Application of systems thinking in the work area

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At a very basic level, a system is simply a set of interdependent components interacting to achieve a common specified goal. Systems are such a ubiquitous part of our lives that we often fail to recognize that we are active participants in many systems throughout the day. When we get up in the morning, we are dependent on our household systems (e.g., plumbing, lighting, ventilation) to function smoothly; when we send our children off to school, we are participants in the school system; and when we get on the highway and commute to work, we are participants (and sometimes victims) of our transportation system. At work, we find ourselves engaged simultaneously in several systems at different levels. We might report to work in a somewhat self-contained setting such as the intensive care unit (ICU) or operating room (OR),what human factors practitioners refer to as microsystems,yet the larger system is the hospital itself, which, in turn, is likely to be just one facility in yet a larger health care system or network, which in itself is just one of the threads that make up the fabric of our broader and quite diffuse national health care system. The key point is that we need to recognize and understand the functioning of the many systems that we are part of and how policies and actions in one part of the overall system can impact the safety, quality, and efficiency of other parts of the system.

Systems thinking offers you a powerful new perspective, a specialized language, and a set of tools that you can use to address the most stubborn problems in your everyday life and work. Systems thinking is a way of understanding reality that emphasizes the relationships among a system's parts, rather than the parts themselves. Based on a field of study known as system dynamics, systems thinking has a practical value that rests on a solid theoretical foundation. Ecological systems and human social systems are living systems; human-made systems such as cars and washing machines are nonliving systems. Most systems thinkers focus their attention on living systems, especially human social systems. However, many systems thinkers are also interested in how human social systems affect the larger ecological systems in our planet.

Systems have several defining characteristics:

• Every system has a purpose within a larger system. Example: The purpose of the engineering projects department in my organization is to generate new ideas and features for the organization.

• All of a system's parts must be present for the system to carry out its purpose optimally. Example: The contract management system in my organization consists of people, equipment, and processes. If you removed any one of these components, this system could no longer function.

• A system's parts must be arranged in a specific way for the system to carry out its purpose. Example: If you rearranged the reporting relationships in engineering department so that the head of outage section reports to the entry-level Project Manager, the department would likely have trouble carrying out its purpose.

• Systems change in response to feedback. The word feedback plays a central role in systems thinking. Feedback is information that returns to its original transmitter such that it influences that transmitter's subsequent actions. Example: Suppose you turn too sharply while driving your car around a curve. Visual cues (you see a mailbox rushing toward you) would tell you that you were turning too sharply. These cues constitute feedback that prompts you to change what you're doing (jerk the steering wheel in the other direction somewhat) so you can put your car back on course.

• Systems maintain their stability by making adjustments based on feedback. Example: Your body temperature generally hovers around 98.6 degrees Fahrenheit. If you get too hot, your body produces sweat, which cools you back down.

• It emphasizes wholes rather than parts, and stresses the role of interconnections-including the role we each play in the systems at work in our lives.

• It emphasizes circular feedback (for example, A leads to B, which leads to C, which leads back to A) rather than linear cause and effect (A leads to B, which leads to C, which leads to D and so on).

• It contains special terminology that describes system behavior, such as reinforcing process (a feedback flow that generates exponential growth or collapse) and balancing process (a feedback flow that controls change and helps a system maintain stability).

2.2 Systems Thinking as a Set of Tools

The field of systems thinking has generated a broad array of tools that let you (1) graphically depict your understanding of a particular system's structure and behavior, (2) communicate with others about your understandings, and (3) design high-leverage interventions for problematic system behavior.

These tools include causal loops, behavior over time graphs, stock and flow diagrams, and systems archetypes all of which let you depict your understanding of a system to computer simulation models and management "flight simulators," which help you to test the potential impact of your interventions. Whether you consider systems thinking mostly a new perspective, a special language, or a set of tools, it has a power and a potential that, once you've been introduced, are hard to resist. The more you learn about this intriguing field, the more you'll want to know!

