Resilient Procedures: Oxymoron or Innovation?

An interesting chapter from the late Bob Wears around ‘resilient procedures’.

I’ve skipped heaps.

They specifically explore:

·???????? what baggage tends to accompany procedures

·???????? what is bad about procedures

·???????? what is good about them

·???????? how procedures might be designed to support or even enhance resilience, instead of degrading it.

Procedures are said to come with excess baggage, and these issues tend to be sociopolitical and have little to do with the procedures themselves; they often result from the process of proceduralisation.

Procedures also may have goals other than providing guidance, as they can “can be performances for external audiences, demonstrations that system leaders have adequate control of any hazards, and so used counter demands for external oversight”

Others have criticised the ‘technocratic’ view of procedures as prescriptions of reality, with an “objectivist presumption that the world and its technologies are ultimately knowable, and that epistemic ambiguity and uncertainty can be swept away”.

Model 1 / model 2

The rest of the paper relies heavily on the model 1 / model 2 frame for procedures, originally proposed by Dekker and developed by Hale & Borys.

Model 1 views procedures from a top-down, rationalist and prescriptive perspective: procedures are written by experts and represent the best or ideal way to complete the work. Work should mirrir procedures. Hence, “procedures precede work and guide it”.

Model 2 is bottom-up and views procedures more from the social construction perspective, where experts apply and adapt procedures to suit the local context. It sees procedures not as complete representations of reality but as incomplete abstractions. Hence, “procedures follow work and are guided by it”.

Model 2 is said to be more hidden from view, with workers hiding their routines in practice (work-as-done) to avoid criticism, or preserve resources.

Problems with Procedures

A host of problems relate to procedures. They can be seen as a specific type of standardisation, and as such, they “inherit all its associated advantages and disadvantages”.

They argue procedures are “necessarily decontextualized: abstractions of what generally is done, but not necessarily what specifically should be done in every situation”. Importantly, “Complex organizations always run in mildly degraded states – someone is always absent, some device is inevitably out of service, some supplies are missing”. Hence, people must always adapt to some degree to ensure work happens against procedures which “presume ideal conditions”.

They make a few other arguments but quote some other source saying that “You cannot improve safety and performance by thickening the rule-book”.

Because procedures are also decontextualised and abstract artefacts, they rely on the learned intuition of people using them. Even something ‘simple’, like documenting how to make a sandwich by necessity leaves out a lot of complex, coordinated steps about opening the jar, coordinating hand action etc. But, “this common grounding is seldom explicitly acknowledged or even recognized by procedure writers or users”.

They argue that many procedures in practice “deny the existence of trade-offs among goals, placing workers in a classic double bind based on the outcome of events, not on the adequacy of their judgement in negotiating trade-offs”.

Further, any trade-off conflicts that couldn’t be resolved by the procedure writer are “pushed onto the front-line worker”. An example is given of a simulation study at a nuclear plant. Workers identified an instance where following the rules would lead to a negative outcome, so departed from the procedures to stabilise the plant. They were instructed that this was wrong and they should adhere to the procedures; they adhered to the procedures in the next simulation, knowing it was the incorrect course of action, and “the operators were then cited for ‘malicious compliance’”.

The authors then argue that while procedures can be restraining to agility, they don’t need to be. They highlight that musical sheets convey a lot of meaning and interpretation for musicians.

Strengths of Procedures

Procedures do have strengths, though. They can be seen as “distillations of experience, expertise and tactic, vernacular knowledge”, which has accumulated over many years and by many workers.

They can also work well with seldom-encountered situations, and particularly during activities which may be counter-intuitive. They can serve as “resources for situated actions”, and can be a good place to start, as a way to make sense of unfolding situations.

Also they note that “By automating, in a sense, some bits of work, they allow workers to direct scarce energy and attentional resources to its more important or more demanding aspects”. They serve as valuable guides for novices.

They say that when procedures are well adapted to the context, are well understood and generally observed, they are suitable for coordinating work at a distance and reducing the burden of cognitive articulation work by multiple people.

