1. Lawrence Livermore National Laboratory Managing Complex Interdependencies Cynthia A. Wagner Manager, Office of Performance Excellence November 28, 2007 The Emerging Challenge of Human Performance Improvement:

2. 2 Option:UCRL#Option:Additional Information Lawrence Livermore National Laboratory The Challenge Barriers and Practices are Dynamic

3. 3 Option:UCRL#Option:Additional Information Lawrence Livermore National Laboratory Balancing Acts at Play  Dynamic and Multi-dimensional Influence Proficiency Flexibility

4. 4 Option:UCRL#Option:Additional Information Lawrence Livermore National Laboratory 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?

5. 5 Option:UCRL#Option:Additional Information Lawrence Livermore National Laboratory 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

6. 6 Option:UCRL#Option:Additional Information Lawrence Livermore National Laboratory 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

7. 7 Option:UCRL#Option:Additional Information Lawrence Livermore National Laboratory Convergence of Information and Thinking  Do Causal Teams Really Achieve Common Understanding?  How Can We Create Transparency and Traceability of the Sensing and Thinking Process? USER NEEDS: TRANSPARENT and TRACEABLE

8. 8 Option:UCRL#Option:Additional Information Lawrence Livermore National Laboratory Human Limitations  We always know more than we can tell  We always tell more than we can write down

9. 9 Option:UCRL#Option:Additional Information Lawrence Livermore National Laboratory 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

10. 10 Option:UCRL#Option:Additional Information Lawrence Livermore National Laboratory 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

11. 11 Option:UCRL#Option:Additional Information Lawrence Livermore National Laboratory 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

12. 12 Option:UCRL#Option:Additional Information Lawrence Livermore National Laboratory Why Stream Analysis? * M. Beer and N. Nohria, “Cracking the code of change” Harvard Business Review for turnaround, p 1 1997.  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 Performance Behavior

13. 13 Option:UCRL#Option:Additional Information Lawrence Livermore National Laboratory Interdependent Components  Core Structure (organization)  Social Factors (behaviors and values)  Technology (integrated work processes)  Physical Setting (environment)

14. 14 Option:UCRL#Option:Additional Information Lawrence Livermore National Laboratory Streams

15. 15 Option:UCRL#Option:Additional Information Lawrence Livermore National Laboratory Process Management Divergence Group Consensus Review Process Retrieval Method Vertical Slices Shared Assumptions Meaning of Issues Organization Feedback Loops Timing Actions Convergence

16. 16 Option:UCRL#Option:Additional Information Lawrence Livermore National Laboratory Stream Analysis provides a step by step procedure for: Procedure 1.Forming Change Management Team 2.Collecting Data 3.Categorizing Problems 4.Identifying Interconnections 5.Analyzing the Problem Chart 6.Formulating a Plan of Action 7.Tracking the Intervention Process

17. 17 Option:UCRL#Option:Additional Information Lawrence Livermore National Laboratory Example of Discussion File 5.2.3Inadequate 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

18. 18 Option:UCRL#Option:Additional Information Lawrence Livermore National Laboratory 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

19. 19 Option:UCRL#Option:Additional Information Lawrence Livermore National Laboratory 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.

20. 20 Option:UCRL#Option:Additional Information Lawrence Livermore National Laboratory 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

21. 21 Option:UCRL#Option:Additional Information Lawrence Livermore National Laboratory Stream 1

22. 22 Option:UCRL#Option:Additional Information Lawrence Livermore National Laboratory Diagnostic

23. 23 Option:UCRL#Option:Additional Information Lawrence Livermore National Laboratory Theme – Ineffective Characterization

24. 24 Option:UCRL#Option:Additional Information Lawrence Livermore National Laboratory Theme – Reliance on Others

25. 25 Option:UCRL#Option:Additional Information Lawrence Livermore National Laboratory Stream 2

26. 26 Option:UCRL#Option:Additional Information Lawrence Livermore National Laboratory Stream 2

27. 27 Option:UCRL#Option:Additional Information Lawrence Livermore National Laboratory Theme on Safety Culture

28. 28 Option:UCRL#Option:Additional Information Lawrence Livermore National Laboratory Theme – Safety Culture 2

29. 29 Option:UCRL#Option:Additional Information Lawrence Livermore National Laboratory Questions?