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Near Misses or Good Catches in your organization

toolbox_falling_on_worker_18726Near miss reporting is one of the most powerful information streams your organization has the ability to learn from. Do people in your organization understand and know what to report and how? Are they encouraged to report by the leadership team and by each other? What is the minimum threshold for how significant an incident is before it is recommended to be reported? Do you have a system in place where the issue is first discussed with supervision and then written up if leadership deems the issue noteworthy? Would  everyone in your organization answer questions related to near misses with the same answers? Regarding metrics, it is worthy to note that how well your reporting culture thrives is a positive and true indicator of your company’s safety culture in general, but don’t get stuck on reporting counts. Instead, get stuck on a lack of reports when accidents and incidents are still occurring.

Classification

Consider these examples:

A tool falls off a beam and…
Level One  …nobody is around as it falls to the floor below.

Level Two  …someone is in the area, but it misses them completely as it falls to the floor below.

Level Three  …someone gets hit on the hardhat and the tool bounces safely away as it falls to the floor below.

Level Four  …someone gets hit on the shoulder and it doesn’t cause a first aid, but it did hit the individually before falling to the floor below.

Are ALL four of these levels considered near misses in your organization? What level needs to be reported? How do you describe a near miss to your organization? If you know the answers to these questions, then kudos, but if your organization knows the answers to these questions, then you may very well have a healthy and intact Near Miss reporting program.

Definitions:

The National Safety Council identifies a Near Miss as an unplanned event that did not result in injury, illness, or damage – but had the potential to do so. Only a fortunate break in the chain of events prevented an injury, fatality or damage; in other words, a miss that was nonetheless very near.
Good Catch?

Do you scrap the near miss concept and only discuss the incident as a good catch?

How important is it to call it a good catch program, and not a near miss program?

Consider the Texas Nurses example by clicking here:

Good Catch Program Encourages Reporting Near-Miss Medical Errors

Reporting

How do you report near misses? You should do your best to describe the hazard and the associated risk, and any ideas for either eliminating the hazard, or reducing future risk.

Fire fighters have a universal place to submit their near misses: http://www.firefighternearmiss.com

Even some colleges have reporting programs:

https://scsapps.unl.edu/EHSNearMissReporter/

Reasons for not reporting:

According to an Underwriter’s Laboratory Article, the three reasons why people would not report a near miss are:

  1. Fear of blame – Individual does not want to tell on co-workers or themselves for fear of ridicule or personal accountability/culpability.
  2. Incoherent indifference – Individual believes nothing will happen anyway, so why bother taking the time.
  3. Lack of supervisor support – Leadership does not encourage or embrace the advantages of learning lessons when there are no significant consequences.
What is the difference between a hazard and a risk?

Hazard: Anything that can cause harm

Risk: Potential that a hazard will cause harm

Do you think it matter when talking about safety and near misses to get the terminology right? It absolutely does! Using terminology properly models that you know what you are talking about and that this is important to you. These two terms are very important when discussing Good Catches and Near Misses.

Check out these related articles and videos:

The Value of Near Miss Reporting by the Ohio Bureau of Workman’s Comp

Seton article contains best practices when creating a new program

National Safety Council: More reasons why people won’t report

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CAT Near Miss Reporting Video

HillSolomon’s Near Miss Training Video

Hazard vs. Risk Training Video

Kuala Lumpur’s USMC Good Catch Reward Video

Good Catch Video Brooke Army Medical Center

Offering Human Performance Improvement Training

hpi4Human Performance Tools, LLC is offering affordable human performance improvement training for any and all industries looking to reduce human error and prevent events caused by them. The training content is sourced straight from the collaboration efforts of the Department of Energy (DOE) and the Institute of Nuclear Power Operators (INPO). After contacting the Department of Energy and their Liaison to INPO, I have been directly authorized to use the content within these human performance manuals as my basis for these training sessions.

Human Performance Improvement Training

Understanding the genesis of human error teaches us how it can be better managed. This translates to positive results in all parts of your organization, and at an individual level. Nobody wants to be the person singled out for an error, especially when anyone given the same situation would have made the same mistake. These courses are designed with teaching students how to predict, prevent, and correct human error within the framework of the systems they work within.

What is it?

