High Reliability Organizations Quotes

In high-performing organizations, everyone within the team shares a common goal—quality, availability, and security aren’t the responsibility of individual departments, but are a part of everyone’s job, every day.

I am, reluctantly, a self-confessed carbon chauvinist. Carbon is abundant in the Cosmos. It makes marvelously complex molecules, good for life. I am also a water chauvinist. Water makes an ideal solvent system for organic chemistry to work in and stays liquid over a wide range of temperatures. But sometimes I wonder. Could my fondness for materials have something to do with the fact that I am made chiefly of them? Are we carbon- and water-based because those materials were abundant on the Earth at the time of the origin of life? Could life elsewhere—on Mars, say—be built of different stuff? I am a collection of water, calcium and organic molecules called Carl Sagan. You are a collection of almost identical molecules with a different collective label. But is that all? Is there nothing in here but molecules? Some people find this idea somehow demeaning to human dignity. For myself, I find it elevating that our universe permits the evolution of molecular machines as intricate and subtle as we. But the essence of life is not so much the atoms and simple molecules that make us up as the way in which they are put together. Every now and then we read that the chemicals which constitute the human body cost ninety-seven cents or ten dollars or some such figure; it is a little depressing to find our bodies valued so little. However, these estimates are for human beings reduced to our simplest possible components. We are made mostly of water, which costs almost nothing; the carbon is costed in the form of coal; the calcium in our bones as chalk; the nitrogen in our proteins as air (cheap also); the iron in our blood as rusty nails. If we did not know better, we might be tempted to take all the atoms that make us up, mix them together in a big container and stir. We can do this as much as we want. But in the end all we have is a tedious mixture of atoms. How could we have expected anything else? Harold Morowitz has calculated what it would cost to put together the correct molecular constituents that make up a human being by buying the molecules from chemical supply houses. The answer turns out to be about ten million dollars, which should make us all feel a little better. But even then we could not mix those chemicals together and have a human being emerge from the jar. That is far beyond our capability and will probably be so for a very long period of time. Fortunately, there are other less expensive but still highly reliable methods of making human beings. I think the lifeforms on many worlds will consist, by and large, of the same atoms we have here, perhaps even many of the same basic molecules, such as proteins and nucleic acids—but put together in unfamiliar ways. Perhaps organisms that float in dense planetary atmospheres will be very much like us in their atomic composition, except they might not have bones and therefore not need much calcium. Perhaps elsewhere some solvent other than water is used. Hydrofluoric acid might serve rather well, although there is not a great deal of fluorine in the Cosmos; hydrofluoric acid would do a great deal of damage to the kind of molecules that make us up, but other organic molecules, paraffin waxes, for example, are perfectly stable in its presence. Liquid ammonia would make an even better solvent system, because ammonia is very abundant in the Cosmos. But it is liquid only on worlds much colder than the Earth or Mars. Ammonia is ordinarily a gas on Earth, as water is on Venus. Or perhaps there are living things that do not have a solvent system at all—solid-state life, where there are electrical signals propagating rather than molecules floating about. But these ideas do not

too little—and complex, because the manufacturing and marketing of food products has changed dramatically. Dr. David Kessler, former head of the U.S. Food and Drug Administration, has extensively documented how food manufacturers and restaurant and fast food chains carefully combine fats, sugar, and salt in precise ratios that reach the “bliss point”—which means they trigger brain systems that increase the desire to eat more, even after our stomachs are full. On a global basis, the World Health Organization has found a pattern of increased consumption of “energy-dense foods that are high in fat, salt and sugars but low in vitamins, minerals and other micronutrients.” Hyper-urbanization has separated more people from reliable sources of fresh fruit and vegetables. Quality calories in fruits and vegetables now cost ten times as much as calories per gram in sweets and foods abundant in starch. In a report for the Johns Hopkins Bloomberg School of Public Health, Arielle Traub documented the increase from 1985 to 2000 in the price of fresh fruits and vegetables by 40 percent, while prices of fats declined by 15 percent and sugared soft drinks by 25 percent.

No amount of high fashion can make up for a lifetime of poor posture.

Hiring SREs well is critical to having a high-functioning reliability organization, as explored in “Hiring Site Reliability Engineers” [Jon15]. Google’s hiring practices have been detailed in texts like Work Rules! [Boc15],1 but hiring SREs has its own set of particularities. Even by Google’s overall standards, SRE candidates are difficult to find and even harder to interview effectively.

