Real leaders leave a legacy. They capture the hearts and minds of their teams. Their origin story puts the safety and wellbeing of their people first. Great companies ubiquitously have safe yet productive operations. For those companies, safety is an investment, not a cost for the C-suite. It’s a real topic of daily focus. This is The Safety Guru with your host, Eric Michrowski, a globally recognized ops and safety guru, public speaker, and author. Are you ready to leave a safety legacy? Your legacy success story begins now.

Hi and welcome to The Safety Guru. Today I’m very excited to have with me Craig Clapper. He’s a systems engineer, founder of Reliability for Life, or R4L, and we’re going to have a really interesting conversation today around systems, healthcare. It will be fascinating. So, Craig, welcome to the show. Very excited to have you with me.

Good. Thanks for having me with you today.

So, let’s get started with your background and how you got passionate about safety, because it was quite an interesting journey.

Excellent. Yeah, I got into this business as an engineer, and I was doing failure analysis work in nuclear power. And I noticed an interesting effect. We had a lot of repeat events, sometimes the same equipment failing for the same reasons.

Right. 

So, in an effort to improve reliability of nuclear power, is I got into this business, which is more about human reliability and systems. I didn’t know at the time, but it kind of took over my professional career. So, I worked in nuclear power, then power in general, transportation, manufacturing, and then for the last 25 years in healthcare.

And so, one of the things you’re looking at is, is essentially why would smart people repeat the same problems, right?

Yes, and repeat other people’s problems as well. I think both are important, us learning over time, but then the shared learning of learning from each other.

And so, tell me a little bit more about this theme around smart people making the same mistakes, or as you said, making some— the same mistake that somebody else did.

Excellent. Yeah, is that we know that, you know, people when they go to work or when they’re at home or at play, for that matter, is that their intent is always to do well.

Right.

Human error is a natural byproduct of people, and when we work in complex systems, that byproduct shows up even more frequently. Right. I think Jeff Raskin said it better than I. He said that everybody is human first and then either an expert or a novice second, but there is no such person that never experiences a mistake, or more accurately, an error.

Yes, an error, right? I think I only met one person who admitted in their mind they had never made a mistake. He was a tax accountant, but he was corrected by his CFO who questioned his assertion.

Yeah, so maybe even saying that was a mistake on his part.

That would be one of them for sure. And so, you talk about systems. Phil, so first, what are systems? We’ve talked about this topic quite a few times on this podcast. And why are they becoming so complex?

You bet. I think the fastest way to kind of smooth over the controversy is that when some people say process, they’re probably talking more about a work system. Sure. Systems are made up of everything, you know. So, when you talk about systems thinking, we say they’re made up of things. And together those things provide functions.

Right.

So, everything that we point to is a work system.

Mm-hmm.

So, we say aviation is a work system, nuclear power is a work system, a power plant is a work system, and then it gets even a little smaller and more granular.

Sure.

But I think what’s different is that it takes us away from processes, which makes us think everything’s linear, right, to thinking more about the nonlinear effect of real work. And over time, you know, technology becomes more complex. The needs of the system to perform become more complex. So, complexity is always increasing around us. And that makes it difficult for us as individuals because we can’t see everything that we’re doing. So, we’re reliant on other people and trying to grasp that situational awareness in the moment to see where we’ve been and where we’re headed.

Yeah, and I think your point is— so definitely there’s a sense that systems are getting more complex. You talk about technology. I remember I had an MIT professor join the podcast a little while back, and his analogy was talking— you might have heard about this one about Ford Mustang from the 1960s versus a Ford Mustang today, and how many engineers does it take because of the complexity of everything that’s engaged and involved. But even when you think about healthcare in terms of way back when, we didn’t have the fields of expertise to the degree we have now. And something like cancer treatment is no longer the domain of one doctor. It’s a domain of multiple different doctors that are essentially speaking different languages.

Oh yeah, that’s an excellent point, both on the car and the healthcare analogy. And everybody becomes hyper-specialized to deal with all that complexity. And then there’s creases, the number of handoffs and the number of people involved. I really relate to the auto example. My first car was a 1970 Chevy Impala, and my dad taught me how to do a lot of the work on it. And now when I open the hood, it’s just— I might be looking for a UL code so I can call somebody that actually knows how to fix it. Right.

