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Managing Complex Interdependencies

Managing Complex Interdependencies. The Emerging Challenge of Human Performance Improvement:. Cynthia A. Wagner Manager, Office of Performance Excellence November 28, 2007. The Challenge. Barriers and Practices are Dynamic. Balancing Acts at Play. Dynamic and Multi-dimensional

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Managing Complex Interdependencies

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  1. Managing Complex Interdependencies The Emerging Challenge of Human Performance Improvement: Cynthia A. Wagner Manager, Office of Performance Excellence November 28, 2007

  2. The Challenge Barriers and Practices are Dynamic

  3. Balancing Acts at Play • Dynamic and Multi-dimensional • Influence • Proficiency • Flexibility

  4. Proactive Management • Human-System Interfaces • Knowledge of Current • Practices • Barriers • Outcomes • Awareness of Emerging Changes USER NEEDS: WHAT DOES WORK, DOESN’T WORK, and IS LIKELY TO CHANGE?

  5. Causal Analysis • Structured, questioning process • Enables recognition of practices and beliefs in an organization, or does it? • Why don’t we do more Root Causes? USER NEEDS: DISCUSSION OF VALUES AND BELIEFS

  6. Human Nature of Analysis • Does our preference for causal methods simply reflect our relationship with the tools? • Do our linear approaches oversimplify the complexity we face? • What might keep us from being willing to explore further? USER NEEDS: ROBUST, SYSTEMATIC and SYSTEMIC

  7. Do Causal Teams Really Achieve Common Understanding? How Can We Create Transparency and Traceability of the Sensing and Thinking Process? Convergence of Information andThinking USER NEEDS: TRANSPARENT and TRACEABLE

  8. Human Limitations • We always know more than we can tell • We always tell more than we can write down

  9. Making Sense for Others • Are expectations reasonable given the complexity of interdependencies? • Are traditional analysis reports effective for making sense of findings and creating buy-in? USER NEEDS: EFFICIENT and EFFECTIVE COMMUNICATIONS

  10. Summary of User Needs • Method • Robust, Systematic and Systemic • Easy to Learn and Use • Output • Knowledge and Insight • Traceable and Transparent Discussion • Effective and Efficient Communications

  11. Consider Stream Analysis • Compatible with HPI • Open Systems Theory • Social Cognitive Theory • In Practice • INPO experience • Applicable across the organization at all levels • Project leaders, unit managers, organizational advisors, oversight teams, business executives “Stream Analysis - A Powerful Way to Diagnose and Manage Organizational Change” by Professor Jerry Porras, Stanford Graduate School of Business

  12. Why Stream Analysis? • Human-System interfaces are not linear in nature • Complex interconnections between organizational components control and influence behavior, processes and performance • Enterprises spend billions on Improvement initiatives • 70% of change initiatives by the fortune 100 fail* Processes Behavior Performance *M. Beer and N. Nohria, “Cracking the code of change” Harvard Business Review for turnaround, p 1 1997.

  13. Interdependent Components • Core Structure (organization) • Social Factors(behaviors and values) • Technology (integrated work processes) • Physical Setting (environment)

  14. Streams

  15. Process Management Vertical Slices Divergence Retrieval Method Review Process Organization Convergence Meaning of Issues Shared Assumptions Actions Group Consensus Timing Feedback Loops

  16. Procedure Stream Analysis provides a step by step procedure for: • Forming Change Management Team • Collecting Data • Categorizing Problems • Identifying Interconnections • Analyzing the Problem Chart • Formulating a Plan of Action • Tracking the Intervention Process

  17. Example of Discussion File 5.2.3 Inadequate Labeling Labeling requirements provide a barrier that communicates the presence of potentially hazardous materials. This barrier failed because workers and management did not implement ES&H labeling requirements. Whether the NR-1 check source was a Class I sealed source or not, the level of radioactive material it contained qualified it for labeling requirements as specified in ES&H Manual Document 20.2. Had the NR-1 check source been accurately labeled, it would have been clearer that additional controls applied, such as being in an inventory, periodic swiping, and storage. In addition, labeling-related deficiencies from the 2003 Radiation Protection Assessment were closed without being fully corrected

  18. Comparison to User Needs • Systematic and Systemic • 4 Streams represent the system • Software aids execution of the process • Transparent and Traceable • Discussions remained fact-based. Assumptions and questions were captured for reference. • Binning provides a self-check on understanding of the issues. • Diagnostics captures the logic used • Effective and Efficient Communications • Creates a “Rich” Picture

  19. Case Study • Incident Analysis on Contamination • 13 Judgments of Need • Investigation summarized: • Several of the conclusions of the IA Committee involve the failure of controls associated with sealed sources. • This is because the NR-1 check source was assumed to have been a sealed source at the time the contamination began to spread. • Had the controls for sealed sources been applied, the IA Committee believes the contamination would have been detected before being spread to other facilities and off-site. However, the reader is urged to remember that the real core of this incident was the handling of a legacy item.

  20. Case Study • Stream Analysis Results • Unclear Roles and Responsibilities • People “jumped the turnstiles” • Process was Error Prone • Error Traps for Unidentified Sources • Flawed assumptions • Lack of Questioning Attitude • Safety was not first

  21. Stream 1

  22. Diagnostic

  23. Theme – Ineffective Characterization

  24. Theme – Reliance on Others

  25. Stream 2

  26. Stream 2

  27. Theme on Safety Culture

  28. Theme – Safety Culture 2

  29. Questions?

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