Human error reduction and event prevention are two areas every company can benefit from. The Institute of Nuclear Power Operators (INPO) and the Department of Energy (DOE) came together a few years ago and developed a manual that addresses the roles of individuals, leaders, and the organization in improving performance, as well as practical methods that people can employ in their day-to-day lives. This training brings that content alive in the classroom employing an expert instructor with a vast array of technical hands-on human performance experience in nuclear power plants around the United States.

Principles of human performance are the foundation blocks for the behaviors described and promoted in the handbook. The strategic approach for improving performance is to reduce human error and manage controls so as to reduce unwanted events and/or mitigate their impact should they occur.

For the purposes of this training, an event is an undesirable change in the state of structures, systems, or components or human/organizational conditions (health, behavior, controls) that exceeds established significance criteria.

Human performance improvement (HPI) as addressed in this training is not a program such as Six Sigma, Total Quality Management, etc. Rather, it is a set of concepts and principles associated with a performance model that illustrates the organizational context of human performance. The model contends that human performance is a system that comprises a network of elements that work together to produce repeatable outcomes. The system encompasses organizational factors, job-site conditions, individual behavior, and results. The system approach puts new perspective on human error: it is not a cause of failure, alone, but rather the effect or symptom of deeper trouble in the system. Human error is not random; it is systematically connected to features of people’s tools, the tasks they perform, and the operating environment in which they work.

Who should come?

The principles and practices of human performance improvement are universally applicable regardless of the industry or agency you work. This training is for anyone who desires to improve productivity, safety, and quality.

How are the courses separated?
The material has been distributed into 6 separate training courses, 4 levels for Individual Contributors and Teams, and 2 levels for Management. Students will engage in a dynamic learning environment using activities, videos, and real-life examples that will encourage demonstration, practice, and behavior changes.

Level 1: Introduction to Human Performance

  • Overview
  • Human Performance
  • Anatomy of an Event
  • Strategic Approach for Human Performance
  • Principles of Human Performance

Level 2: Reducing Error

  • Human Fallibility
  • Performance Modes
  • Error-likely Situations
  • Error Precursors

Level 3: Managing Controls

  • Controls
  • Defense-in-depth
  • Performance Model
  • Managing Controls
  • Tools for Finding Latent Organizational Conditions
  • Warning Flags-Factors that Defeat Controls

Level 4: Human Performance Tools for Individuals and Teams

  • Task Preview
  • Job-site Review
  • Questioning Attitude – at the Activity Level
  • Questioning Attitude – Work Planning and Preparation
  • Pause When Unsure
  • Self-Checking
  • Procedure Use and Adherence
  • Validate Assumptions
  • Signature
  • Effective Communication
  • Place-keeping
  • Pre-job Briefing
  • Technical Task Pre-job Briefing
  • Checking and Verification Practices
  • Flagging
  • Turnover
  • Technical Post-job Review
  • Project Planning
  • Problem Solving – with PACTS
  • Decision Making
  • Project Review Meeting

Management Level 1: Culture and Leadership/Human Performance Evolution

  • Organizational Culture
  • Safety Culture
  • Leadership
  • Key Leadership Practices
  • Behavior Engineering Model
  • Create a Just Culture
  • Performance of a Gap Analysis
  • Culpability Decision Tree
  • Establishing a Reporting Culture
  • Factors that Impact Organizations

Management Level 2: Management Tools

  • Benchmarking
  • Observations
  • Self-Assessments
  • Performance Indicators
  • Independent Oversight
  • Work Product Review
  • Investigating Events Triggered by Human Error
  • Operating Experience
  • Change Management
  • Reporting Errors and Near Missed
  • Culpability Decision Tree
  • Employee Surveys
What do you get to take away?

Each attendee walks away with a Certificate of Completion for the associated level of training, a reference book and a PDF electronic copy of the slides.