2.3 Outage department's safety system "As is"

The current safety systems that we using in my department are very much reactive systems, with a very minimum period of time woking for Eskom I have realized that preventative measures for incidents are only put in place after an occurrence of an accident. The system thinking approach is currently not applied within the outage department especially on the safety side, and this is not only not applied by my department, but the eighty to nighty percent of the organision. Upon to my experience within the organization I have observed that most preventative systems are being applied only when/after an incident has occurred and the system's approach is the same over an over again. This approach is not only applied repeatatively, but also it is a reactive approach. Where the incident will be analysed on the area where incidents took place(Observatios), Investigations/findings, learning points, incidents causes(Direct Cause, Root Cause & Contributory Causes), Barrier Analysis and Recommendations.

Where as systems thinking steps back or up and get a bigger picture of the situation, and then contemplate the numerous win/win interdependencies required to optimize the various systems needed in a Total Safety Culture. This is systems thinking for safety. It is relevant for various aspects of safety management and safety improvement. The following principles emanate from such a perspective, and run counter to some traditional approaches to safety and health management.

There is not one root cause:Systems thinkers do not try to find one root cause of an incident or injury. Small-scale and independent thinking leads to a search for one single cause of a mishap. And, some consulting firms market flow charts and computer programs to help us analyze an incident in order to find the root cause.

At risk behavior contributes to nighty five percent or more of most injuries, whether intentional or unintentional. But does this mean a particular individuals at risk behavior is the root cause of the injury? If you raise your helicopter higher to get a bigger picture of the situation, youll undoubtedly find a number of other factors contributing to the most relevant at risk behavior.

Injury is caused by environment, behavior, and person factors: The factors that cause a near miss or injury can be classified into three domains: environment (including tools, equipment, and climate of the work setting), person (including attitudes, beliefs, and personalities of the individuals involved), and behavior (including the safe and at-risk practices of relevant individuals). Factors within and between these three domains are interactive, dynamic, and reciprocal. A change in a factor within one domain influences other factors in that domain, and eventually has impact on factors within the other two domains. For example, changes in an environmental factor affect peoples behaviors and attitudes; and behavior change usually results in some change in the environment.

When people choose to change their behavior, they adjust their attitudes and beliefs (person factors) to be consistent with their actions. This change in attitude can influence more behavior change and then more attitude change. This spiraling of behavior influencing attitude, and then attitude influencing behavior reflects the reciprocal interdependency between our outward actions and our inward feelings. And, an initial change in behavior or attitude can be sparked by an environmental

factor. Thus, systems thinking requires a consideration of interactive variables within two human domains (person and behavior) operating within a particular set of environmental factors.

The management system of an organization is one environmental factor that has dramatic impact on the human factors of person and behavior. But, the true affect of the management system might not be apparent without a comprehensive measurement system. For example, a top-down authoritarian approach to management (as in safety is a condition of employment) might influence certain behavior to occur in certain situations, but the negative person factors affected by such a management style might influence contrary behaviors in situations where people cannot be held accountable to a supervisor for their actions. And, such negative person states might inhibit feelings of personal ownership, commitment, and loyalty needed to facilitate long-term total involvement in a safety process.

Assess safety with measures of environment, behavior, and person factors: The systems perspective reflected in the interactive domains of environment, behavior, and person leads logically to the basic principle that a safety measurement system include measures of factors within each of these domains.The environment and behavior domains can be systematically assessed with periodic audits of environmental conditions and work practices. And, perception and attitude surveys can be useful barometers of person factors. The point here is that systems thinking means our on-going proactive measure of organizational safety must include an evaluation of environment, behavior, and person factors. The traditional reactive measures of safety (such as number of recordable injuries or work compensation costs) have little diagnostic.Value with regard to understanding or changing the system variables that are causing the outcomes, whether desirable or undesirable.

