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Blue Wave Consulting Company

Consultancy

A Different, Doable and Directed Approach

Unlike traditional approaches to safety, we see deviations from the rules as a reason to analyse the situation rather than as a violation. We defer judgement and try to understand how the work is really done, especially when conditions are challenging and resources are scarce. Rather than citing “human error” as the cause of an adverse event, we assume that the error is a symptom of underlying causes, such as system design, training, supervision or conflicting objectives.

Our approach requires top-down guidance because its rationale is somewhat controversial. In the approach, I reject the term “human error”, question the established culture of absolute compliance with rules, suggest that a “zero harm” policy is counterproductive and defend the acceptance of accidents as part of the job. Your team should be curious about events without judging, to find out how work is really done in practice. The press, the public, politicians and even our colleagues generally demand that we comply with our own procedures, and we should indeed work to improve compliance. But first we need to know what is really going on and your guidance is needed to support managers and safety staff in embracing bad news.

I explain how you can tackle safety by outlining the concrete steps you can take. I strive for clarity, conciseness and practical applicability.  First, you and your team identify where safety might be at risk and then I help you address those risks. I explain how stories and sensemaking help to get clear about what is going on. I explain how you can innovate wisely and monitor the impact of improvements on safety and performance. I explain how to keep the discussion about risk alive and how to ensure that those involved have the necessary skills to continue to perform even in difficult circumstances.

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Local Ingenuity

Employees in organisations are constantly faced with variations in processes, possibly influenced by the complexity of regulations and a scarcity of resources and people. Behaviour is a logical outcome of the circumstances in which employees find themselves, in which professional employees perform their jobs to the best of their ability and with what we call ‘local ingenuity’ in order to get the tasks and missions done and succeed. Blue Wave Consulting Company helps companies to promote, make visible and secure local ingenuity so that no new risks are introduced. We close the rules gap by bringing rule users and rule makers together – something that often doesn’t happen naturally despite the procedural change processes available.

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Micro-experiments

When we need to adapt rules and procedures quickly, want to innovate, or need to close a large gap between paper and practice, a specific approach is required. In a complex environment, where behaviour is difficult to predict, we cannot be sure that the interventions we devise will actually produce the results we intend, or that unintended side effects will be avoided. We need an approach that allows us to try different things, that is harmless and that can be stopped if we do not achieve the desired results. We call this micro-experiments. Micro-experiments are interventions that are safe to fail and are monitored to determine whether they are successful or not. Micro-experiments differ from ad hoc interventions based on trial and error in that they are planned before they are carried out, and are carefully monitored to check whether the intended results are achieved. They differ from large-scale projects in that the latter are not supposed to fail, while micro-experiments are temporary and allow for unexpected, even disappointing results.  The results are used to adjust rules, define new practices and rules or eliminate rules.

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Restorative practice

Restorative Practice focuses on restoring relationships damaged after an adverse event. In doing so, we meet the needs of direct victims, but also the needs of those who feel responsible (‘second victims’) and of the organisation as a whole. The approach is not only focused on victims, but also relies on recognition by practitioners of the physical and reputational damage done to the organisation. As well as recognition by management of the pain and remorse experienced by these practitioners. This process takes time and effort, but has been shown to reduce feelings of guilt, enable transparency, improve motivation and bring economic benefits. The benefits of Restorative Practice for the learning process are obvious: the experience surrounding the event is retained for the organisation and often those involved will help disseminate the lessons. There are numerous examples where the direct victims of an adverse event prefer to be heard rather than seek financial compensation. However, restoring relationships after a serious incident is not easy and various constraints can get in the way.

Restorative Practice is distinctly different from a ‘Just Culture’. A traditional ‘Just Culture’ focuses more on who is responsible than on how we can learn from the factors that led to the event, potentially leaving them unsaid. A traditional ‘Just Culture’ approach leads to a lack of openness, honesty, learning and prevention. A traditional ‘Just Culture’ tends to view existing procedures and rules as legitimate, even though those rules may not have been appropriate in the context of the incident. This is exacerbated when the rule-makers or rule-makers are involved in assessing (the actions of) the ‘offenders’. While a traditional ‘Just Culture’ in organisations seems to mirror justice in society at large, here it lacks the crucial elements of an independent judge and the right of appeal. Not coincidentally, managers are more likely to believe that their organisation is just than those lower down the hierarchy.

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