On The Art of Creating and Managing Policies: Facilitating the Emergence of Resilience

Available on: http://www.resilience-engineering.org/REPapers/Sundstrom_Hollnagel.pdfInternational audienceResilience denotes an organization's ability to adjust effectively to the multifaceted impact of internal and external events over a significant time period. To be resilient, an organisation must be able to deal with unexpected and disruptive events as well as to understand the longer term impact of such events. In the Financial Services domain this translates into the ability to identify and successfully manage risk at all levels in the organization while sustaining a profitable business. Key tools for risk management include effective policy design and policy management processes. Based on a system state view of businesses, the paper outlines some principles for organising policy design and processes related to policy management, using an example from the Financial Services as an illustration

Modelling Risk in Financial Services Systems: A Functional Risk Modelling Perspective

http://www.resilience-engineering.org/proceedingsRE3_1.htmlInternational audienceFinancial market events in 2007 and 2008 pose a fundamental challenge for traditional Financial Services industry risk assessment approaches such as Value at Risk (VaR) models and capital adequacy risk measures. Unexampled events such as the liquidity crunch of the global credit markets, and its impact on individual Financial Services firms, clearly demonstrated the need to complement VaR risk models and traditional risk metrics with other types of risk models and metrics. The goal of the present paper is to introduce such a different type of risk modelling framework, i.e., functional risk modelling. Key concepts from resilience engineering are introduced and leveraged to define the approach. The primary goal of the proposed modelling framework is to identify functional dependencies between a firm's business functions and the functions that drive key behaviours of the global financial markets. An example from 2007's financial markets is used to illustrate the proposed framework, i.e., the rapid demise of the UK based residential mortgage firm Northern Rock

Error by design: Methods for predicting device usability

This paper introduces the idea of predicting ‘designer error’ by evaluating devices using Human Error Identification (HEI) techniques. This is demonstrated using Systematic Human Error Reduction and Prediction Approach (SHERPA) and Task Analysis For Error Identification (TAFEI) to evaluate a vending machine. Appraisal criteria which rely upon user opinion, face validity and utilisation are questioned. Instead a quantitative approach, based upon signal detection theory, is recommended. The performance of people using SHERPA and TAFEI are compared with heuristic judgement and each other. The results of these studies show that both SHERPA and TAFEI are better at predicting errors than the heuristic technique. The performance of SHERPA and TAFEI are comparable, giving some confidence in the use of these approaches. It is suggested that using HEI techniques as part of the design and evaluation process could help to make devices easier to use

Toward General Principles for Resilience Engineering

Maintaining the performance of infrastructure‐dependent systems in the face of surprises and unknowable risks is a grand challenge. Addressing this issue requires a better understanding of enabling conditions or principles that promote system resilience in a universal way. In this study, a set of such principles is interpreted as a group of interrelated conditions or organizational qualities that, taken together, engender system resilience. The field of resilience engineering identifies basic system or organizational qualities (e.g., abilities for learning) that are associated with enhanced general resilience and has packaged them into a set of principles that should be fostered. However, supporting conditions that give rise to such first‐order system qualities remain elusive in the field. An integrative understanding of how such conditions co‐occur and fit together to bring about resilience, therefore, has been less clear. This article contributes to addressing this gap by identifying a potentially more comprehensive set of principles for building general resilience in infrastructure‐dependent systems. In approaching this aim, we organize scattered notions from across the literature. To reflect the partly self‐organizing nature of infrastructure‐dependent systems, we compare and synthesize two lines of research on resilience: resilience engineering and social‐ecological system resilience. Although some of the principles discussed within the two fields overlap, there are some nuanced differences. By comparing and synthesizing the knowledge developed in them, we recommend an updated set of resilience‐enhancing principles for infrastructure‐dependent systems. In addition to proposing an expanded list of principles, we illustrate how these principles can co‐occur and their interdependencies.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/156462/2/risa13494_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/156462/1/risa13494.pd

Task analysis for error identification: Theory, method and validation

This paper presents the underlying theory of Task Analysis for Error Identification. The aim is to illustrate the development of a method that has been proposed for the evaluation of prototypical designs from the perspective of predicting human error. The paper presents the method applied to representative examples. The methodology is considered in terms of the various validation studies that have been conducted, and is discussed in the light of a specific case study

Implementing resilience engineering for healthcare quality improvement using the CARE model: a feasibility study protocol