It’s impossible to— tweak it like you could way back when.

Yeah.

And so, you talk about the complexity that comes in, um, that brings— I like the expression you use, that, that systems become very brittle. Um, so tell me, what are some of those things that we can do to make systems more resilient?

You bet. Yeah, because, uh, resilient means they’re tough and can bounce back. And sometimes we use the word resilient to mean like after an event. But you can also talk about resiliency in the middle of event or even at the very beginning to prevent events outright. Sure. So, in complex systems, safety comes from resiliency. And I think the best thing to do when you start on this aspect of your safety journey is to think, you know, systems can be simple. Where the knowledge and skill and the tools kind of rule the reliability.

Sure.

But then they can be complicated, like assembling a jet aircraft.

Sure.

You know, a plane is a very complicated machine, yet we want it to be the same. So putting it together just requires standard work. So standard work is our best friend. 

Yep.

But when we get to complexity, is that things aren’t always the same and they’re not predictable, and some things that are unknown are unknowable. So, what makes reliability in complex systems work is our ability to think as an individual, but think together as our team, as a team. 

Sure. 

And then to extend that to resiliency is that you have to think, I believe situational awareness is the root of all resiliencies.

Sure.

Somebody realizes that something is different, and they can think together and then they have an adjustment that they could make. So, they make the adjustment and then they get back on track. In fact, David Woods, you know, from Ohio State, the cognitive psychologist, he had observed that we really don’t have safety events because people make mistakes. We have safety events because they don’t perceive the need to make an adjustment. So, they don’t adjust.

Sure.

And I paraphrase that. I’m sure his quote is better than that.

And so that makes a very interesting perspective as well, because it’s what you talk about, the situational awareness. You see it very regularly in terms of something changes in the environment, the conditions, but we’ve done the same routine work many, many times and we don’t notice. We may have a blind spot to changing conditions. We may not realize that a new risk is introduced or that new risk could be a small change that’s happening in the system. And so, when you talk about resilience, you also talk about this element of learning and bouncing back. And then there’s also this element of a better recovery. Tell me a little bit more about what that entails.

Sure. Yeah, it’s in Eric Hollnagel’s work in resiliency engineering. He includes learning as one aspect of resiliency. And I think that was very insightful. Is that, you know, we learn from our past experiences. So now we know what to look for. And when we perceive that, then the sensemaking is both faster and more accurate. Plus, we have ideas on what adjustment that we’ll want to make. Sure. So, I think that learning aspect, you know, is very important. And earlier when we touched on shared learning, I think it becomes even more important because I’ve also come to realize in doing this work is that we don’t have a lot of foresight. Usually what we call foresight is actually somebody else’s hindsight.

Yeah.

And we recognize that because we heard it from a colleague or we read about it in a report or we heard it on your podcast. Right. So suddenly why it’s novel, it hasn’t happened to us, is that we have some insight because we’ve learned from you, perhaps.

Right. And the element of better recovery. So, there’s the element of how we learn, but what about better recovery?

Yeah, I think the recovery aspect is both like traditional and well understood and still at the same time poorly understood. Remember that television show MacGyver? I think there’s even a reboot on MacGyver.

Yes. 

Yeah, so each generation can relate to MacGyver. And his recoveries were all improvisation, which is nothing what safe systems look like. Right. In safe systems, recovery is more preset. So, we’ve anticipated to this, we’ve written some instructions, we may be trained in simulators. So at least we have a plan B in place. So now when we perceive the need, we can invoke the plan, and we can perform reasonably well. But to kind of add to that is I’d worked with a physician. He was the chief medical officer. He was the ED physician who received the patients who came from the hotel, the Hyatt Regency Hotel in Kansas City, when their walkway collapsed. 

Oh, right. Yeah.

That was a very well-known event in the engineering world. And what Bill told me was none of our pre-planned stuff worked. You know, we had all of these things in place, and we had done the drills, but really what worked, what gave us that resiliency was getting people to the ED that knew both about the patients as well as the ED as well as how the hospital worked. There, the thinking together with the people, that’s what made the resiliency work in his mind. I believe that as well, because I’ve not been in the Technical Support Center on many real nuclear events. I was in one alert, but I’ve also been in many, many drills. The thing I remember most about the drills is the NRC people controlling the drills Nothing that we had ready to go ever worked because they wanted to test us. They wanted to test and see how resilient we were when our plan B didn’t work and what was our plan C as in Charlie and D as in Delta.