Systems thinking for safety enables a clear understanding that outcome measures can be influenced by a number of factors unrelated to safety improvement. For this reason, holding people accountable for numbers of injuries rather than for completing certain proactive procedures for injury prevention can do more harm than good. In such situations, the system puts pressure on people to cover up their injuries, and even their near misses. The result might be a decrease in negative outcome numbers, at least over the short run, but what about the bigger picture? Might such a situation decrease peoples belief that they can truly control safety? Could such system pressure to hide injuries lead to reduced personal motivation to accomplish the proactive activities needed to prevent injuries?

With systems thinking you will answer yes to both of these questions. In this case, you will consider behavior-based and person-based factors potentially influenced by management system factors focused on reducing the numbers. In some environments employees are disciplined (actually punished) for being injured, or at least made to feel embarrassed. Other companies offer rewards if employees avoid injury and keep the numbers down. Some even add peer pressure to the situation with the contingency that all employees lose their reward when one person reports an injury. Systems thinking enables us to understand the problems with these kinds of programs.

Injury investigation is fact finding, not fault finding: Systems thinkers see the fallacy in punishment and reward programs based on injuries. They view such reactive attempts to reduce the outcome numbers from a broader perspective. They realize that injury prevention requires a focus on proactive activities upstream from an injury. For example, because its critical to investigate minor injuries and near misses, system thinkers attempt to remove any aspects of their environment that could inhibit the reporting of safety-related incidents (including penalties for injuries and rewards for not having injuries). They also add factors to facilitate the reporting and investigating of near misses, first-aid cases, and minor injuries -- incidents that are not typically recorded but could be informative regarding the prevention of more serious injuries.

Obviously, injury investigation must be seen as finding facts to prevent more injuries. If factors or contingencies in the system promote a fault-finding perspective toward injury investigation, then information critical to preventing injuries could be stifled. It's been proven experience that the fault-finding perspective usually begins with undue focus on outcome rather than process when evaluating safety success.

Feedback directs and motivates. The best evaluation numbers provide feedback we can use to improve the relevant process. When feedback follows our actions, it is a consequence that affirms or contradicts our behavior. Positive (supportive) feedback tells us we are correct and motivates us to keep doing what were doing. In contrast, negative (corrective) feedback informs us of a mistake and motivates us to stop a particular behavior and try another approach. Sometimes supportive or corrective feedback follows our behavior naturally, as when we hit a nail with a hammer, drive a golf ball with a five iron, or cook a delicious meal. Each of these examples is actually a response-consequence system which allows us to adjust our behavior on successive trials according to the built-in feedback. When we change our behavior as a function of natural feedback, the consequence becomes an activator for the next behavior. In this way, feedback both motivates and directs behavior in a spiraling system of behaviors producing consequences that provide information for continuous improvement. Rarely if ever does safe behavior have a built-in feedback system to support and direct it. In other words, when we take the extra time and inconvenience to protect ourselves or others from a potential injury, we usually do not receive a natural consequence to motivate us to continue. With systems thinking, however, we see the bigger picture and realize that someday someone in the work system will gain directly from the protection. Thus, systems thinkers dont need immediate quick fixes to keep them safe. They understand that cause and effect is not necessarily immediate nor linear. Taking the time to be safe today, for example, can help develop a personal habit that could pay off personal dividends in the future, or it could teach others by example and protect them now or later from injury.

Systems thinkers realize the special need to add extra feedback to motivate and activate safe behavior. They understand that the natural feedback from convenience, comfort, or a faster outcome usually competes with the completely safe way to do something. Thus, systems thinkers look for ways to support safe behavior and correct at risk behavior.

2.4 Departmental's silo operation

3. Steps taken to the system "as it should be"

3.1 Creative & proactive Approach to Safety

As it has been mentioned previously on the system "As is" in my department, now we going into the system "As it should be" putting more focus on proactive safety systems. Creating and sustaining safety in the workplace is a common goal for all companies, although one that few accomplish. It is possible, though, so why does this goal elude so many companies? One issue is that of the status quo repeating itself the relationship and response to safety is typically one of reaction-prevention instead of proactive-prevention. Until the cycle is reversed, companies will continue the unnecessary and frustrating struggle for a safer working environment. "Prevention often turns out to be reaction in disguise".(Geoffrey Gioja)

