Stream Analysis: Enhancing Human Performance Improvement

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 • Influence • Proficiency • Flexibility

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?

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

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

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

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

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

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

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

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.

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

Streams

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

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

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

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

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.

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

Stream 1

Diagnostic

Theme – Ineffective Characterization

Theme – Reliance on Others

Stream 2

Theme on Safety Culture

Theme – Safety Culture 2

Questions?

Stream Analysis: Enhancing Human Performance Improvement