We’re renowned for our Just Culture work, but it’s HRO, Highly Reliable Outcomes, that began our journey.  We’ve been helping high-consequence organizations improve their outcomes for over 20 years.  And we’ve done it by sticking to a core set of principles that may not necessarily align with conventional wisdom.  A few of these include:

1. Zero is not possible. Zero is a marketing tool that often prevents us from obtaining truly reliable outcomes.  Zero lets leaders off the hook for good system design, and it puts employees in peril when they’re attached to the inevitable adverse event.

2. There is no such thing as a high reliability organization; there are only organizations that are highly reliable around those things they value. Just look at airlines in the US – heralded as HROs while having twice the national average rate of employee injuries.

3. It’s all about system design and choices. Yet today’s culture is more than happy to focus on two questions:  How bad was the outcome?  Who did it?  Frankly, we’re managing the wrong things.

4. It’s not about a preoccupation with failure, but a preoccupation with risk. Faulty equipment and fallible human beings can still produce great results.  We need not be preoccupied with perfection.

5. Humans are not inherently rule followers; we are threat and hazards avoiders. Why do you slow down for the police officer parked ahead, but not for the speed limit sign? Steering humans to make good choices is at the heart of HRO.

6. We should strive, where possible, to put ourselves three human errors away from harm. Today, we ask humans to work in terribly thin systems.  If only our team would develop a better culture, we’d get to zero?  That’s only half the equation.  Robust system design is the start.

7. Dependencies are the hidden threat. Remember Sully?  Two engines, yet only one flock of birds.  Sometimes we only think we have a robust design.

8. Doing less is often the better path. Why is it our RCAs only add rather than delete steps?  Supporting safety does not mean adding more – it means adopting smart designs that are often less extensive than you have today.

9. A model-based approach to managing risk will outperform an event-driven approach. Reactive reporting and investigation programs will only get you so far.

With these principles and others guiding our work, we’ve been able to help organizations achieve extraordinary results – most often with a greater than 90% rate of adverse event reduction.

And we’re the only organization we know of who has been willing to guarantee these type of results, even before the work has begun.  Examples of our work include:

  • Task: Mitigate risk of Aircraft Ground Damage

Industry: Aviation                        Result: 95% reduction in aircraft ground damage

Summary: “We need more wing walkers” is how one of our first prospective modeling tasks started.  It was the statement made by the aircraft technicians who were convinced they knew the cause; yet by the end of the modeling exercise, they had reversed course, now convinced that wing walkers were the problem.  What we needed was a system of barriers and redundancy.  And it gave them a 95% reduction in aircraft ground damage.

  • Task: Mitigate risk of Mislabeled Blood Specimens

Industry: Healthcare                   Result: 90% reduction in mislabeled specimens across six hospitals

Summary: The modeling task developed an intervention called the “Final Check” which required any clinical staff collecting blood specimens to read out loud the last 3 digits of the Medical Record (MR) number printed on the label against the MR number on the patient armband.  We cut the size of the task in half to get a 90% reduction in mislabeled specimens.

  • Task: Mitigate risk of Vehicles in Reverse (VR) Accidents

Industry: Utilities                          Result: 93% reduction in vehicle accidents

Summary:  “Stop – Scan – Primary” was the key intervention to control a number of sensory inputs a driver was required to assess while the vehicle was in motion.  In other words, Stop and Scan for threats, when a threat (i.e., another vehicle) is identified, pick a Primary input (left side mirror) to deal with that threat.  Once the threat has been navigated, restart the process of “Stop – Scan – Primary.”  We simplified the task of backing up a vehicle and got a 93% reduction in accidents.

So, we’re not only the Just Culture developers.  Helping our clients build highly reliable outcomes is actually the centerpiece of our work.  And now we’ve developed the tools and software to help make it the centerpiece of what you do.  Ingenious you say?  Yes, and it’s what you should expect from Outcome Engenuity. 

We invite you to view our Highly Reliable Outcomes Champion Certificate course dates or contact our Client Relations team here.