Safety management has evolved over the years from one of no formal relationships, procedures or processes around safety,to a reaction-based mode to the current reaction-prevention based model. The first change was provoked by the 1940s passage of the Worker Compensation Act, which for the first time held companies financially liable for injuries on the job. As a result, companies became more proactive and safety performance improved.Nearly 30 years later, the OSHA Act an industry-wide management focus on compliance was enacted provoking a new wave of reaction. While the 1950s saw an awaking of a desire to focus on at-risk behavior instead of just the hazardous conditions, the OSHA Act and the ensuing compliance

focus pushed that approach aside until later. Many of the workplace changes that have since transpired, including systems that are characterized as proactive, are

usually more preventative in nature. These are positive changes steps in the right direction that should not be minimized. However, there is more work to be done. There is need for a genuine reaction and commitment to an injury-free


History tends to repeat itself at organizations: react, prevent; react, prevent. Examining the daily management of safety reveals that on good days, prevention prevails, but on bad days, reaction takes over. Our best managers will oftenshift to prevention mode even when things go wrong. Even so, much of the efforts to prevent incidents are based on a desire to avoid the consequences of those incidents. In fact, employees and supervisors are most often more concerned about preventing the organizational consequences of a first-aid injury, for example, than they are about preventing a firstaid incident itself. As said above, "Prevention often turns out to be reaction in disguise."

The next step to a system of safety management is goal-oriented, based on these ideals:

• A shared commitment to the complete elimination of workplace injury

• Authentic leadership engagement in the safety effort

Next organizations can focus on:

• Transforming safety from a priority to a valuesbased mind set

• Developing a culture of genuine concern about safety, rather than the company's rules and compliance

• Creating an environment in which the individual's intrinsic values are respected, instead of being regarded primarily for their instrumental value.

3.2 A Shared Commitment to the Elimination of Injury

While most companies we encounter are committed to safety, relatively few are committed to eliminating injury in the workplace. Many companies do, in fact, espouse a zero-injury focus. However, when questioned, the overwhelming majority

of individuals in those organizations do not truly believe this is a viable goal. "Eliminating Injury" in these cases is merely the company code for "doing the best we can", which fosters a demotivated environment in which people think they are

working toward something that they do not actually believe is attainable. The company's safety culture and performance are then compromised by what it says is possible verses what it actually believes is possible. When commitment is established, there can be no doubt in the minds of managers, supervisors and workers that safety is not and never will be a numbers game. Without this clearly spoken and widely believed commitment, people will not have a place to stand upon to bridge the gap between reaction and prevention. One of the tests of whether safety is sincerely held as a value is management's approach (toward attitude) about off-the-job injury. If leadership is seen as being unconcerned or less than genuine in their speaking about safety off the job, they will be perceived as less than sincere about their professed concern for safety on the job. Safety is a value not a strategy.

3.3 Authentic Leadership Engagement

A shared goal, across the company, to the elimination of injury is a necessary step to enterprise transformation. Traditional safety environments stifle workers from expressing concerns and voicing what's "not popular" for fear of retaliation. It is

vital to create a culture in which people are encouraged to speak openly and honestly, rather than fear being punished. The commitment to this culture must permeate

the entire organization both old and new employees. Once established, the safety vision, commitment, and process require nurturing. Even the most powerfully spoken,

thoroughly integrated, genuine commitments naturally devolve toward a "check the box" approach when not monitored. It is the responsibility of each level of the organization to regularly re-engage people in the safety initiative. Once these conditions are established (and then consistently renewed), management can focus on the issues and opportunities, which will not be in short supply. It is important

for management and employees to collaborate on ways to support each other in meeting the challenges that accompany any truly creative undertaking.

3.4 From a Priority to a Value

Safety as a value is a simple statement, but one that is not always as easily executed as one would assume. Safety as a value and number one priority is a common goal of many managers; however, it can lead to difficulties because it requires transforming the behavior and beliefs of leadership, individual employees and the general culture.