Interesting.

So, I’ve become a big believer in both is, you know, get prepped, be ready, have things to go, but then also be prepared to be there and make adjustments so that your adjustments work.

It’s very similar to pilot training. What you’re describing in terms of putting different scenarios where we know things have not go per plan and then having that complexities go into different additional scenarios to see how you respond to those events.

Yeah, that’s an excellent example. And, you know, not being a pilot is, you know, we get to see a lot more about aviation safety than I think other people get to see of things like nuclear safety or patient safety.

Sure.

But, you know, to your example, Eric, I think Al Haynes, who was the captain of that United flight that lost all their hydraulics and was able to land in Sioux City, a good example of with all the preparation work in air transportation, that was still something that was outside of their experience and training.

Correct.

Yeah. To circle back to our earlier point though, is after that event, you know, changes were made, both in procedures as well as training. And I think even there was some hardware changes that were made to give them additional capabilities when they lose hydraulics.

Yeah. The sad part on that particular one is from a system design standpoint, there was the engineer, one of the engineers that designed the hydraulic system for it, for the DC-10, allegedly. So he wrote a book afterwards, allegedly had Escalade raised the concern that there wasn’t a failover if the hydraulic line was cut, but it was ignored as a very low probability risk at the time, and struggled living with himself afterwards and trying to deal with the aftermath, knowing that he saw something, but whether he pushed far enough to drive the change.

Well, my, my hope is he came out okay. Yes, in the long run after that.

Exactly.

I think to touch on another aviation event, there was a large airliner for one of the Japanese carriers that they had a structural failure and lost their tail.

Oh yeah, yep, Japan Airlines.

And remember, the engineer who designed the repair actually took his own life, so he did not work through that.

He didn’t. It helped. Exactly. Yeah. So, so this element you touched on as well in terms of situational awareness. Is that something you can train, and how do you do it in a context like healthcare?

Yeah, that’s an excellent question. I follow the work of Micah Ensley quite closely on situational awareness. So oftentimes when I speak, I’m talking directly from the Ensley model. Remember that she was the chief scientist for the United States Air Force. When she developed that. If I was the chief scientist for the United States Air Force, I’d tell everybody. In fact, I would lead the podcast with that. But as 3 elements, there’s the perception first, and then there’s the sensemaking, and then there’s the projection part. And I think we really have to talk as we go and as we train and as we educate the new folks on what do we look for and why and what’s good and bad look like. And that’s part of that learning aspect. That you were touching on is that you can teach people what to look for. In fact, back to Hall Nagel, his first step of the 4 is knowing what to look for. So, I think that’s one of the overlooked parts of situational awareness is getting people to understand where they should be looking and what they should be looking for and what the good and bad look like.

But if you can get that first step, the perception, then you have a good chance to do that second step, which is that cognition, and think about, okay, what does that mean for us in the moment?

And so, in a scenario like this, because it assumes that the scenario is knowable, or is there ways of even sensing if you don’t know that the particular scenario could occur?

Yeah, yeah, a good point is that, you know, things that have happened before, we tend to have a little more collective insight into, but then we want to be prepared for things that we haven’t seen before. And I think to touch on another book, the Wyckoff and Sutcliffe book about high reliability organizing, they call it managing the unexpected. Sure. So, we have managing the expected Hey, this is a known event. But then we also need to be prepared for what happens when things look like they’re not known events, or maybe even it’s an event that’s unknown to everybody.

Sure.

So, in James Reason’s work, he talks about situational surprise. Hey, this happens. I just didn’t think it was going to happen today. Yep. But then there’s fundamental surprise where we never thought this would ever happen. And maybe in that United flight with the loss of hydraulics, they viewed that as a fundamental surprise. That one engineer mentioned that maybe we should prepare for this. And they said, oh, that hasn’t happened and will never happen because we have 3 independent and redundant hydraulic systems. You know, the probability that we would lose all of the hydraulics. Even though on that United flight, Their American Flight 191 had lost all hydraulics takeoff at Chicago’s O’Hare Airport.