What will it cost?
I encourage you to do your research – Average human performance improvement training sessions cost anywhere from $225 per seat up to about $400 per seat for a full day of professional training, and certain vendors even go over $4000 for 5 days of error prevention training per seat! James is able to reduce much of the overhead and can offer courses to the public for a fraction of the cost. James can come straight to your facility or make other arrangements as needed. Minimum class size is 8 for a class to kick off and maximum class size is 20. Each Level is a separate calendar date than can be scheduled consecutively based on need. (All prices are inside of U.S. and in U.S. dollars)
The pricing for these separate sessions works like this per seat:
  • Level 1, 2, 3, or 4: $175
  • Management Level 1 or 2: $200
Package deals for all classes work like this per seat:
  • Level 1-4 package (4 training sessions): $600
  • Level 1-4 package plus Management Level 1-2 (6 training sessions): $900
Tell me about the Instructor:

hpi meJames Newman is the founder of Human Performance Tools, LLC (HPT) whose primary mission is to aid companies in their quest to become event-free due to human error through Human Performance Improvement methodologies. Besides years of technical training as a Nuclear Instrument Technician, James’ college background highlights Nuclear Engineering and Workforce Education Development. He also holds a training certification from the Institute of Nuclear Power Operators (INPO). He has worked directly with the following power and delivery companies supporting a role in a Human Performance Improvement: Dominion, Entergy, TVA, Wolf Creek Nuclear Operating Corporation, Westar Energy, ITC Holdings, NV Energy, and NRG.

James is a multi award-winning training designer and has also recently been presenting to Pharmaceutical and Energy Industries.

Why your Human Performance Improvement effort needs a “Strategic Plan”

retro_robot_playing_chess_11446-2You need a solid human performance strategic plan. First, I need to define a role in this research – the CFAM: in commercial nuclear power Corporate Functional Area Managers are fleet leaders who act together similar to a user’s group, one representative in a given discipline for each fleet. A few years ago a really bright set of human performance CFAMs came together to look for trends in the American nuclear industry. I believe the Institute of Nuclear Power Operators (INPO) hosts the frequent gatherings as a way to share best practices. This particular meeting was set up to discover top areas for improvement (AFIs) that were consistent for a period of the preceding 5 years. So, they poured through data of about 100 nuclear plants that are evaluated at least every two years by INPO, found the leading problems (which I do not have in front of me to share), but came to a pretty serious conclusion that I want to share with you right now…

When separated out, companies that had one of these rose to the top of the performance spectrum, and those not towards the top, did not have this one thing.

What is that one thing?

Above all things you need a human performance strategic plan. Without a plan specifically designed to move your efforts forward, you will remain in disarray and you will be stuck hoping or guessing if the random improvement efforts are paying off. If your operations group wants to do something different than your Maintenance group, make sure it is captured in the plan. If you’re human performance effort is struggling, or if it’s seeing amazing gains with less events and fewer errors, congratulations, but remember to keep your effort ideas fresh and interesting, and put them in a strategic plan. This is also a great way to track a sometimes hard question to answer: What have you done lately to improve performance?

The strategic plan cannot be pieces in your Business Plan. It should be a stand-alone living document that shows where you are in your improvement effort, who is responsible for each phase if implementation, and also the due dates associated with each item. The plan can certainly be a few line items on the Business Plan, but it’s control and design should be in the hands of your Human Performance Steering Committee and your HP Program Manager.

The HP Strategic Plan must be proactive as well as reactive, including major corrective actions or improvement ideas based on benchmarking and research.

Fortunately, INPO already had a template document put together by a group of other human performance professionals called the “Human Performance Strategic Plan Template.” That template is the skeleton you should be building your strategic improvements on.

The reason for the plan straight from the document:

“This long-term strategic plan will provide the foundation to guide your company toward human performance excellence in both the present and the future. Use, understanding, and support of the Human Performance Program is vital to the company’s mission and vision.”

What’s in the template?

I. Vision, Mission and Strategic Initiative

II. Principles of Human Performance

III. Examples of Strategic Plan Elements

  1. High Standards and Expectations
  2. Using Error Reduction Tools
  3. Managing Defenses and Risk
  4. Analyzing Trends and Behaviors
  5. Metrics and Indicators

IV. Template for Actions

V. References

The bulk of the plan follows the recommended eight stages of implementing a Human Performance initiative from fledgling to a mature program.

Remind me again – What are the 8 Stages?

