety Research Network HPME, University of Toronto, 20 October, 2009 www.spsrn.ac.uk 1

Welcome to the Industrial Psychology Research Centre. The centre specialises in the application of psychology to high reliability workplaces. The group has worked with the oil industry since 1986, and regularly engage in consultancy projects. We are currently working with the offshore oil industry, civil aviation, nuclear power generation, surgery, emergency services, conventional power generation and transportation. Interests of the centre include: • Accident analysis • Incident command • Occupational stress • Emergency decision making • Crew Resource Management Crew Resource Management • Measuring and managing safety culture/ climate • Human factors aspects of safety management and emergency response Clients include: Agip, AKER Offshore (Norway), AMEC, Amerada Hess, AMOCO, British Energy, BHP, BP, Brown & Root, Chevron, Civil Aviation Authority, Coflexip Stena Offshore, Conoco Phillips, Defence Evaluation and Research Agency (DERA), EC (DGTREN), First Group, Halliburton, Health & Safety Executive, KBR, Kerr McGee, National Power, NHS, Powergen, Royal College of Surgeons, Salamis SGB, Schlumberger, SCPMDE, Shell, Talisman, Texaco, Total Fina Elf, Transocean Sedco Forex, UBS Warburg & UK Nuclear Imc. Organisational Safety Technical Technical Factors (30-20%) Accident Causation Managers + (70-80%) Human Worker = + Organisation Behaviour Factors Culture (+/- 80%?) (+/- 20%?) 2

Theories of Leadership • Trait theories – characteristics of leader? h t i ti f l d ? • Behavioural and Style theories – what do good leaders do? • Situational and Contingency theories – under given conditions, what behaviour is likely to be effective? Adaptability. be effective? Adaptability. • Transformational and Authentic leadership theories – Interaction between leader and follower. Charisma, vision, inspiration. Authenticity. Does leadership matter? � 45% of organizational performance can be explained 45% of organizational performance can be explained b b by executive leadership (Day & Lord, 1988) by executive leadership (Day & Lord, 1988) i i l l d d hi (D hi (D & L & L d 1988) d 1988) • 60-70% of employees report that their immediate supervisor is the most stressful aspect of their job (e.g. Fiedler) • Negative effects: lost productivity, absenteeism, turnover, stress, litigation, apathy, quality of work life, job satisfaction, motivation, organisational commitment, attention, rule compliance, …safety 3

Which one of these Management Levels would you focus on? • Senior Managers? • Site Managers? • Supervisors/ Team leaders? (200 power generation managers - May 2000, Electricity Association) Which one of these Management Levels would you focus your attention on to achieve maximum safety impact? (200 managers) � � Senior Managers Senior Managers 42 � Site Managers 11 � Supervisors / Team Leaders 47 4

Industrial Safety Legislation “Top management shall take p g ultimate responsibility” … for safety and safety management systems (OHSAS 18001:2007;Section 4.4.1) BP Texas City explosion “BP has not adequately established process safety as a core value…BP executive and corporate refining management have not provided d f h d d effective safety leadership.” (Baker, 2007, p. 60) “BP has not provided effective leadership on or established appropriate operational expectations regarding process safety performance at its U.S. refineries [and] the panel believes that the lack of effective leadership is systemic, touching all levels of BP’s corporate management having responsibility for BP’s U.S. refineries (Baker, 2007 p.66). p.66). U.S. Chemical Safety and Hazard Investigation Board (CSB, 2005, p3) urged: “corporate officials (to) exercise appropriate leadership to promote adherence to safety management systems” 5

Organisational factors associated with a safety culture (HSE, 1999) • Senior management Senior management commitment • Management style • Visible management • Good communication between all levels of employee [management l [ t action] • A balance of health and safety and production goals [management prioritisation] Traditional safety approaches • Focus on : – human fallibility/ error – how components and barriers fail – post accident analysis – minor incident reporting • Safety treated as an isolated phenomenon y p • Insufficient attention paid to production demands and other competing drivers of organisational and human behaviour 6

Organizational Resilience “ Organizational resilience is the characteristic of managing the organisation’s activities to anticipate and circumvent threats to its existence and primary goals. This is shown in particular in an ability to manage severe p y g pressures and conflicts between safety and the primary production or performance goals of the organization”. (Hale & Heijer, 2006, p36) Managerial Resilience Managerial resilience is the ability of Managerial resilience is the ability of managers and supervisors to manage severe pressures and conflicts between safety and the primary production or performance goals of the organization. (Flin, 2006). 7

Gustavus Adolphus King of Sweden King of Sweden from 1611-1632 Vasa Erosion of managerial resilience? ‘On several occasions the Master Shipbuilder cautiously tried to dissuade the king but the cautiously tried to dissuade the king, but the king would not listen’ Master Shipbuilder died in 1627 and was replaced by new manager. Stability tests in 1628 had to be halted as ship ‘h ‘heeled violently’ – but the Admiral decided l d i l tl ’ b t th Ad i l d id d ‘not to delay the commissioning’ Vasa sinks on maiden voyage one month later - 50 deaths 8

VASA: Accident investigation: 1628 • Lack of external learning capability • Lack of external learning capability • Goal confusion • Obsession with speed • Feedback system failure • Communication barriers • Poor organizational memory • Top management meddling (Kessler et al, 2001) NASA Challenger (1986) During the critical meeting on O rings and a low temperature launch, one of the engineers was asked to... “take off his engineering hat g g and put on his management hat” (Vaughan, 1996, p398) 9

NASA Challenger (1986) During the critical meeting on O rings and a low temperature launch, one of the engineers was asked to... “take off his engineering hat g g and put on his management hat” (Vaughan, 1996, p398) NASA Columbia (2003) Faster, Better, Cheaper Schedule pressure was p creating .. “strong incentives to move forward and look askance at potential disruption to schedule.” (Woods, 2003) 10

NASA Columbia Accident report Accident was more to do with holes in organizational decision making than holes in the wing of the Shuttle th i f th Sh ttl (Gehman, 2003) ‘This investigation confirmed doubts … concerning the relative priority for safety. .. ProRail and the operators have effectively placed the continued smooth flow of train traffic above smooth flow of train traffic above train safety.’ Through Red at Amsterdam Central (2005) 11

Middle managers’ resilience skills • Situation awareness Situation awareness – detection and recognition of threats • Decision making – balancing competing pressures – ability to make ‘sacrificial decisions’ (Woods) • Assertiveness – speaking up – challenging the leader • But needs a supportive organizational culture The Bristol Royal Infirmary Inquiry • BBC News November 1999 • Money came first, baby inquiry told • Stephen Bolsin blew the whistle at Bristol • The Bristol heart scandal whistleblower has told a public inquiry that managers ignored him because they thought they might lose government cash. • Consultant anaesthetist Dr Stephen Bolsin said that senior staff wanted to maintain the hospital's designation as a specialist children's heart facility. • He told the inquiry: "The analogy that was used was of a train where occasional passengers were falling off, and the train had to keep moving in order to attract funding. • "That was one of my concerns about the subjugation of patient safety by reasons of funding and continued activity in high risk areas." • Former Bristol Royal Infirmary chief executive Dr John Roylance, later struck off by the General Medical Council, was "dismissive" of his attempts to bring the high death rates to his attention, he said. • And surgeon James Wisheart, who was also banned from practising, was angry that he had discussed the unit's performance with other doctors. 12