At Bridgewater, every employee has a believability score on a range of dimensions. In sports, statistics for every player’s performance history are public. In baseball, before you sign a player, you can look up his batting average, home runs, and steals; assess his strengths and weaknesses; and adjust accordingly. Dalio wanted Bridgewater to work the same way, so he created baseball cards that display statistics on every employee’s performance, which can be accessed by anyone at the company. If you’re about to interact with a few Bridgewater colleagues for the first time, you can see their track records on seventy-seven different dimensions of values, skills, and abilities in the areas of higher-level thinking, practical thinking, maintaining high standards, determination, open-mindedness yet assertiveness, and organization and reliability.

Correlation is enough,” 2 then-Wired editor in chief Chris Anderson famously declared in 2008. We can, he implied, solve innovation problems by the sheer brute force of the data deluge. Ever since Michael Lewis chronicled the Oakland A’s unlikely success in Moneyball (who knew on-base percentage was a better indicator of offensive success than batting averages?), organizations have been trying to find the Moneyball equivalent of customer data that will lead to innovation success. Yet few have. Innovation processes in many companies are structured and disciplined, and the talent applying them is highly skilled. There are careful stage-gates, rapid iterations, and checks and balances built into most organizations’ innovation processes. Risks are carefully calculated and mitigated. Principles like six-sigma have pervaded innovation process design so we now have precise measurements and strict requirements for new products to meet at each stage of their development. From the outside, it looks like companies have mastered an awfully precise, scientific process. But for most of them, innovation is still painfully hit or miss. And worst of all, all this activity gives the illusion of progress, without actually causing it. Companies are spending exponentially more to achieve only modest incremental innovations while completely missing the mark on the breakthrough innovations critical to long-term, sustainable growth. As Yogi Berra famously observed: “We’re lost, but we’re making good time!” What’s gone so wrong? Here is the fundamental problem: the masses and masses of data that companies accumulate are not organized in a way that enables them to reliably predict which ideas will succeed. Instead the data is along the lines of “this customer looks like that one,” “this product has similar performance attributes as that one,” and “these people behaved the same way in the past,” or “68 percent of customers say they prefer version A over version B.” None of that data, however, actually tells you why customers make the choices that they do.

it’s worth investing ongoing effort into a suite that is reliable. One way to achieve this is to put automated tests that are not reliable in a separate quarantine suite that is run independently.5 Or, of course, you could just delete them. If they’re version-controlled (as they should be), you can always get them back.

Having automated tests that are reliable: when the automated tests pass, teams are confident that their software is releasable.

Too many test suites are flaky and unreliable, producing false positives and negatives—it’s worth investing ongoing effort into a suite that is reliable.

high performers were twice as likely to exceed profitability, market share, and productivity goals. And,

In technology, our work happens almost entirely within complex systems with a high risk of catastrophic consequences. As

for those organizations that provided a stock ticker symbol, we found that high performers had 50% higher market capitalization growth over three years. They also had higher employee job satisfaction, lower rates of employee burnout, and their employees were 2.2 times more likely to recommend their organization to friends as a great place to work.

high-performing manufacturing operations require and actively promote learning—instead of work being rigidly defined, the system of work is dynamic, with line workers performing experiments in their daily work to generate new improvements, enabled by rigorous standardization of work procedures and documentation of the results.

Even high-profile product and feature releases become routine by using dark launch techniques. Long before the launch date, we put all the required code for the feature into production, invisible to everyone except internal employees and small cohorts of real users, allowing us to test and evolve the feature until it achieves the desired business goal.

In the technology value stream, we optimize for downstream work centers by designing for operations, where operational non-functional requirements (e.g., architecture, performance, stability, testability, configurability, and security) are prioritized as highly as user features.

What these organizations have in common is a high-trust culture that enables all departments to work together effectively, where all work is transparently prioritized and there is sufficient slack in the system to allow high-priority work to be completed quickly. This is, in part, enabled by automated self-service platforms that build quality into the products everyone is building.

