Presentation on theme: "(c) 2007 - Wade Schuette1 Towards Spectacular Teams R. Wade Schuette 9/9/2006."— Presentation transcript:
(c) Wade Schuette1 Towards Spectacular Teams R. Wade Schuette 9/9/2006
(c) Wade Schuette2 Spectacular results are possible
(c) Wade Schuette3 T. S. Eliot’s observation of us all They constantly try to escape From the darkness outside and within by dreaming of systems so perfect that no one will need to be good TS Eliot "The Rock"
(c) Wade Schuette4 Does systematizing work? “High-Reliability Organization” literature for nuclear power plants, cockpits, etc. describes teams that can rise-above protocols and occasionally challenge every level of the model in real-time. What is required for that to be an improvement, instead of a collapse of authority and control?
(c) Wade Schuette5 Culture conflict How does the culture “above and beyond protocols” (e.g., “Threat and Error Management”) connect to the culture that stresses protocols as the end-all and be- all of quality? Are they in conflict, or are they compatible if viewed correctly? (the latter.)
(c) Wade Schuette6 What it takes – I think My conclusion – we have to move from reliance on protocols to internalizing the protocols, digesting them, mastering them, and then floating a single concept in their place that encompasses them all, and more, stabilized and made safe by operating only in an “active strength” context team members must create for each other (you can’t make your own).
(c) Wade Schuette7 Linear model: more systematic process yields more reliable output
(c) Wade Schuette8 New model with only one section linear (region II)
(c) Wade Schuette9 Reliablity goes up, then down as more and more is standardized
(c) Wade Schuette10 Five stages as we try to manage active systems with more protocols I – chaos II – Quality improvement III – diminishing returns, soaring costs IV – paradoxical reductions in safety V – catastrophic collapse
(c) Wade Schuette11 Comparison of models Linear model assumes more is always better, and perfection is possible. Nonlinear model assumes there is a “gap”, and a maximum point beyond which a different strategy is needed.
(c) Wade Schuette12 The problem of the “gap” Protocols can only close about 99.5% of the gap. The real world doesn’t lie flat or stay still long enough to ever capture the remaining half-percent. In case of ulta-high cost accidents (say, nuclear power or bio-war situations) that 0.5% is way too much. Expected cost is equal to low Risk times huge Cost, which is a very large number
(c) Wade Schuette13 Also, regulatory model collapses under its own weight Attempting to define every possible case in protocols or regulations becomes prohibitively expensive. After the first several hundred pages, adding another 1000 pages to the manual in an effort to make it more helpful is well-intentioned, but not actually helping. Laws piled on laws forever cannot close the gap. Period. Ever. So, Now what?
(c) Wade Schuette14 We need a “phase transition”, and it turns out one is possible
(c) Wade Schuette15 Phase transition – to spectacular Once get to maximum value of more procedures, stop adding them. More will never cross the chasm – it’s like trying to write team rules for how to always win at football. Procedures must be mastered, 105%, internalized, and then stepped beyond “Visual-on-top” state is what to seek, with eyes open and all the dots connected.
(c) Wade Schuette16 Three states of flight: visual, by instruments, and visual-on-top – we need to get to “VFR on top”
(c) Wade Schuette17 Flying “on top” is tricky Emergent control from above is required to stabilize motion, because definition by a limited human based on limited- experience rules will always be incomplete and under-specified. Guidance “from above” is not mystical, it’s a social-engineering application of what civil engineer’s call “active strength.” or “intelligent materials.”
(c) Wade Schuette18 Spirit-stabilized mastery – “active strength” in human systems
(c) Wade Schuette19 Phase transition – to spectacular Need to get to a very specific sense of “throwing away the rule book”, removing the scaffolding, because the higher-order concept has clicked, made sense, and is now in control from above. This is a realization in a human system of the “active strength” / intelligent materials feedback concept now used in the design of modern buildings.
(c) Wade Schuette20 What is “active strength”? Engineers now realize that structures can be made hyper-strong by using feedback to damp out tiny variations that are the precursors to collapse failures. This “tiny” intelligent-context feedback makes all the difference in the world, by stabilizing the intrinsic strength that is lost by “just small imperfections”.
(c) Wade Schuette21 What is “active strength”? Engineers now realize that structures can be made hyper-strong by using feedback to damp out tiny variations that are the precursors to collapse failures. For example – how “strong” is a rolled- tube of one sheet of typing paper?
(c) Wade Schuette22 Pretty strong – if it stays “aligned”
(c) Wade Schuette23 Nonlinear effects in structures Some buildings now use a central control that uses a very light touch of active pressure devices to damp out vibrations that, if allowed, could cascade into a structural collapse. The opposite end of that dimension is the famous Tacoma Narrows Bridge which ripped itself apart and collapsed. See the amazing video clips at oma/tacoma.html#mpeg
(c) Wade Schuette24 “Active Strength” citations Active structural vibration control: A review, Rabih Alkhatib, The Shock and Vibration Digest, Vol. 35, No. 5, (2003) ct/35/5/367?maxtoshow=&HITS=10&hits= 10&RESULTFORMAT=&searchid=1&FIR STINDEX=0&minscore=5000&resourcetyp e=HWCIT
(c) Wade Schuette25 “Intelligent Materials” Centers are springing up everywhere tmhttp://depts.washington.edu/cims/about2.h tm And have their own journals c.nav?prodId=Journal201582
(c) Wade Schuette26 Phase transition – to spectacular The only valid time when “above the law” actually works, in total submission to a higher-order law that’s all that and more. We no longer have 500 dots to connect, but a single graceful curve that fills in all the dots and is 1000 times easier to remember.
(c) Wade Schuette27 Take home message This effect cannot be accomplished with “stronger” joints. Ever stronger and heavier joints still won’t work, but will instead collapse under their own added weight. “Strong” is a system property, not a “joint” property. It won’t just emerge, but needs only a light-touch from some system that has “the big picture” It will not happen without that guiding context.
(c) Wade Schuette28 Threat and Error Management Links to BMJ, and latest wisdom in how to manage cockpits and operating rooms: eat-and-error-management-tem_05.html
(c) Wade Schuette29 High-Reliability Organizations "Organizational Learning From Experience in High- Hazard Industries: Problem Investigation as Off-Line Reflective Practice", on the MIS Sloan School of Management Working paper site (Working paper # , March 2002). It is by John S. Carroll, Jenny W. Rudolph, and Sachi Hatakenaka. It's on the Social Science Research Network Electronic Paper Collection at