Right.

So, they had a chance to realize that one assumption was poor and maybe even make some adjustments in those few years they had between the American flight and the United flight. Keep in mind, I’m not an aviation safety expert, but when you’re into the safety business like yourself, is you tend to look at aviation events and power events and bridge failures and dam failures. And here’s a traffic, you know, situation. And there’s a lot of commonalities in how and why we experience these safety events.

Yep. And I know when we spoke, you had some very powerful examples from healthcare, from some of the work from healthcare that illustrate systems, how they can be brittle, but also how you can increase resiliency. I’d love if you could share some of those stories and examples.

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Sure. Yeah, you know, so the system that’s brittle fails suddenly without warning. So, brittleness is the opposite of resiliency.

Sure.

So resilient systems are a little tougher. And if you like trees, you can say oak is a little more brilliant or brittle.

Yep.

And the palm tree is a little more resilient. It bends over in the wind.

Sure.

I actually prefer the candy analogy a little better. So, there’s the toffee, which snaps. It’s brittle, but the caramel, you know, is a little more resilient.

Yes.

And in healthcare, we need to be a lot more like the caramel.

Right.

And the idea is that They’re both made of the same basic ingredients, but the caramel is prepared at a different temperature. So, the sugar molecules are a lot longer and they’re more connected.

Sure.

And in healthcare, when we’re more connected with each other is that we team better and it makes us more resilient. And you know, that’s a good lesson. So, in healthcare, there’s many medication errors where it happens all at once and it’s over.

Right.

But then there’s also examples of where we have good second chances. If we monitor well after the patient receives the med, we realize they’re in distress and maybe there’s a reversal agent or maybe there’s some longer-term treatment. I think the best healthcare event to know in terms of resiliency happened in the Pacific Northwest. There’s actually an equipment failure a catheter malfunctioned in an open-heart procedure and burned a hole through this patient’s heart.

Oh wow.

And they realized, hey, this is trouble. How do we bounce back from this? So they, they kept him alive on a mechanical heart, an assistive device.

Sure.

And then they looked for a transplant, and they found a donor, and he received a heart transplant. And he wakes up weeks later at another medical center to hear quite a story about how they saved his life.

My goodness.

So that, that in my mind is like the Apollo 13 resiliency story showing up with our healthcare providers. 

And also, a failure that is likely not on the radar of the average surgeon that’s performing. You’re not expecting the equipment maybe to malfunction, but also then to burn, to cause a burn.

Definitely. So, so we don’t know if that was situational or fundamental surprise, but I’m positive that when they were doing their procedure, they weren’t thinking that, hey, this Swan-Ganz catheter is going to get hot as a firecracker and burn a hole right through this man’s heart. And then what would we do?

Right. 

And as far as I know, that, that was the first time that healthcare ever encountered something like that. So that was them managing the unexpected.

No kidding. Any other examples of the work that you do in terms of healthcare space to make the system more resilient?

Yeah, yeah. Our thinking is that, you know, if we practice good safety science, we should be able to reduce those harm events in healthcare by 80% every improvement cycle. So for big hospitals, that’s about every 2 years. Sure. In practice, most people see more of a 50% reduction.

Still substantial.

Still, still good enough. And we look for that both in patient safety as well as workforce safety. Mm-hmm. I think the difficulty in resilience engineering is that it’s not something that you can buy. It’s an emergent property of the work system.

Sure.

So, for systems to become more resilient, you have to get healthcare leaders to understand what makes us brittle, what makes us resilient, so they can jealously guard the things that they have while they work on adding more. So, you know, people who can think, like strong critical thinking skills, including questioning attitude.

Yep.

Getting response teams together. In healthcare, almost everybody has like a rapid response team or a medical response team.

Sure.

But then also, I think the untapped part is with technology and information systems. Can we use what we know in the electronic healthcare records to create more situational awareness among the caregivers and providers?

Sure.

Remember that show House? Another TV show. I have a kind of a TV show theme today. House seems to be the most opposite of all the healthcare television shows. Because they have one patient with a group of doctors that has nothing better to do but sit around and talk about their one patient. And in my experience is that it’s, there’s many patients and everybody has to split their time among many patients, but they’re never sitting around with their other doctors talking about one patient. Sure. But then the healthcare record, if we can use, uh, AI perhaps, or, or other, uh, more straightforward technologies to tell us what’s going on with our patients. So, I hold out a lot of hope for things like automated global trigger tools.