Control system overlays must be faster and more reliable than the underlying systems being controlled. The Nyquist-Shannon Sampling Theorem, first introduced in 1928, explains why. A receiver (sensor) must sample at least twice the rate of the sender (the thing being monitored and controlled) to accurately measure and control a system. This theorem forms the basis of all things digital, including telecommunications, medical imaging systems, astronomy, and more. In reality, to control a complex engineered or biological system, the receiver and controller must be much faster to maintain resilience and agility. This has stark implications for top-down management. For instance, if reports are generated and reviewed once a week, they can be used to control (manage) only situations that change no faster or more frequently than every two weeks. Anything faster moving may not be detected or is not controllable. This explains why exemplary organizations are typically characterized by overlays of people in supportive roles that are uncharacteristic of their lower-performing peers. That is not “overhead” but absolutely necessary bandwidth for sustaining high performance of fast-moving, complex, dynamic systems.

In high-performing organizations, everyone within the team shares a common goal—quality, availability, and security aren’t the responsibility of individual departments but are a part of everyone’s job, every day.

For example, high performance with a functional-oriented and centralized Operations group is possible, as long as service teams get what they need from Operations reliably and quickly (ideally on demand) and vice-versa. Many

Because our goal is to enable small teams of developers to independently develop, test, and deploy value to customers quickly and reliably, this is where we want our constraint to be. High performers, regardless of whether an engineer is in Development, QA, Ops, or Infosec, state that their goal is to help maximize developer productivity.

The absence of failure was taken as positive indication that hazards are not present or that countermeasures are effective. In this context, it is very difficult to gather or see if evidence is building up that should trigger a re-evaluation and revision of the organization’s model of vulnerabilities. If an organization is not able to change its model of itself unless and until completely clear-cut evidence accumulates, that organization will tend to learn late, that is, it will revise its model of vulnerabilities only after serious events occur. On the other hand, high-reliability organizations assume their model of risks and countermeasures is fragile and even seek out evidence about the need to revise and update this model (Rochlin, 1999). They do not assume their model is correct and then wait for evidence of risk to come to their attention, for to do so will guarantee an organization that acts more riskily than it desires. The

20% on detailed planning (Their poor throughput and high lead times were misattributed to faulty estimation, and so, hoping to get a better answer, they were asked to estimate the work in greater detail.)

high performers use a disciplined approach to solving problems. This is in contrast to the more common practice of using rumor and hearsay, which can lead to the unfortunate metric of mean time until declared innocent—how quickly can we convince everyone else that we didn’t cause the outage. When there is a culture of blame around outages and problems, groups may avoid documenting changes and displaying telemetry where everyone can see them to avoid being blamed for outages.

DevOps and its resulting technical, architectural, and cultural practices represent a convergence of many philosophical and management movements (including): Lean, Theory of Constraints, Toyota production system, resilience engineering, learning organizations, safety culture, Human factors, high-trust management cultures, servant leadership, organizational change management, and Agile methods.

The Third Way enables the creation of a generative, high-trust culture that supports a dynamic, disciplined, and scientific approach to experimentation and risk-taking, facilitating the creation of organizational learning, both from our successes and failures.

Agile often serves as an effective enabler of DevOps because of its focus on small teams continually delivering high-quality code to customers.

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As Protestant philosopher Max Scheler explained it, a sectarian movement begins enthusiastically embracing a prophet's call to high standards of morality and piety. To survive, the sect must have its relative few members united in intense revivalistic fervor. They view their founder as one who leads by example and points the way. It is up to the disciple to follow him. But after the movement enters its second generation, and the founder is gone, its members tend to relax. Their values slip back toward the mainstream and intensity relaxes. Standards fall to levels of mediocrity, and all this is rationalized by the elevation of the founder to the status of a divine savior.' He does not put before us an example to follow, because we are sinners/mortals. His achievement was superhuman. He did what he did because he was a god. And in fact he did it for us, not to show us how to do it, but rather so we could be excused for not doing it! In fact it would be sheer effrontery to think oneself capable of emulating the savior. Instead, he will be satisfied with token efforts. Here is the shift from sect to church. Here is the passage from Theravada to Mahayana, from the religion of Jesus to the religion about Jesus. And from our point of view, it represents the passage of early Christianity into a kind of moral pessimism (or laziness, as Feuerbach would have it).

conformity as a way to relieve the anxiety springing from separateness, another factor of contemporary life must be considered: the role of the work routine and of the pleasure routine. Man becomes a “nine to fiver,” he is part of the labor force, or the bureaucratic force of clerks and managers. He has little initiative, his tasks are prescribed by the organization of the work; there is even little difference between those high up on the ladder and those on the bottom. They all perform tasks prescribed by the whole structure of the organization, at a prescribed speed, and in a prescribed manner. Even the feelings are prescribed: cheerfulness, tolerance, reliability, ambition, and an ability to get along with everybody without friction.

