The Effects of Organizational Culture on System Reliability: A Cross-Industry Analysis

 

Management often attempts to design and control the culture, but culture is difficult to manipulate from the top

down. These attempts are often viewed skeptically by the workforce at large, often because of lack of follow

through and the impression that the effort is “just another flavor of the month” policy. In many cases, senior

management does not exhibit the attributes of the culture they are trying to create within the organization,

confirming these suspicions.

The effects of organizational culture on system reliability

A complete investigation of all potential influences of culture on system reliability is beyond the scope of this paper.

The areas with the greatest potential for reliability improvement will be highlighted and discussed.

 

1 Communication

Perhaps the area where organizational culture has the most significant and often negative impact on reliability is in

vertical communication. Vertical communication refers to the ability of upper management to transmit corporate

values, strategies, and priorities to employees as well as the ability of employees to convey relevant insights and

challenges upstream to management. Technology has made communication easy by supporting company Intranets

where executives can distribute mass communications to employees and employees can either respond directly or

send their own communications via email to senior executives. However, this has led to a greater volume of

communication, but added volume is as likely to decrease reliability as it is to improve it. The psychodynamics of

management-employee relationships creates challenges that cannot be overcome through advanced communications

technology. Instead, intra-organizational communication must be managed with a focus on reliability rather than

simply capability.

For example the CAIB report concluded that NASA did too little to encourage vertical communication from

flight engineers and technical staff to mission decision makers. Management also suffered from an information

cocoon in which the culture encouraged fitting in by buying into a common perspective. Research has shown that

when the only information entering the deliberation process already coincides with existing consensus, there is no

opportunity for deliberation. This reduced NASA’s mission reliability and led to the Columbia disaster.

Similarly, the 2004 report from the Senate Select Committee on Intelligence reported that the CIA succumbed to

groupthink when it concluded that there was a serious threat of Iraq weapons of mass destruction . In part this

was due to a deliberation process that ignored or missed relevant information held by many employees. The CIA

had formal methods to avoid groupthink, but these procedures were not followed because of the force of the

organizational culture.

There are also potential challenges to horizontal communication. Horizontal communication refers to

communication among and between work groups at the same level of the organizational hierarchy. Indicators that

are noticed out of range must be communicated to individuals who can use that information to perform needed

repairs or adjustments. Often, it is taken for granted that these individuals already are aware, particularly when the

organization culture does not stress individual responsibility or it penalizes risk taking. In contrast, the Toyota

Production System philosophy encourages any worker who sees a potential fault to immediately, and without fear of

repercussion, halt the production process.

Another type of horizontal communication that suffers from organizational limitations are shift handoffs. Handoff

errors can occur when incidents span multiple shifts and transition processes from one shift to the next are not

designed to accommodate typical challenges. Often, organizations in this domain do not support effective handoff

processes by providing adequate resources and incentives. At the end of shifts, workers are interested in leaving the

workplace as quickly as possible and at the beginning of shifts workers are interested in jumping immediately into

those activities for which their performance is judged. The mechanisms of performance evaluation thus degrade the

quality of handoff communication and reduce the reliability of the system. This effect can be observed in many

industries, including health care, industrial process control, and others.

 2.Accountability and blame

When personnel in an industry are motivated by fear to hide errors, this can have a significant negative impact on

reliability. This is a particular challenge in the medical field because of the fear of litigation. Not only might

individual errors fail to be corrected [8], but the learning opportunities to identify recurring trends to allow

different facilities to benchmark their performance against each other is lost. For example, hospital pharmacists

described in are more likely to report errors they find from other departments. Social pressures discourage

reporting errors within the department and tangible penalties discourage any reports of ones own errors. In order to

overcome these kinds of challenges, Daly [9] describes a voluntary system in which names are removed. By

maintaining anonymity, the fear of liability is eliminated. Resolving the damage of a particular error is not

supported, but identifying trends and benchmarking can still be accommodated.

Accountability can also play a role in whether employees report near misses into an error reporting system. In

addition to formal rules and regulations, organizations develop psychological contracts that either supplement or

supersede official policies. A psychological contract is when both parties feel an obligation to engage (or not

engage) is specific behaviors, contingent on the other party engaging in a complementary set of specific behaviors.

 

In the safety arena, psychological contracts emerge from the organizational culture. If workers perceive that

the organization will not take action to address reported unsafe conditions (part of its behavioral commitment), then

workers feel absolved from reporting them, even if this reporting is required by official policy. In this way, an

organizational culture can eliminate the benefits of a well designed policy.

3 Incident investigation

Organizations must establish a culture that cherishes mistakes as opportunities for improvement. In complex

systems, where root causes can only be identified after a large volume of incidents are mined for common trends,

industry-wide databases are necessary. The aerospace industry has been able to achieve this through federally

supported incident investigation efforts and the concomitant increase in reliability across the entire industry has been

significant. It is possible for medical care to duplicate this success, however, there are additional challenges because

of the complex management structure of the health care industry, in which doctors are often independent contractors

for hospitals, multiple organizations, (different medical specialties, insurance providers, clinics, technical staff,

medical labs) must work collectively to coordinate care, and each component has a different lexicon and process

model .

Examples in workplace safety and injury reporting also reflect the effects of organizational culture. A reporting

system is dependent on the organizational culture to encourage reporting of minor events and near misses (near hits)

which are critical to achieve a sufficient sample size in the incident database to identify trends and root causes.

According to Heinrich’s injury triangle, every major incident has a large number of similar near misses and minor

incidents that have the same underlying causes. The culture must encourage the reporting of these events so that the

major incidents can be prevented. But without organizational support, workers do not see the benefit of reporting

such events. There is little chance that this reporting will lead to any direct benefit to the worker and there is a

larger probability of negative repercussions if reporting is not supported culturally.

4 Enforcement

An organization’s normative efforts to enforce its rules and regulations also can be a major contributing factor of its

culture to system reliability. When an organization has lax enforcement, rules are interpreted more as guidelines

than rules. Employees then feel an unspoken sanction to violate them. This trend generally starts when the violation

allows them to satisfy dominant organizational values and objectives, such as violating safety rules to increase

productivity. But it can expand to include personal benefits such as avoiding fatigue or just taking shortcuts to make

an activity easier.

5 Collaboration

In many cases, inter-departmental collaboration is necessary to achieve overall system reliability [2]. This has

become increasingly relevant for organizations that have geographically dispersed teams and diverse cultures.

Communities of practice have been shown to increase the power of collaborative activities among knowledge

workers, but only when collaboration is supported by the appropriate performance evaluation system. Without a

supportive organizational culture, valuable information that can be used to enhance system reliability will be missed.

Similarly, knowledge databases can be used to enhance system reliability , but only if supported by the

appropriate organizational culture. As illustrated by the CaSIDA model of knowledge management systems , a

systematic process to manage knowledge capture and dissemination is necessary to complement the technological

processes of knowledge integration. The capture and dissemination aspects of knowledge management are

significantly impacted by cultural norms.

Conclusions

There are many aspects of organizational culture that can impact system reliability. These impacts can occur

throughout the system lifecycle. It is important for organizations, particularly those in reliability-critical industries

such as health care and aerospace, to assess their cultures and determine how they are affecting reliability.

Organizations can work towards developing cultures that enhance reliability rather than degrade it.