Sure.

And how the triggers can set situational awareness and maybe even create a central nervous system for a hospital where instead of having safety huddle for 15 minutes in the morning, we have more of a control room for the hospital, where we have people that can watch over populations of patients and do that perception in the Ensley model.

Interesting. When you were touching on that, you started out by talking about people becoming critical thinkers. How do you help people improve their critical thinking skills? Because it’s so important in the system view, right? 

Yeah, so important. I don’t think it matters which industry you look at, that the thinking errors are the single largest contribution to the severe loss events. In healthcare, it’s 40%. 40% of the acts leading to serious patient harm are critical thinking breakdowns. And then as you go to other industries, you know, the numbers can come up and come down, but it’s the single largest bit.

Sure.

The experts in talking about thinking are split. Some of them say that it’s a talent and others say, no, it’s a skill. And I’m firmly in the skill family. Is that not everybody can be great as a thinker, but everybody can become a little better. Sure. I think the best way to teach thinking is to create a vocabulary so you can talk about it. And then through the context of job experiences, share how you think and think differently. The nuclear power operators and the physicians I work with both say the same thing. In our training, there are a lot of technical details. We have to learn the right answers, but we also learn how to think differently. They’re a little more structured in their thinking. They have more discipline. They use logic more like the physician’s differential diagnosis. 

Sure.

In fact, if you want to get started, I’d recommend two well-known books, especially for your healthcare listeners. How Doctors Think by Jerome Groopman. He uses case study method and it’s an easy read. Better by a nurse, Gay Rubenfeld. Critical Thinking Tactics for Nurses. Now, she’s a nurse and a nurse educator and researcher, so she wrote it from a nursing perspective. She could have easily entitled her book Critical Thinking Tactics for Everybody on the Planet. She does a good job in saying, here’s what we mean when we say critical thinking, and here’s how to get started with some skills. But that might be the best answer, you know, to your question is that You know, human performance in general and culture and even the bigger picture, 3-step approach. Define a behavior as an expectation, something like questioning attitude.

Sure.

Then enable them with the knowledge and skills so they can do that if they choose. So now I have somebody that knows what to do and knows how to do it if they choose. And then step 3, that habit, that accountability is that big step where they actually practice that skill that they know as a habit. And that’ll give you that human reliability and to a large degree, that resiliency that you’re looking for.

And you touched on this element of questioning attitude and that struck me in any nuclear operation I’ve worked with. Is how embedded that mindset, or even the terminology around questioning attitude, is in everyone. And it turns into habits, rituals that occur daily. You would think that that’s something you can easily transpose in any environment as well.

Yeah, I think transpose, yes. And then when you said easily, that one didn’t strike me as strong, but that might be that questioning attitude that you talked about is that, you know, growing up in that environment, I was, I was 22 and right out of college when I worked in a nuclear power plant. So, I grew up in that environment, and it’s surprising how much, how sharply they think and then think with each other.

Yes.

So, in a nuclear power plant, you don’t make any bold assertions because now you have the entire room, you know, kind of picking apart your thinking, right? You get out into the rest of the, the world especially like on social media, is that the critical thinking not nearly as sharp. And people don’t question assumptions and they don’t really look for the logical fallacies. But I think you’re exactly right with those reactor operators, pilots on the flight deck, is those operators that are at the sharp end tend to have a very keen questioning attitude. Cause it might be, you know, the saying, which I heard it from a reactor operator, but maybe it was also a pilot saying, is that there’s old pilots and there’s bold pilots, but you don’t see too many old, bold pilots.

They haven’t made it. I think there’s an element as well to get to that questioning attitude. I’ve observed definitely within pilots, there’s a sense of once you’re in the air, it’s an unforgiving environment. So, you don’t want to be in that scenario, that situation. There’s also this, I call it a healthy paranoia. Others have created other terminology that’s probably more eloquent around it, but there’s a healthy degree of expecting something could go wrong. And I see very similar characteristics in nuclear because the consequence is huge, you know, it’s unforgiving. And so, there’s this paranoia, healthy paranoia, which supports questioning attitude. You expect things to not go necessarily per the plan.

