Disaster Series: High-Reliability Organizing (HRO) as Self-Organization

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Daved van Stralen, MD, FAAP, Sean D. McKay, Thomas A. Mercer, RAdm, USN (Retired)

Abstract

Oscillatory processes, basic to the functions of life, are intrinsic to the stability of physiological systems. After oscillations gain stochastic resonance, the power spectrum increases in lower frequencies – as environmental stochastic noise, uncommon events gain greater influence on the system. Even weak or relatively small stochastic noise can create and sustain significant oscillations. In physiology, stochastic noise disruption beyond normal bounds is associated with disease, creating the phenomena we observe and treat. Pink noise, the 1/f oscillation, has an increasing power spectrum at low frequencies producing abrupt, rapid fluctuations that bring catastrophic failure. Self-organization promotes stability and stable patterns. As a response to stochastic noise, self-organization is an agile, adaptive response that starts with the engagement of the situation. Paraconsistent and modal logics work with inconsistent and contradictory information and the different ways things are true. Motor cognition adjusts our actions to changing situations; we learn through physical actions. Mirror neurons help us understand the intent and actions of others during self-organization, creating a gateway to social cognition. During a disaster, operations occur in a topological space which constrains and facilitates actions in pink noise crises. Self-organization is the natural and effective response to disruptive environmental stochastic noise.

Introduction: 

Random fluctuations of energy, independent of time, form ‘white noise’ following a Gaussian distribution. Feedback within the system creates stochastic resonance and time dependence, increasing the power spectrum in the lower frequencies, called ‘red noise.’ Time dependence forms a power distribution describing greater influence on the system from uncommon low-frequency events. These red noise events are also poorly predictable. A special relationship occurs at the ‘flicker’ frequency, the 1/f oscillation, where increased power spectrum at low frequencies produces abrupt, rapid fluctuations and catastrophic failure. This noise is ‘pink noise.’ 

As critical infrastructures, hospitals have a dual function for reliability. They must maintain stability and prevent failures while responding to infrastructure failures. Emery Roe and Paul Schulman described the similarities and differences of these two approaches in nuclear power plant control operators and wildland fire emergency responders. ‘Control room operations’ prevent failure of healthcare infrastructure and undertake recovery while ‘emergency response’ activates when the infrastructure fails (1). 

In a disaster, healthcare professionals accustomed to the support of the hospital infrastructure must continue the infrastructure-dependent control operator approach and assume the infrastructure-independent emergency response. Healthcare professionals and administrators often lack experience with the ‘logic of operations’ used in emergency response, which differs significantly from control room operations (1-3). Environmental stochastic noise, particularly the rapid fluctuations from fractal 1/f ‘pink noise,’ affects both responsibilities for healthcare infrastructure. The method to respond by organizational control room operations and emergency response is the same – self-organization. 

Healthcare professionals focus on protecting and treating neonates within an extreme environment (4-6). And the environment may have changed, but the processes did not. “All natural disturbances of various sizes can be seen as part of a seamless l/f-noise process. In this picture, we need not make any special distinction between normal environmental variation and ecological ‘catastrophes’: it is the same thing seen at different scales,” John M. Halley (7). 

Onsite healthcare professionals are the hospital’s and NICU’s response to a disaster. We cannot foresee every possible deviation in the disaster. Increased task uncertainty and exceptions to routine operations will overload the organizational hierarchy. Control transfers to the work domain level where teams embrace structural forms that fit situational demands by ‘self-organizing’ (8). 

Pre-planned routines are inherently ‘brittle’ and, when rotely invoked and followed, performance breaks down. Instructions are under-specified for the conditions and contexts. “This is the problem of unanticipated variability, which frequently happens during emergencies at complex technological systems. Operators need to continue operating and controlling the system in a new and unprecedented environment and adverse conditions. Coming up with an unprecedented plan is strongly culturally driven,” Najmedin Meshkati and Yalda Khashe (8). 

The 2011 Fukushima earthquake and tsunami damaged the Fukushima Daiichi and Fukushima Daini nuclear plants. (Geologists refer to this earthquake as the “2011 Tōhoku earthquake and tsunami.”) The majority of the “pre-planned” response plans did not apply to the situations that operating staff encountered. Control operators became emergency responders. Fukushima Daini operators made personal sacrifices to bring the four reactors to the cold shutdown state. The Fukushima Daiichi operators used their ingenuity on the scene to develop and implement alternative mitigation plans in real-time, showing “courage and resilience … under extraordinarily difficult conditions. Their actions potentially prevented even more severe outcomes at the plan.” “The Fukushima Daiichi accident reaffirmed that people are the last line of defense in a severe accident” (9). 

Emergency response problems did occur, generally described as coming from the Emergency Response Center (ERC) or with external teams. Planning was also faulted, “…they did not assume that a situation in which multiple nuclear reactors losing all power sources almost simultaneously would occur and thus did not provide the training and education necessary to implement measures to control such a serious situation.” “You can’t adequately prepare for a disaster that you don’t admit can ever happen” (9). 

At the Onagawa Nuclear Power Station plant, the earthquake and tsunami damaged some equipment and structures without affecting structural integrity. The plant “shut down safely” and was “remarkably undamaged.” The Onagawa plant experienced the most vigorous shaking that any nuclear plant has ever experienced from an earthquake. 

The distances from the epicenter were: Fukushima Daini 100 miles (160 km), Fukushima Daiichi 93 miles (150 km), and Onagawa 50 miles (80 km). Fukushima Daiichi and Daini plants were owned and operated by Tokyo Electric Power Company (TEPCO). Only the Onagawa power plant, owned by Tohoku Electric, went unscathed (9). 

“Operators are maintained in [complex technological] systems because they are flexible, can learn and do adapt to the peculiarities of the system, and thus they are expected to plug the holes in the designer’s imagination.” 

Jens Rasmussen (10) 

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Conclusion

The study of white-noise influences and environments relies on time independence and equal energy across all frequencies. Feedback creates stochastic resonance, increasing the power spectrum in low frequencies. This is not a gradual change, but an abrupt, punctuated shift as the power distribution replaces the Gaussian distribution. New properties emerge but not new principles. We make no special distinction between normal environmental variation and catastrophes – we can adapt our routines through self-organization.

This assumes that we developed our operations used in the white noise environment from operations effective in red or pink noise environments. There is a smooth transition from pink noise to white noise operations. When a dramatic fluctuation occurs, we readily engage through self-organization. This is HRO.

On the other hand, operations developed for or in the white noise environment will fail during catastrophic fluctuations. The difference is whether the stochastic noise creating the fluctuations is time-dependent or time-independent. White noise operations can handle time-independent fluctuations.

Catastrophes will happen, but they arise from normal processes and respond to human self-organization. Staff must routinely practice self-organization for it to be effective.

In his discussion of issuing orders, George S. Patton, Jr. (85), wrote, “Never tell people how to do things. Tell them what to do, and they will surprise you with their ingenuity.”

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Conflict of Interest: The authors have indicated they have no potential conflict of interest relevant to this article to disclose. 

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