BACKGROUND: Resilience engineering (RE) is an emerging perspective on safety in complex adaptive systems that emphasises how outcomes emerge from the complexity of the clinical environment. Complexity creates the need for flexible adaptation to achieve outcomes. RE focuses on understanding the nature of adaptations, learning from success and increasing adaptive capacity. Although the philosophy is clear, progress in applying the ideas to quality improvement has been slow. The aim of this study is to test the feasibility of translating RE concepts into practical methods to improve quality by designing, implementing and evaluating interventions based on RE theory. The CARE model operationalises the key concepts and their relationships to guide the empirical investigation. METHODS: The settings are the Emergency Department and the Older Person's Unit in a large London teaching hospital. Phases 1 and 2 of our work, leading to the development of interventions to improve the quality of care, are described in this paper. Ethical approval has been granted for these phases. Phase 1 will use ethnographic methods, including observation of work practices and interviews with staff, to understand adaptations and outcomes. The findings will be used to collaboratively design, with clinical staff in interactive design workshops, interventions to improve the quality of care. The evaluation phase will be designed and submitted for ethical approval when the outcomes of phases 1 and 2 are known. DISCUSSION: Study outcomes will be knowledge about the feasibility of applying RE to improve quality, the development of RE theory and a validated model of resilience in clinical work which can be used to guide other applications. Tools, methods and practical guidance for practitioners will also be produced, as well as specific knowledge of the potential effectiveness of the implemented interventions in emergency and older people's care. Further studies to test the application of RE at a larger scale will be required, including studies of other healthcare settings, organisational contexts and different interventions

Identification of parvalbumin interneurons as cellular substrate of fear memory persistence

Parvalbumin-positive (PV) basket cells provide perisomatic inhibition in the cortex and hippocampus and control generation of memory-related network activity patterns, such as sharp wave ripples (SPW-R). Deterioration of this class of fast-spiking interneurons has been observed in neuropsychiatric disorders and evidence from animal models suggests their involvement in the acquisition and extinction of fear memories. Here, we used mice with neuron type-targeted expression of the presynaptic gain-of-function glycine receptor RNA variant GlyR {beta}3L(185L) to genetically enhance the network activity of PV interneurons. These mice showed reduced extinction of contextual fear memory but normal auditory cued fear memory. They furthermore displayed increase of SPW-R activity in area CA3 and CA1 and facilitated propagation of this particular network activity pattern, as determined in ventral hippocampal slice preparations. Individual freezing levels during extinction and SPW-R propagation were correlated across genotypes. The same was true for parvalbumin immunoreactivity in the ventral hippocampus, which was generally augmented in the GlyR mutant mice and correlated with individual freezing levels. Together, these results identify PV interneurons as critical cellular substrate of fear memory persistence and associated SPW-R activity in the hippocampus. Our findings may be relevant for the identification and characterization of physiological correlates for posttraumatic stress and anxiety disorders

Virtuality in human supervisory control: Assessing the effects of psychological and social remoteness

Virtuality would seem to offer certain advantages for human supervisory control. First, it could provide a physical analogue of the 'real world' environment. Second, it does not require control room engineers to be in the same place as each other. In order to investigate these issues, a low-fidelity simulation of an energy distribution network was developed. The main aims of the research were to assess some of the psychological concerns associated with virtual environments. First, it may result in the social isolation of the people, and it may have dramatic effects upon the nature of the work. Second, a direct physical correspondence with the 'real world' may not best support human supervisory control activities. Experimental teams were asked to control an energy distribution network. Measures of team performance, group identity and core job characteristics were taken. In general terms, the results showed that teams working in the same location performed better than team who were remote from one another

A field study of team working in a new human supervisory control system

This paper presents a case study of an investigation into team behaviour in an energy distribution company. The main aim was to investigate the impact of major changes in the company on system performance, comprising human and technical elements. A socio-technical systems approach was adopted. There were main differences between the teams investigated in the study: the time of year each control room was studied (i.e. summer or winter),the stage of development each team was in (i.e. 10 months), and the team structure (i.e. hierarchical or heterarchical). In all other respects the control rooms were the same: employing the same technology and within the same organization. The main findings were: the teams studied in the winter months were engaged in more `planning’ and `awareness’ type of activities than those studies in the summer months. Newer teams seem to be engaged in more sharing of information than older teams, which maybe indicative of the development process. One of the hierarchical teams was engaged in more `system-driven’ activities than the heterarchical team studied at the same time of year. Finally, in general, the heterarchical team perceived a greater degree of team working culture than its hierarchical counterparts. This applied research project confirms findings from laboratory research and emphasizes the importance of involving ergonomics in the design of team working in human supervisory control