Stage 1 – Obtain Senior Management Commitment

Stage 2 – Establish an Oversight Structure

Stage 3 – Identify the Gaps to Excellence

Stage 4 – Develop a Human Performance Strategy

  1. Create a risk-based approach to reduce the frequency and severity of human performance events with structures, systems, and components important to safety and reliability
  2. Adopt a systematic, systemic, and results-based approach to solving specific human performance problems.
  3. Establish a fair-minded policy that encourages voluntary reporting of errors and conditions adverse to safety and reliability.
  4. Develop measures that monitor the effectiveness of the human performance strategy.
  5. Establish roles, responsibilities, expectations, values, and beliefs important to excellent human performance.
  6. Develop a human performance improvement plan that includes milestones for key initiatives.
  7. Modify the human performance improvement plan based on feedback from key stakeholders.

Stage 5 – Communicate With and Engage Stakeholders

Stage 6 – Implement the Human Performance Strategy

Stage 7 – Evaluate the Effectiveness of the Human Performance Strategy

Stage 8 – Maintain the Right Picture of Excellence in Human Performance

Business proposition

If you want to implement a Human Performance Strategic Plan at your facility, that is something Human Performance Tools, LLC can help you do. You can always contact us through the phone number on the top of the home page or feel encouraged to email James@HumanPerformanceTools.com for more information.

References

The Strategic Plan Document references all of these documents and the hard work by human performance nuclear professionals throughout the American nuclear fleets:

  1. INPO 09-011, Achieving Excellence in Performance Improvement, September 2009
  2. INPO 09-004, Procedure Use and Adherence, February 2009
  3. INPO 08-004, Human Performance Key Performance Indicators, June 2008
  4. INPO 07-007, Performance Assessment and Trending, December 2007
  5. INPO 07-006, Human Performance Tools for Managers and Supervisors, December 2007
  6. INPO 06-002, Human Performance Tools for Workers, April 2006
  7. INPO 06-003, INPO Human Performance Reference Manual, October 2006
  8. INPO 05-002, Human Performance Tools for Engineers and Other Knowledge Workers, February 2007
  9. INPO 05-003, INPO Performance Objectives and Criteria, May 2005
  10. INPO 05-005, Guidelines for Performance Improvement at Nuclear Power Stations, August 2005
  11. INPO Guideline, Human Performance Leadership Framework, May 2000
  12. INPO Principles Document, Principles of a Strong Nuclear Safety Culture, November 2004
  13. INPO Principles Document, Principles for a Strong Nuclear Safety Culture, Addendum I, Behaviors and Actions That Support a Strong Nuclear Safety Culture, October 2009
  14. INPO Principles Document, Excellence in Human Performance, September 1997
  15. SOER 92-1, Reducing the Occurrence of Plant Events Through Improved Human Performance, October 1992
  16. NRC Inspection Manual Chapter 0305, Operating Reactor Assessment Program

 

The Medical Human Performance Improvement Movement

custom_pill_pack_16502Do you know what is happening in the field of medicine to improve outcomes? Have you been as curious as I have been? I have only seen a small peek inside this huge community that truly cares about getting this right. Dr. Kristin Klein (from the University of Michigan College of Pharmacy and Health System) and I started collaborating on the subject of Pediatric Pharmacy Error Reduction in November 2015 and developed a living presentation (constantly being updated with new data) with intentions of writing a white paper. Since January 2016, it has been presented to over 500 workers in the field of Pharmacy (pharmacy technicians, pharmacy residents, pharmacy students, pharmacists, etc.) most with specialty in pediatric pharmacy. We also shared an update on our research with a poster presentation at a patient safety conference in early April. The goal of this project is to determine event prevention best practices and see if introducing interventions like human performance tools are valuable to the medication use process, which sure seems like they would be.

The Medication Use Process

The medication use process has only five (simplified) layers to the system, yet pieces of it are cause for the error that leads to events that may involve our children. We’ve been asking the right people where the system is most susceptible to error and seeking recommendations to prevent events.

Screen Shot 2016-04-29 at 4.59.45 PM

This is always personal

As far as I know, I have never specifically been involved in a medication error other than having a doctor give me so many different prescribed meds, that my heart started palpitating and I soon after found a new physician. I have also been involved in communication errors that were devastating to me emotionally, but not physically – both being errors where the medical staff assumed I knew the person I loved was already passed away, and in both completely different situations, I had to figure it out in person. This obviously gets very personal, and we all have our own stories, because we all need medical care at different points of time in our lives. So, can you imagine the amount of possibility for error that exists on a daily basis in this enormous field with language barriers, long hours, lack of qualified personnel (because these jobs should pay more), and a myriad of other factors that contribute to error.