Yeah, yeah, excellent point. I would probably frame that around the preoccupation with failure, which is one of those 5 Wyckoff and Sutcliffe HRO principles, is, you know, that to have a preoccupation with failure is you have a very healthy skepticism and you attend to all of the little things that you need to go right in an effort to have nothing go wrong. Maybe what James Reason called the dynamic non-event. So, I think preoccupation with failure is very misunderstood, especially in healthcare. They make it sound like we just sit around with this anxiety that things are going to go horribly, horribly wrong. But no, no, it’s that you know that you have to be focused on a lot of important details to give yourself some assurance that it’s okay. So, it can add up to success.

Correct.

And, and so the way you had framed that, I think, is, is very accurate and very helpful in advancing that in the positive about what we should be doing.

Yeah, because if you assume, if you have an overconfidence bias, assume a positive outcome, you’re more likely to miss some of those early warning signs that something is happening in the system.

Exactly. Yeah, now to add to that point is, you know, in a nuclear power plant, the one that I worked in most recently was worth $4.5 billion. And if we made a mistake, we could turn a $4.5 billion asset into a $500 million liability.

Right.

Plus, we all would lose our jobs and maybe we would spread radioactive contamination apart. Across the eastern United States. That, that could all happen, right? But I thought in healthcare, where there was a living person in your hand and you had the ability to either make them better or to harm them and maybe take their life away, that seemed to be even a closer link to safety in my mind.

You think so? Yeah.

So, I’ve talked to some of my clinician colleagues about this, and they said, “No, I still think that the airline pilot and the nuclear power operator have a bigger responsibility.” But having worked in those industries, I wonder if it’s back maybe into the caregivers and providers in healthcare. I think like a perfusionist who is running a machine that has the blood from their patients circulating and becoming oxygenated. Right. They are literally controlling the life of that patient. Absolutely. And it’s not like being on the flight deck of a 787 to say like, well, if this happens, then this might happen. And then if this goes bad and we don’t recover here and you go through like 8 things, is then we can have an event. I mean, I think it’s a more direct linkage. Sure. I would maintain that everybody’s job and safety is important. Absolutely. And I think it’s an element of how you see your role and the ownership you take in that direct call. Yeah, yeah.

Especially that idea of that risk sensitivity, that what you’re doing at the moment is, is very important. And if it goes wrong, here’s what happens. And then how do we know that it’s go wrong? Because there’s usually a story behind it. Sure. Where here’s what happens.

And Craig, you’ve authored books, um, and you help organizations improve the resilience of their system. Um, tell me about your books and tell me a little bit about how somebody can reach out to you if they want, um, your to carry this conversation forward, or also think about how I could make my system more resilient.

Exactly. Well, thanks. Yeah, I think the best way to read about our work in healthcare is through Zero Harm. Sure. So, it talks about safety management systems in healthcare and improving both patient safety and workforce safety. If you wanted a more compact form, I wrote a chapter with our chief executive officer, who’s a nurse, Tammy Strong. And that shows up in the Healthcare Quality book. It’s Chapter 5 on safety science and high reliability organizing. So given the opportunity, read a whole book or read a chapter. I think a lot of people go for the chapter. And I admire that, you know. But I like to talk to leaders, especially who are safety minded. And the easiest way to get a hold of us at Reliability for Life is through our website. Or we have a strong LinkedIn presence, and you could either look for the company Reliability for Life, or you can look for me, Craig Clapper, PE.

Excellent. Well, thank you so much, Craig, for joining me today and sharing your thoughts around systems, uh, how we can make them more resilient, how individuals can become better critical thinkers and, and surface, uh, potential brittle systems. Or items within a brittle system. Excellent.

Thank you for having me. Excellent.

Thank you so much. Take care.

Thank you for listening to The Safety Guru on C-suite Radio. Leave a legacy. Distinguish yourself from the past. Grow your success. Capture the hearts and minds of your teams. Elevate your safety. Like every successful athlete, top leaders continuously invest in their safety leadership with an expert coach to boost safety performance. Begin your journey at execsafetycoach.com. Come back in two weeks for the next episode with your host, Eric Michrowski. This podcast is powered by Propulo Consulting.