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Part II of this three-part series presents a roadmap to human error prevention.
This article is the second in a series designed to offer industry leaders and managers at all levels a road map to excellence in human performance and human error prevention. The benefits of human error prevention are many. High reliability organizations enjoy reduced costs, increased efficiencies, and a sharp competitive edge. Achieving human performance excellence, the hallmark of a high-reliability organization, is not a fantasy; it is a proven, eminently achievable method of cultivating and sustaining exceptional levels of performance. This proven approach is a coordinated implementation and integration of three key elements: human factors training, the establishment of an open reporting system, and a thorough incident investigation process. Such a system is complementary to the biotechnology industry’s cGMP requirements for training and corrective action, as human errors pose risk and must be investigated for appropriate corrective action commensurate with that risk. Through human factors training and an open reporting system, the organization can be transformed to one where the workforce is empowered, engaged, and proactive in the pursuit to reduce human error and achieve human performance excellence.
Part one of this series discussed how an organization can begin making the journey to human performance excellence by learning from the experts and adopting a new perspective. The recognition that human performance requires a systemic approach to error reduction is a pivotal first step. As the aviation and nuclear power industries have shown, deviations reflect weaknesses in an organization’s systems, not in its people. When human performance is embraced, knee-jerk, corrective responses to errors disappear and are replaced by meaningful, effective reforms, not the least of which is the implementation of an open reporting system that all can learn from (see Figure 1).
The second article in this series explores the fundamental principles of high-reliability organizations and key knowledge from BioPhorum Operations Group (BPOG) members.
Key Principles for Success
The nuclear power and aviation industries have emerged as world-class leaders in the field of human performance. Their hard-won experiences underline the need for “Right First Time, Every Time” operational excellence. In such organizations, human performance is an integral part of the culture, embraced at all levels and demanded by regulators. From these high-reliable organizations, the following practical principles for success can be drawn:
• Human performance is not a project or a program. Human performance excellence doesn’t have a beginning, middle, and end. It is simply a part of the way things get done every day. It is ingrained in the organization’s DNA, and a proactive, open reporting culture is the norm (see Table I for more on open reporting cultures).
• CEO sponsorship and top executive buy-in are essential for success. The quest for human performance excellence requires champions, effective advisory boards, investments, and the time and means to deliver the expected returns on investments.
• Behaviors and standards are clearly defined at every level, in all areas. Be clear about what human performance excellence requires. Requirements might include discussion of prior events during briefings prior to high-risk activities, expectations for shop-floor after action reviews following these activities, and organizing simple informal learning group activities to teach techniques and best practices.
• Performance is managed. Human performance objectives are visible and aligned with corporate and site performance goals, and managers ensure that everyone understands how their actions contribute to the achievement of the organization’s objectives.
• Management adopts a strong presence. Managers at every level need to observe their people regularly. They know what the right behaviors look like and they coach their people effectively. Managers must regularly step out of the office and onto the work floor to ensure that human performance tools are being used in the right way and performance is meeting expectations.
• Technology is used wisely. Knowledge management programs have a large technology component that can be used to search for prior incidents, share lessons learned, and help staff learn from events in other industries.
• Metrics are visible and consistent. Human error types are categorized and applied consistently. Examples of error types include lack of knowledge or understanding, cognitive process, problem detection/diagnosis, execution errors, and skill/performance errors. Reports are timely and show the rate of learning as well as error reductions, and are communicated effectively in ways that people can relate to and understand.
• Effective learning from failures and successes is supported. The open reporting process and follow-up actions must be executed under an environment of a “just culture.” In a “just culture,” there is an atmosphere of trust, where honest mistakes are treated fairly. Errors are learning opportunities and people are encouraged to speak up about their issues, which must then be acted upon. People must be confident that reported issues will be handled in a fair and just manner that not only protects the integrity of the company but also and of equal importance the individuals involved. In the same manner, those individuals who are found to have knowingly violated company policies are treated firmly but fairly.
• Leaders lead. Leaders should demonstrate and reward the right behaviours.
Learning From BPOG Members’ Experience
BPOG members engage in internal and external benchmarking activities, regularly share lessons from experience in online meetings, co-create tools and other assets and meet face-to-face to synthesize ideas and recommendations. Key among their recommendations form experience are the following:
• Provide human performance awareness training for everyone. No exceptions. Begin with top management. Training typically can take at least two hours to half a day; don’t underestimate the effort that is required to enable people to understand what human performance is all about and what the organization is doing to embrace it. Plan on several months to put everyone through the training.
• Implement causal factors analysis (CFA). Establish investigation teams, including key managers, and train them to effectively use CFA.
• Provide superior human performance skills training. Training should be directed to three target audiences: workforce, managers, and engineers/other specialists. Begin with core skills training. After core skills, train cross-functionally as much as possible. Implement an effective process and resources system (e.g., learning management systems) that enables people to continually refresh, test, and develop their skills in using human performance tools.
• Implement a leader observation and coaching program. At all levels from site lead to line, have managers conduct 6-12 active observations to support the use of human performance thinking and tools in practice. This can be run as part of existing practices such as regular gemba walks and safety checks. Show and train your leaders to do it well.
• Introduce a human performance practitioner role. Individuals who have the respect of their peers and colleagues should be selected to drive change and coach the leaders and teams in human performance. Be sure to provide them sufficient time to accomplish this properly.
• Speak with data. Have meaningful human error categories and establish true root causes, making ‘effectiveness and performance,’ and not simply compliance, the incentive for corrective and preventive action.
The final installment of this series will review the eight crucial steps for success in human performance.
About the Author
Gerry McAuley is an experienced business consultant and facilitator to the Human Performance Group at the BioPhorum Operations Group.