Some numbers to educate, scare, and caution you

Hospitalized patients, regardless of age, are susceptible to one medication error per day, and 1999 data shows that the third leading cause of death in the United States is preventable medical errors that account for 44,000 to 98,000 people dying each year.

What is PPAG?

The Pediatric Pharmacy Advocacy Group is an international, nonprofit, professional association representing the interests of pediatric pharmacists and their patients. They are dedicated to improving medication therapy in children. Their sole purpose is to promote safe and effective medication use in children through communication, education, and research.

Our presentation starts:
DSC_0349

 Dr. Timothy Todd introduces us:DSC_0353

From www.Thinkreliabilty.com

Rights are Tools

Geared towards nurses in the administration process, the video links below explain 10 “rights” which actually represent human performance tools:

10 Rights of Medication Administration

  1. Right Patient
  2. Right Medication
  3. Right Dosage
  4. Right Route
  5. Right Time
  6. Right Documentation
  7. Right Client Education
  8. Right to Refuse
  9. Right Assessment
  10. Right Evaluation

Video 1

Video 2

We actually are speaking a similar language

Medical professionals call a “Sentinel Event” what nuclear power stations would consider a “Site Clock Reset.” Both terms hold groups of errors that lead up to events of significant consequence, but Sentinel Events will typically involve a legal aspect, as well, which is rarely the case in commercial nuclear power, because asset damage or shutdowns may not involve human harm at all.

Conclusion

The road to improvement starts with care, and everyone I’ve ever spoken with in the field of pharmacy cares about patient safety. “Caring” alone, certainly isn’t enough to bring about enough change, unless people in the right positions care enough to prioritize advances in those areas most susceptible to error. Unfortunately, it seems as if pharmaceutical providers feel like the entire medication use process holds opportunity for mistakes.

9 Questions and Answers for New Human Performance Practitioners

woman_interview_hand_shake_12435Full-time equivalent (commonly called FTEs) positions in this field sometimes rotate through without spending more than 2 or 3 years in a given Human Performance Practitioner position. Some of us figure out that this has the opportunity of becoming a life-long passion and will stick with it for the long-haul, but that is definitely a small community. This role can be like opening your eyes to a new perspective on how people work individually, and as a group. You will hear that it is all about behaviors, but that is not entirely true – it is also about the pressures and the processes in place when work is being performed or prepared, and the systems that people work within and put up with day to day.

1 – What is my position title at other companies?

I’ve been doing this since 2007 and these are the titles I’ve come across, all with the same major goals and functions in mind:

Human Performance and/or Work Observation:

  • Program Owner
  • Coordinator
  • Manager

Sometimes the word “Station” or “Department” is in front of that title, as well. This role could be known as “Resilience Engineering,” as well! My last director and I preferred to call it Event Prevention over Human Performance.

2 – What is my mission?

Well, this may sound weird, but this role is specifically designed to help organizations prevent events, and everything that doesn’t support that function is useless noise. Some facilities, even commercial nuclear power, use this role as a dumping ground for investigation backlog or implementing corrective actions that really will have no value to your overall goal, but so be it – “other duties as assigned” applies here. Unfortunately, if you are under leadership who doesn’t really understand your true purpose to the organization, and you don’t put your foot down, you will end up in an almost entirely administrative role, and not really accomplishing your position’s true mission – preventing events.

3 – What should my elevator speech be?

This is one of the hardest things to consider the enormity of when just starting out, and a lot of us in these niche roles have a hard time quickly explaining to others our primary function. It is difficult to sum up what we do, but I think this covers most of it:

“My job is to help organizations detect, prevent, and correct events related to human error. I do this by measuring and analyzing data, assessing vulnerabilities, making and implementing corrective recommendations, and teaching management and the workforce about event prevention.”

4 – How should I assist in a Root Cause Evaluation?

You are there to cover the human side of an event. Understanding the system the workers were working within, and why their actions made sense to them at the time they made them may require some great interviewing skills, and certainly the ability to build and earn trust and rapport with the workers and leadership team members.

