April 20, 2023

You can’t solve problems using the same thinking that created the problem in the first place!

Paula Gilbert
Project Manager
Resource & Process Group, Transforming Delivery Directorate (HMPPS)

How thinking like a High Reliability Organisation can help

Two years ago, I joined the HMPPS High Reliability Organisations (HRO) Team.  You might think, “what is High Reliability, and what has that got to do with working in HMPPS, Civil Service or the Criminal Justice Sector?” Initially, I didn’t appreciate its relevance but my mission was to understand how it could be used in our setting and support a pilot of activities in prisons and HMPPS headquarters. Two years later I’m still amazed at the journey our small team has been on and the scope for positive change that High Reliability can give us.

What is a High Reliability Organisation?

A high reliability organisation is one that has succeeded in avoiding catastrophes in an environment where normal accidents are expected to occur due to risk factors and complexity.

Have you ever wondered, when you go to hospital, why you’re asked the same few key questions by each different professional?

And did you know that when a plane takes off, the pilot completes the same standardised checklist that is used across the world?

These are both examples of how these industries have reduced errors by using High Reliability thinking. The approach seeks to learn from failures and errors, without seeking to blame.

Fundamentally, High Reliability organisations focus on:

  • how we deliver our work by better understanding our resource needs and how these can limit our ability to deliver well
  • the effects of our policies and processes and how well they support our people to deliver consistently to a good standard,
  • our people - recognising that everyone is different and;
  • recognising humans make mistakes and creating strong systems that promote standardisation, digitalisation and efficiency help us to mitigate against future mistakes and errors.

In HMPPS we often face complex issues which need breaking down into smaller parts to understand how to deal with them effectively. Using High Reliability approaches to tackle problems and errors can lead to benefits, including more efficient use of resources; joined-up thinking; consistent delivery; and standard ways of delivering and communicating.

High Reliability organisations embrace systems thinking, viewing problems as a collection of interconnected parts which interact and change. The approach also embraces people and how they work as part of that system too, rather than people being independent of the process itself.  High Reliability organisations are mindful that people are different and how this can affect delivery and outcomes.

Using systems thinking means understanding that we and our work sit within a system, not outside it. If we change one part of a system, we are likely to indirectly, or directly, affect another part. That means we need to identify and engage with others in the system and build a shared understanding to ensure the changes we make are coherent and likely to succeed.

This thinking places safety at the centre of everything we do, building and evaluating delivery systems that work  to reduce errors.

The High Reliability Pilot

We took on three different challenges:

  1. Acknowledging the significant organisational and public protection risks that exist when we are unable to deliver effective sentence management, we led a Headquarters pilot to better understand the complexities of sentence calculation processes and information flows across the criminal justice system. We provided support and tools to assist Offender Management Units, introduced enhanced training, professional accreditation for Case Management practitioners, and have trialled the introduction of digital services to increase accuracy and improve efficiency.
  2. In prisons we tested a new residential wing Checklist Briefing to improve how risk and safety-based information is communicated within teams during handovers. We created and tested the briefings in real operational settings to ensure staff were central to their development and that issues important to them were embedded. The approach also allowed for the escalation of risks in a quicker manner, meaning that our leaders were able to address safety related problems before they resulted in harm.
  3. We looked at increasing systems thinking capability for operational and HQ staff as a way of achieving High Reliability. This was the most fascinating challenge for me - looking at error and how we currently manage it. Error is often linked to blame, and that culture stops us really understanding the root causes of why errors occur, and this can prevent us from embracing an open learning culture in HMPPS.

Learning from other industries that use a systems-based approach to problem solving, we have developed learning materials and a Systems Investigation Toolkit for staff*. It provides information, advice and practical application for taking a systems approach to understanding problems or investigating incidents. The toolkit will help staff across HMPPS to develop a systems led approach to understanding what went wrong and why. Our work was peer reviewed by international members of the Chartered Institute of Ergonomics & Human Factors who lead the way in this field.  

What’s next?

Supporting our managers to use System Thinking is important to solve work-place problems, reduce error and work more consistently. We are building Systems Thinking into development programmes for managers and leaders. Our next challenge is to develop our understanding further to inform future operational delivery models and estate delivery reviews.

HMPPS isn’t travelling down this pathway in isolation. Many other government departments and public service bodies are also exploring better outcomes through consistent delivery, and this could be equally as useful for any organisation working in a complex system such as criminal justice. A good starting point for anyone interested is: An introductory systems thinking toolkit for civil servants - GOV.UK (www.gov.uk).

Please also feel free to contact me if you would like to find out more: HighReliability@justice.gov.uk

*HMPPS staff can find the toolkit on the HMPPS Intranet by searching 'Solve an issue using Systems Investigation'

Paula Gilbert is Project Manager – Resource & Process Group, Transforming Delivery Directorate (HMPPS): HighReliability@justice.gov.uk.

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