What sparks the passion for procedures? - Chapter 2

What does claim 1 entail?

Claim 1 is "Teaching people procedures helps them perform tasks more skillfully". The process of transforming skills into procedures is irresistible. All we have to do is break a complex task down into steps and provide some tips about when to start and finish each step.

Procedural checklists are a shield against interruptions, reducing the chance of distraction. Procedures also help us to evaluate performance. We can see if someone knows the procedures, and is following them.

Procedures are also relevant to health care. Peter Pronovost developed a procedural checklist approach for a specific and common problem in intensive care units, line infections:

• Step 1: Wash your hands with soap

• Step 2: Clean the patient’s skin with antiseptic.

• Step 3: Cover the patient with sterile drapes.

• Step 4: Wear a sterile mask and gloves.

• Step 5: Put a sterile dressing over the line once it is inserted.

Results: Line infections dropped to zero for the next year, and the hospital saved several million dollars.

The Dreyfus model of expertise emphasizes intuition and tactic knowledge that can’t be captured in rules and procedures. People might need some rules in order to get started, but they have to move beyond rules in order to achieve mastery.

Procedures are tools. Every tool has limitations. Organizations often overstate the importance of procedures. Example: during an accident investigation, if someone finds that a procedure wasn’t followed, even if it didn’t directly cause the accident, there is a good chance that procedural violation will be trumpeted as one of the contributing factors.

By appreciating the limitations of procedures and checklists we’ll be able to make better use of them. What are those limitations?

Procedures alone aren’t sufficient

In complex settings in which we have to take the context into account, we can’t codify all the work in a set of procedures. No matter how comprehensive the procedures, people probably will run into something unexpected and will have to use their judgment. It often takes government regulation to force organizations to compile reasonably comprehensive sets of procedures, and those procedures usually have gaps.

One way to ensure that a set of procedures is sufficient is to take every eventuality into account. However, this strategy can result in the opposite problem: procedural guides that are over-sufficient and sometimes incomprehensible. The problem here is that the more comprehensive the procedures are, the more voluminous they become. And the more voluminous, the more forbidding they appear, the more work to find what is needed, and the lower the chances that anyone will try.

Why is it difficult to keep procedures updated?

Procedures are often out of date, because work practices keep evolving. This is called procedural drift. Another problem is that procedural changes that get made are often excessive. The changes, though imposed to reduce the chance of adverse consequences, may create inefficiencies in working with the new procedure.

Because procedures keep evolving, procedural guides are rarely complete.

Greg Jamieson & Chris Miller (2000) studied four petrochemical refineries in the United States and Canada to see how they managed their procedures. In none of the four cases did the workers ever completely trust the procedural guides and checklists, because they never knew how updated these guides were. Over time, some procedures had become obsolete or even counterproductive.

But there is a bigger problem than the fact that procedures are rarely sufficient and often out of date. In many cases, procedures can make performance worse, not better. They can lull us into mindlessness and complacency, and cause an erosion of expertise. In some cases, procedures can mislead us.

How can procedures lead to mindlessness and complacency?

Procedures can lull people into a passive mindset of just following the steps and not really thinking about what they are doing. When we become passive, we don’t try to improve our skills. The checklists and procedural guides can reduce our motivation to become highly skilled at a job.

Important example for forecasters. It might be cheaper to hire inexperienced forecasters and give them enough procedures to get the job done, but those who depend on accurate forecasts might pay the costs and hire experienced forecasters.

How can procedures erode expertise?

When we get comfortable with procedures, we may stop trying to develop more skills. Why bother, if procedures usually get the job done? The result may be an erosion of expertise in organizations that rely too heavily on procedures.

Research supports the idea of eroding expertise. A number of studies have shown that procedures help people handle typical tasks, but people do best in novel situations when they understand the system they need to control. People taught to understand the system develop richer mental models than people taught to follow procedures.

How do procedures mislead us?

The biggest worry is that following procedures can lead us in the wrong direction and that we won’t notice because the reliance on procedures has made us so complacent.

Example: Lia Dibello found the same thing in her observations of maintenance technicians. Experts may claim to follow procedures, but when DiBello watched them she saw them deviate from the procedures when they needed to. Typically, Experts don’t compulsively follow the procedures. If they did they wouldn’t be doing their job.

Summary: We can see that procedures are insufficient, can get in the way, can interfere with developing and applying expertise and can erode over time. Procedures work best in well-ordered situations in which we don’t have to worry about changing conditions and we don’t have to take context into account to figure out how to apply the procedures, or when to jettison them.

Unintended consequences

We would establish ‘adequate performance’ as the new ideal. It is too difficult and inefficient to continually fiddle with better procedures, which creates an endless cycle of updating. By signing on the procedural strategy we would live with ineffective designs. Then we:

• Would discourage people from using their judgment.

• Generate massive volumes of procedures, because it is too expensive to go back and cull procedures we don’t need anymore

• Would save money by retaining our current ways of doing the work. Anyone who proposed a different business or work strategy would have to ensure that it was consistent with all the existing procedures. Or else, we would just let the paperwork discourage anyone from suggesting improvements.

• We would issue procedures as a way to change behavior, even though there may be simpler and more effective strategies.

Replacement

By now it should be understandable why "Claim 1: Teaching procedures helps them perform tasks more skillfully" doesn’t always apply.

• Well ordered situations: Procedures are most useful, they can substitute for skill, not augment it.

• Complex situations: Procedures are less like to substitute for expertise and may even stifle its development.

Like all tools, procedures have strengths and weaknesses. Although I have been describing their limitations, we certainly shouldn’t discard them:

• They are training tools. They help novices get started in learning tasks.

• They are memory aids. In many jobs they help workers overcome memory slips.

• They can safeguard against interruptions. For example, pilots following a flight checklist often get interrupted, the checklist helps them carry out all the steps.

• They reduce workload and make it easier to attend to critical aspects of the task.

• They are a way to compile experience and historical information. Procedures are useful when there is a lot of turnover and few workers ever develop much skill. They help less-experienced workers do a reasonably acceptable job.

• They can help teams coordinate by imposing consistency. If the people on the team know the same procedures, they can predict one anothers next moves.

Getting procedures ‘right’ is not just a matter of getting them to be accurate or efficient or updated or covering all needed contexts, which may well be impossible and prohibitively expensive. It is also a matter of getting the organization to have the right attitude toward procedures. To put procedures into perspective, it is very important to consider the difference between directions and maps.

Teaching procedures

When we do want to teach some procedures, the typical way is to present the standard procedures and make everyone memorize them. Another way to teach procedures: set up scenarios for various kinds of challenges and let the new workers go through the scenarios. If the procedures makes sense, then workers should get to see what happens when they depart from the optimal procedures.

When procedures are taught in a scenario format, people can appreciate why the procedures were put into place and can also gain a sense of the limitations of the procedures. The scenario format seems to work better than having people memorize the details of each step. The scenarios provide a good counterpoint for learning the steps of complicated tasks.

Why does claim 1 matter?

Claim 1 matters because it creates a dilemma for workers. Too often supervisors insist that workers follow some shallow rules that never were validated. It matters because when we emphasize procedures over skills we set a standard of mediocre performance. The standard procedures become a basis for evaluating job performance, making people even less likely to adapt or improvise and more careful to comply with the rules.

It also matters because we too often issue procedures in order to change behaviour even though there may be simpler and more effective ways to do that.