Enough of working in silos: how do leaders, regulators, investigators, and practitioners work together?

The issue

As documented in international research literature and seen in practice, there are difficulties, a disconnect, in understanding work processes, practices, and roles across system levels from the micro- to the macro level in different sociotechnical systems. Leaders and practitioners in high-risk organizations and regulatory bodies often have different views of what safety is, how it is created, maintained, and how it is influenced (e.g. Rasmussen 1997; Vincent & Amalberti 2016).

When accidents happen and investigations are commissioned, the results often show that weak signals could have been identified, whistleblowers could have been heard. We also see that certain safety elements that regulatory bodies and policy makers argue should have been emphasized by leaders in high-risk organizations, are in fact sometimes counterproductive and could increase risk (Kirkup 2015; Kennedy 2001; Vaughan 1996; CSB 2016). Sadly, accidents happen again and again with the same sort of causalities and recommendations issued. Could this have been better if groups of key people in the entire sociotechnical system worked more together?

It has been argued that work as imagined, and work as done are so different that there is a need for better understanding and integration across system boundaries on continuous basis. Part of the picture is also that different high-risk sectors are exposed to the same problems resulting in accidents and loss of lives. However, there is limited learning across sectors, despite the opportunities of meeting, sharing, and learning together in modern society. The reality is that learning across sectors and picking up and taking advantage of innovations and successful ideas from other high-risk industries are nicely advocated for but rarely happens in practice. To take one example, healthcare, why can’t healthcare implement safety interventions that other industries such as aviation and nuclear power have spent years developing? The reason and argument to explain this is often anchored in major diversity in context, cultures, and risk origins and the lack of contextual adaptation (Macrae and Steward 2019). But is it necessarily so that this is the main problem? We argue it is time to take a step back and stop working in silos both within and across sectors. We need to listen and learn across system levels and sectors more actively than is currently done.

In this workshop we want to investigate examples of successful collaboration in knowledge networks in complex sociotechnical systems and highlight what are the key factors to accomplish this and how processes of learning and ideas can be transferred to other organizations and sectors. We also want to understand better the sources of failures in collaboration, and the (social) mechanisms in sociotechnical systems that contribute to silos and how these can be used for learning purposes (Edmondson 2023). We wish to see a mix of examples from research and practice to draw from and shape our future safety improvement agenda. Innovation in everyday practice, crisis, and in situations occurring after accidents are highlighted as particularly interesting. Also, how regulators can play a role in fostering conditions under which leaders can work together within organizations and with regulatory bodies to support safe work practices, tools and systems are of particular interest. What is also of interest is the role of ideas or models which become popular across industries, such as the Swiss Cheese or safety culture, and how different actors in academia/consulting/publishing/regulation/industry and on social media platforms create a “safety market”. Within these markets such models, ideas or methodologies may circulate across boundaries and silos, and each time they are potentially being molded, somehow to different contexts. The question may be then what are the potential positive and negative consequences of these processes.

Workshop aim

The aim of the workshop was to critically reflect and develop new knowledge on how practitioners, leaders, regulators and investigators can work together for the common purpose of understanding risk, prevent accidents, and build safer and more resilient learning systems in different high-risk industries.

We would like to investigate into questions such as, but not limited to, e.g.:

• How can regulators foster collaborations across system levels to promote safe work practices?

• What are the incentives to learn and innovate across organizational boundaries and system levels?

• What are the incentives and disincentives for collaboration within the same system level, e.g. inside the organization, versus between system levels, e.g. between the regulator and the regulated?

• What are the sources of failure in collaborating between system levels?

• Why do silos form, what are their benefits and disadvantages for social systems?

• What tools, methods and mechanisms are used to learn from success and failure in different types of high-risk industries?

• What are the success criteria for safety innovations and translating safety into practice in different sectors?

• What is the current state of the art in investigations into accidents across sectors, and what examples of translating recommendations into action have shown evidence of effect and at what level?

• How do accident investigators learn across sectors and how do they collaborate with leaders and regulators when aiming to develop useful recommendations for safety improvement?

• What characterizes safety innovations in different sectors and how do regulatory systems and regimes support or hinder these?

• What is the role of context and adaptation when learning and transferring safety interventions and improvement efforts within and/or across sectors?

• What are the boundaries and limitations of learning and working together without silos?

• Where are there good examples of learning being successfully spread across sectors and what enabled this to happen?

• What enables implementation of change? Understanding the barriers- culture, ‘not invented here’, ‘we are different/special’, suspicion, poor communication; and similarities between sectors.

• Do we inadvertently create further silos and how do we prevent this?

• Do we need some silos to maintain enough independence for safety assurance and verification within the sociotechnical system?

• Which dilemmas may potentially emerge when reducing silos between system levels and how can these be handled?

References

CSB (2016). Macondo Blowout and Explosion, US Chemical Safety Board. Final Report.

Edmondson A. (2023). The right kind of wrong. Why learning from failure can teach us to thrive. Cornerstone Press. ISBN: 9781847943767.

Francis R. (2013). Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry Volume 1: Analysis of evidence and lessons learned (part 1). London: The Stationery Office.

Kennedy I. (2001). The report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984-1995. Learning from Bristol (Cm 5207 (II)). HMSO; 2001.

Kirkup B. (2015). The Report of the Morecambe Bay Investigation. ISBN 9780108561306

Macrae C, Stewart K. Can we import improvements from industry to healthcare? BMJ 2019; 364 :l1039 DOI: 10.1136/bmj.l1039

Vaughan D. (1996). The Challenger launch decision: risky technology, culture, and deviance at NASA. Chicago: University of Chicago Press.

Rasmussen, J. (1997). Risk management in a dynamic society: a modelling problem. Safety Science Volume 27, Issues 2–3, November–December 1997, pages 183-213

Vincent, C., Amalberti, R. (2016). Progress and Challenges for Patient Safety. In: Safer Healthcare. Springer, Cham. DOI: 10.1007/978-3-319-25559-0_1

Workshop organizers

• Siri Wiig, University of Stavanger

• Catherine Calderwood, University of Strathclyde

• Teemu Reiman, Lilikoi

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