A typical view by hourly employees is that production (schedules, productivity and cost) are the real priorities. Leadership must change this perception by consistently treating safety as a value that places human safety above production.

The way in which managers speak about their commitment to safety must align with their actions. Disregard for this challenge undermines even the most sincere effort. Management's task is to ensure that the safety culture has transformed, and continually reinforce open communication and authentic relationships. To be

effective, management must quickly bring to the surface perceptions that are a barrier to realizing the commitment to eliminate injury and greet employee's views and opinions with an open ear. They must be eager to manage and change the environment.

3.5 Judgment and Choice vs. Compliance

In an injury-free environment, management must be willing to recognize compliance-based safety processes and procedures, while stretching their thinking and beliefs beyond the rules. While we will not take the time here to delve into the limits of compliance as a basis for safety management, suffice it to say that it is necessary and should be enforced, but it does not guarantee sound judgment and choice. Compliance does not require that people be safe it merely requires that they give the appearance of being safe. Being "legally safe" is a poor and potentially dangerous substitute for transforming a culture into one that embraces and believes in safety.

3.6 Respecting People for Their Intrinsic Value

Treating people with genuine respect and concern is one of the most effective ways to help create an injury-free environment. Low morale, feelings of disrespect and loss

of dignity, and 'quality of life' issues are all indicators of discontented workers, which can lead to careless work habits. An environment in which individuals are seen primarily in terms of their instrumental worth, such as their value as a worker instead of their value as a human being, does not elicit the safest, most productive work. An environment in which morale is high, and employees feel dignified and respected,

enjoy a high 'quality of life' at work, and feel recognized primarily for their intrinsic worth, will elicit the maximum contribution and capacity from employees.

3.7 Recommendation

When companies experience enterprise transformation, extraordinary results happen. Through our work we see employees harness their intrinsic value in service of eliminating injury on their job. When management and employees consistently take the high road and create environments in which people know they are valued and

cared about, they are more likely to give more to their work, by working harder, better and more safely. The moment the culture transforms into a values-based

environment instead of a strategy, real and lasting change can occur. Breakthrough results are not produced simply by going after the results, but by doing the right things.

4. Casual Loop Diagram


5. Conlusion

Systems thinking offer us a powerful new perspective, a specialized language, and a set of tools that we can use to address the most stubborn problems in our everyday life and work. Systems thinking is a way of understanding reality that emphasizes the relationships among a system's parts, rather than the parts themselves.

Why is systems thinking valuable? Because it can help an organization design smart, enduring solutions to problems. In its simplest sense, systems thinking gives us a more accurate picture of reality, so that we can work with a system's natural forces in order to achieve the results we desire. It also encourages us to think about problems and solutions with an eye toward the long view,for example; how might a particular solution we considering to play out over the long run. And what unintended consequences might it have?

What exactly is a system? A system is a group of interacting, interrelated, and interdependent components that form a complex and unified whole. Systems are everywhere for example, the Finance department in your organization, the circulatory system in your body, the predator/prey relationships in nature, the ignition system in your car, and so on. Ecological systems and human social systems are living systems; human-made systems such as cars and washing machines are nonliving systems. Most systems thinkers focus their attention on living systems, especially human social systems. However, many systems thinkers are also interested in how human social systems affect the larger ecological systems in our planet.

Systems thinking is a perspective because it helps us see the events and patterns in our lives in a new light and respond to them in higher leverage ways. For example, suppose a fire breaks out in your town. This is an event. If you respond to it simply by putting the fire out, you're reacting. (That is, you have done nothing to prevent new fires.) If you respond by putting out the fire and studying where fires tend to break out in your town, you'd be paying attention to patterns. For example, you might notice that certain neighborhoods seem to suffer more fires than others. If you locate more fire stations in those areas, you're adapting. (You still haven't done anything to prevent new fires.) Now suppose you look for the system such as smoke-detector distribution and building materials used that influence the patterns of neighborhood-fire outbreaks. If you build new fire-alarm systems and establish fire and safety codes, you're creating change. Finally, you're doing something to prevent new fires!