They cite an example of Diablo Canyon, which had a high degree of proceduralisation. But their success with this approach was seen to result, at least partially, from the decentralisation of proceduralisation. They allowed each subunit to have veto over formalisation from other subunits, increasing the viewpoints from across the business in producing locally relevant procedures; this resulted in “decreased structural secrecy and diminished the gap between work-as-imagined and work-as-done”.

How to Craft Better Procedures

Next they provide a couple of pointers for crafting better procedures, involving process and content.

Process:

This is setting up the promoting conditions that permit better utilisation of procedures. It includes increasing the skills and viewpoints involved in producing procedures, and especially if accompanied by a flattening of the hierarchy and a shift towards distributed polycentric control.

This also requires careful monitoring of the gap between work-as-imagined and work-as-done, particularly at the coalface. This also requires seeing the gap not as a violation, but “a sign that revision, not enforcement, is required”, and this helps keep procedures abreast of changes in the work environment. This requires commitment to understanding local rationality.

Therefore, if “people are deviating from the procedures, that is because they do not make sense to them, given their locally understood resources, constraints and goals”. By leveraging gaps as learning opportunities to enhance procedures, and by redesigning or removing unworkable or ineffective procedures.

This is also an important continuous process of feedback and reflection since “procedures tend to accumulate but seldom go away”, and these processes, like decluttering, are useful to “combat this ‘rule bloat’”.

They argue that, importantly, although organisations often “train their workers in procedures, they seldom train for adaptations of procedures”. However, unpacking performance variability and how to adapt is necessary to create more flexible procedures, and to enhance how adaptations are interpreted and “applied safely and appropriately”. (** For those people who follow Cynefin and Snowden – they provide suggestions in this area.)

Several methods should be used to assess the effectiveness of procedures prior to implementation, including heuristic evaluation, formal assessments, dry-runs and simulations and more.

?

Content:

For content, they say adopting the principle of equifinality from systems thinking is useful: meaning that there are many paths to the same goal.

This is more relevant under conditions of uncertainty, resource scarcity and time pressure, as organisations can’t always be certain which single path will always be available (as procedures are often written as single path narratives).

They say that instead of trying to perfect a single best rule set, sometimes a suite of “pretty good” rules will be better, or meta-rules (rules on how to interpret and adapt rules).

Another way to think about procedures is from Hale and Swuste who proposed goal, process and action rules.

In short:

·???????? Goal-oriented rules: identify the desired end state, but leave the means to get there open to the stakeholders (these tend to be seen in safety law as broad duties to eliminate or minimise the risk so far as is reasonably practice). They can tend to provide useful guidance in intractable / unstable / uncertain environments

·???????? Process-oriented rules: These don’t say specific actions to take, but how actions should be chosen, who should do the choosing, and factors that should be considered or ignored. These tend to be useful in situations that still require flexibility but also as a means for coordinating control

·???????? Action rules: These are the most detailed and prescriptive, involving listing specific actions that must be taken, by whom and in what order. These are typically what people think of when they think about procedures.

Quoting the paper,

“Grote has noted that in high-risk systems, the most appropriate rules are not those that are most restrictive and therefore uncertainty reducing, but rather are flexible rules that promote adaptive action by providing more degrees of freedom to decision makers and thus increasing, rather than decreasing, their uncertainty”

(Interestingly, this view has been criticised by others, who argue that high-risk systems should have the reverse type of rules – more control and less degrees of freedom).

Next the authors reflect on resilience. Resilience is an easy war-cry but “There must be something about a system that provides the foundation for resilience when called upon”. Moreover, many of the capacities that support resilient performance are “hidden in the form of latent behavioural potential”.

Hence, if we want to nurture and inject capacity into our system, we have to find ways to identify, conserve and develop those potentials. One way of doing this is via designing “effective, flexible procedures that support resilience rather than interfere with it”

But to do this, this “may require organizations to embrace uncertainty rather than to pursue the will-of-the-wisp of rationalist certainty”

Ref: Wears, R. L., & Hunte, G. S. (2016). Resilient procedures: oxymoron or innovation? In?Resilient Health Care, Volume 3?(pp. 163-170). CRC Press.