Want to prevent history from repeating? HR and L&D must turn inquiry recommendations into action – David Buchanan and Steve Macaulay explore how to implement change after serious incidents
- Recommendations from inquiries into serious incidents often sit on a shelf gathering dust, so…
- How can HR/L&D make sure that recommendations are implemented, and prevent further incidents?
Crises can strike any organisation, any size, any sector, at any time. All agree that ‘this must never happen again’. But will it lead to real change? Following an accident or disaster, you might assume that changes would be welcome, automatic, straightforward. Receptiveness to change should be high. Resistance should be low. Implementation should be rapid and easy.
The evidence shows these assumptions are wrong
For example, eight-year-old Victoria Climbié was killed by her guardians in 2000. The public inquiry made 108 recommendations. But in 2007, 17-month-old Peter Connelly was killed by his mother, her boyfriend, and her lodger while supervised by the same agencies that failed Victoria. The chair of the Climbié inquiry noted that child protection agencies ignored his recommendations, adding: “I despair about organisations that have not put in place the recommendations which I judged to be little more than basic good practice.”
In a separate case, we studied the death of a hospital patient. She was admitted for minor surgery, and later died from a drug interaction which was not spotted in time. There was a special inquiry, followed by three reviews of progress in implementing the recommendations. By the time of the final review, five years later, only 19 of the 46 recommendations were completed. The majority were not implemented.
Active learning difficulties
Incidents like these are usually seen as failures of organisational learning. But that can’t be the case. The learning is already there, in the investigation reports and recommendations.
The problem lies with the distinction between passive learning (identifying lessons), and active learning (implementing change). Effort is poured into incident investigation. But recommendations usually come with no advice on how to implement them.
Here is an opportunity to introduce those changes you always wanted. This is the origin of the phrase ‘Never waste a good crisis’
Organisational change failures
There are five main reasons why organisations don’t change following serious incidents:
Time lag: Inquiries can take months, in some cases years, to complete. In the meantime, the sense of urgency around the original incident is lost. And other priorities arise which push the incident out of memory and off the agenda.
Not my agenda: We know that support for change is increased when those affected have a say in what will change and how.But incident inquiries are typically conducted by independent investigators. The resulting change agenda is imposed from outside.
Not my problem: Recommendations for change can often affect the whole organisation, including sections not directly involved. Why should they change? Expect outright resistance or passive apathy from those who see themselves as ‘not guilty’.
Not my job: Responsibility for implementing inquiry recommendations is often vague. If recommendations are wide-ranging, then no one individual may have the authority to implement them. In this case, a dusty shelf beckons.
A lengthy ‘to do’ list: Serious incidents often result from system failures; a search for root causes and individuals to blame is unhelpful. But system failures need system solutions, which is why investigations produce long – and daunting – lists of recommendations.
Five actions HR/L&D can take to embed change
1. Autonomy: Staff at all levels must be empowered to implement changes to working practices, to reduce the chance of future incidents. This means changes to job descriptions, to expand decision rights, and to supervisory practices, to focus on supporting rather than directing. Greater autonomy can strengthen job satisfaction, commitment and motivation.
2. Teamwork: Employees who haven’t worked in teams before (and some who have) can benefit from training in collaborative working, and group problem-solving and decision-making. Using the group involved in the original incident can be valuable in this respect.
3. Training and development: Basic change management practice is important: clarity of purpose and goals, urgency, participation and communication.
4. Performance management: Incorporate change implementation goals in quarterly performance reviews, supported by demonstrable actions linked to inquiry recommendations.
5. Recognition: Publicise and celebrate achievements and successes in implementing changes that will prevent future incidents or reduce the probability of them happening. Praise that is visible and sincere also improves motivation, and the sustainability of the changes.
Don’t be entirely defensive
Serious incident inquiry recommendations are defensive, designed to prevent something from happening. Most changes, in contrast, are developmental, to reduce costs, improve quality, cut time to market, enhance customer experience, grow market share and increase profitability.
A defensive change agenda is less fun. ‘Success’ is defined by the non-occurrence of another incident. Those involved have nothing – literally – to show for their efforts. This is another reason for failure to implement inquiry recommendations: ‘What’s in it for me?’.
It helps, after a serious incident, to design a change agenda that combines defensive and developmental components. Here is an opportunity to introduce those changes to working practices, job design, team allocation, equipment/office layouts and so on that you always wanted. This is the origin of the phrase ‘Never waste a good crisis’.
Get it moving!
Resist, if possible, the temptation to wait for an inquiry or investigation to report. That could take time. You can often second-guess what some of the recommendations are likely to be. You can also start to design and implement a related developmental agenda.
How to ‘sell’ this? Easy – all these changes will contribute to reducing the likelihood of future crises:
- Recognise successes. Let the shelf gather dust on its own.
- Involve those who will be responsible for implementation, so they have ownership.
- Empower them to act, and provide necessary training.
- Adjust your performance management criteria as we discussed earlier.
Steve Macaulay is an Associate at Cranfield Executive Development, Cranfield University. He can be reached at: s.macaulay@cranfield.ac.uk
David Buchanan is Emeritus Professor of Organisational Behaviour at Cranfield University School of Management. He can be reached at: david.buchanan@cranfield.ac.uk