We have been a conservative and non-competitive organization. We engineer for high quality service, with long life, low maintenance costs, [and a] high factor of reliability as basic elements in our philosophy of design and manufacture. But our basic technology is becoming increasingly similar to that of a high volume, annual model, highly competitive, young, vigorous and growing industry.”32 In other words, there would soon be a revolution in electronics. And as he saw it, Bell Labs would need to lead it rather than join it. Kelly wanted his old team back—the team he had handpicked in the late 1930s.

Christy Lodwick, the Vice President of Tyde Systems, brings reliable skills and knowledge to the organization. Having served in the Health Care industry as an Administrator and Consultant, Christy Lodwick has the experience required to manage high-end projects at the company. Many clients benefit from her project managerial and network engineering skills.

high performance starts with organizations whose leadership focuses on building an environment where people from different backgrounds and with different identities, experiences, and perspectives can feel psychologically safe working together, and where teams are given the necessary resources, capacity, and encouragement to experiment and learn together in a safe and systematic way.

Questions About the Past Performance How has this organization performed in the past? How do people in the organization think it has performed? How were goals set? Were they insufficiently or overly ambitious? Were internal or external benchmarks used? What measures were employed? What behaviors did they encourage and discourage? What happened if goals were not met? Root Causes If performance has been good, why has that been the case? What have been the relative contributions of strategy, structure, systems, talent bases, culture, and politics? If performance has been poor, why has that been the case? Do the primary issues reside in the organization’s strategy? Its structure? Its technical capabilities? Its culture? Its politics? History of Change What efforts have been made to change the organization? What happened? Who has been instrumental in shaping this organization? Questions About the Present Vision and Strategy What is the stated vision and strategy? Is the organization really pursuing that strategy? If not, why not? If so, will the strategy take the organization where it needs to go? People Who is capable, and who is not? Who is trustworthy, and who is not? Who has influence, and why? Processes What are the key processes? Are they performing acceptably in quality, reliability, and timeliness? If not, why not? Land Mines What lurking surprises could detonate and push you offtrack? What potentially damaging cultural or political missteps must you avoid? Early Wins In what areas (people, relationships, processes, or products) can you achieve some early wins? Questions About the Future Challenges and Opportunities In what areas is the organization most likely to face stiff challenges in the coming year? What can be done now to prepare for them? What are the most promising unexploited opportunities? What would need to happen to realize their potential? Barriers and Resources What are the most formidable barriers to making needed changes? Are they technical? Cultural? Political? Are there islands of excellence or other high-quality resources that you can leverage? What new capabilities need to be developed or acquired? Culture Which elements of the culture should be preserved? Which elements need to change?

DevOps requires potentially new cultural and management norms and changes in our technical practices and architecture. This requires a coalition that spans business leadership, Product Management, Development, QA, IT Operations, Information Security, and even Marketing, where many technology initiatives originate. When all these teams work together, we can create a safe system of work, enabling small teams to quickly and independently develop and validate code that can be safely deployed to customers. This results in maximizing developer productivity, organizational learning, high employee satisfaction, and the ability to win in the marketplace.

Since the price of aggression can be high, individual fitness depends on the ability to accurately calculate potential costs. This requires a reliable assessment of the condition, motivation, and intent of potential adversaries.

It is in such vast gray zones that highly reliable healthcare organizations demonstrate that they possess more than just policies and procedures: they have philosophies and cultures.