You also can teach the RCE team about human systems, types of errors, and aligning proper corrective actions that will actually work – for example, Knowledge-based errors require a Knowledge-based fix, etc. Also, that the human error corrective actions are in fact, SMART. You should also get the team to pay attention to controlling “antecedents” in order to affect behavior change. If you don’t know about Aubrey Daniels, read his book, “Bringing Out the Best in People.”

You should not be part of the RCE team, EVER. You should be an aide to them, this way your time is not dominated by the RCE mission, which basically requires you to drop everything else and focus on their primary goal, which takes you away from the rest of the organization.

5 – What do I need to know about metrics?

This is the most difficult area to discuss, since your organization most likely follows a  weak, but extremely popular model:

(number of events for last 18 months x 10,000)/ total worker-hours for that 18 month timeframe

Note: 18 months is regarding a fuel cycle for nuclear plants, so that number wasn’t arbitrary.

This number is unfortunately used by INPO to compare nuclear plants against each other for overall event performance, and has a full list of qualifiers for what constitutes an event, ideally, so no one nuclear plant can have a similar event and have it not coded as an event. Some stations even have a “management decision clock reset” that is designed to bring awareness to a station event, even though it didn’t meet the normal criteria. These events are not included in comparative data.

We know that there are two types of indicators:

Lagging – Measures of results or outcomes which represent where you are and what you have accomplished, but do not necessarily predict future accomplishments, and

Leading – Measures of system conditions, which provide a forecast of future performance; measures of organizational “health,” which can predict results and achievements.

We also know that excellent performance is about the PRESENCE of defenses, NOT the ABSENCE of events, which really reminds us that lagging indicators like the primary one used in our profession above are extremely disappointing and rarely a true representation of actual performance. New leading human performance indicators are necessary in our field for it to thrive.

6 – Who are my primary customers?

This may seem like a surprise to you, but the management team, starting with the 2nd level managers. Get them on board, and they will help you get the 1st line supervisors on board, and then they will help you get the workers believing that this program is not going away, and that performance improvement is a culture shift and new way of doing business in your company. It’s much easier to promote change with a smaller crowd of great influence. You will absolutely fail if you start with the workforce and try to promote the shift upwards. You will also fail by just working with 1st line supervision, because you most likely will be adding to their workload, instead of relieving some of it, and it’s hard to build rapport in that environment.

7 – What about Human Performance Tools?

These are ONLY used as a line of defense. The system should be resilient enough to withstand someone forgetting to use a tool. Note that NOT using a tool or lack of situational awareness should NEVER be a cause of any event, EVER. Know these tools inside and out (which are designed with two things in mind: obtaining and maintaining situational awareness), and remember that they are only to be used when they matter the most. I really disagree when I hear anyone (especially a practitioner) state that they are to be used every day, hour, minute, and second. You should disagree, too.

8 – How is this different than safety?

A lot of people struggle with having different roles in these lead areas, safety and human performance. Safety deals with knowing OSHA rules for many given situations, and qualifying people to use protective equipment and special tools like fall protection and oxygen sniffers. Safety falls under the umbrella of Human Performance and as a practitioner you should form an alliance with your safety team, and as a side note if you have an employee concern program, become acquainted with the manager of it.

I used to preach the notion that safety is about protecting people from the plant/grid and human performance is about protecting the plant/grid from the people. I don’t fully see it like this anymore. Industrial safety is about you going home the same way you came into work, and human performance is exactly the same thing. If you broke human performance up into two negative outcomes, personnel accident prevention (safety) and unanticipated system failure (operational upset where nobody gets hurt) I think you’ll understand my comment on the umbrella of human performance a little better.

9 – Do I need to be a good at training?

No, you need to be GREAT at it, and you need to be a great public speaker, too. It’s difficult to get there, but aim for a reputation where people can’t wait to come to your training or hear you speak on a topic. Get to be amazing at story-telling, and expose your passion for the subject material using many references to either case-studies, or your own personal experiences. I have seen people passionate about Human Performance Improvement, but not effective trainers or practitioners. So, if you love this work as I do, read and collaborate with as many past and present practitioners as possible. Find other people at other places that do what you do, and be one of the best of us.