Using a scale from “1 = Strongly disagree” to “7 = Strongly agree,” teams can quickly and easily measure their organizational culture. These items have been tested and found to be statistically valid and reliable. That is, they measure the things they are intended to

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If mutual mate choice is indeed influencing mental characteristics, this may help to explain variability in intelligence, even though intelligence is highly heritable (e.g., Miller, 1997). Recall, that in order to be reliable fitness indicators, traits must demonstrate high individual differences; traits may be highly heritable if they “tap into genetic variation in fitness,” because fitness itself seems to be a heritable characteristic (Miller, 2000b). Although brain size correlates with intelligence (Rushton & Ankney, 1996), creating a large brain is costly for the organism in terms of metabolic energy necessary to support the brain, time necessary to produce it, as well as the physical difficulty and health complications of squeezing through a small pelvic opening during delivery. Intelligence is also correlated with other fitness indicators, in particular, body symmetry (Furlow, Armijo-Prewitt, Gangestad, & Thornhill, 1997). Prokosch, Yeo, and Miller (2005) have found evidence that general intelligence (g) reflects developmental stability. Furthermore, the finding that humans assortively mate with others of similar intelligence, which should increase variability in intelligence in the general population, lends weight to the idea that indicators of g are used as indicators of fitness (Rushton 1989; Rushton & Bonns, 2005).

Human Cloning: The Least Interesting Application of Cloning Technology One of the most powerful methods of applying life’s machinery involves harnessing biology’s own reproductive mechanisms in the form of cloning. Cloning will be a key technology—not for cloning actual humans but for life-extension purposes, in the form of “therapeutic cloning.” This process creates new tissues with “young” telomere-extended and DNA-corrected cells to replace without surgery defective tissues or organs. All responsible ethicists, including myself, consider human cloning at the present time to be unethical. The reasons, however, for me have little to do with the slippery-slope issues of manipulating human life. Rather, the technology today simply does not yet work reliably. The current technique of fusing a cell nucleus from a donor to an egg cell using an electric spark simply causes a high level of genetic errors.57 This is the primary reason that most of the fetuses created by this method do not make it to term. Even those that do make it have genetic defects. Dolly the Sheep developed an obesity problem in adulthood, and the majority of cloned animals produced thus far have had unpredictable health problems.58

12:40 p.m.: start making the plan. Remember when you could be roused from a night being spent on the couch in your pajamas, curled around a pint of Chubby Hubby, and goaded into joining your friends at the bar even though you’d already taken off your bra? Yeah, I can’t either, but I know those days existed. I have the liver damage to prove it. Now when I go out I have to start gearing up for that shit at least three days in advance, and if I’m actually going to go through with it, it has to include both an ironclad reservation and a reliable seating arrangement. Showing up at a restaurant and hoping for the best is a young person’s game. If I’m going out, I need to know that there is a table with my name on it and a comfortable seat pulled up to it. I’m too old to hover anxiously near the door, sweating under my coat in my good outside clothes, watching people who actually planned ahead be ushered to their awaiting tables and served the foods I am dying to eat. I’m not that organized, though, so I spend a long time scrolling through OpenTable to try to find a reservation for 7 p.m. at a place that has more than a few high-tops left and won’t attempt to put us outside. It’s slim pickings.

The salt shortage of the norther fisheries was solved by a commercial group that organized both herring and salt trades. Between 1250 and 1350, a grouping of small associations in norther German cities formed. Known as the Hanseatic League, from the Middle High German word Hanse, meaning 'fellowship,' these associations pooled their resources to form more powerful groups to act in their commercial interests. They stopped piracy in the Baltic, initiated quality control on traded items, established commercial laws, provided reliable nautical charts, and built lighthouses and other aids to navigation.

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The answers are perhaps as varied as the questions one asks, but a common theme that comes through in discussions with caregivers on the front lines and those who think a great deal about patient safety, is our failure to change our culture. What we have not done, they say, is create a “culture of safety,” as has been done so impressively in other industries, such as commercial aviation, nuclear power and chemical manufacturing. These “high-reliability organizations” are intrinsically hazardous enterprises that have succeeded in becoming (amazingly!) safe. Worse, the culture of health care is not only unsafe, it is incredibly dysfunctional. Though the culture of each health care organization is unique, they all suffer many of the same disabilities that have, so far, effectively stymied progress: An authoritarian structure that devalues many workers, lack of a sense of personal accountability, autonomous functioning and major barriers to effective communication. What is a culture of safety? Pretty much the opposite! Books have been written on the subject, and every expert has his or her own specific definition. But an underlying theme, a common denominator, is teamwork, founded on an open, supportive, mutually reinforcing, dedicated relationship among all participants. Much more is required, of course: Sensitivity to hazard, sense of personal responsibility, attitudes of awareness and risk, sense of personal responsibility and more. But those attitudes, that type of teamwork and those types of relationships are rarely found in health care organizations.

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