Human Performance Improvement Through a Just Culture · PDF file Human Performance Improvement...

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Transcript of Human Performance Improvement Through a Just Culture · PDF file Human Performance Improvement...

  • Joel E. Heim Manager, Training & Development

    Human Performance Improvement

    Through a Just Culture

  • Moving from a Reactive Safety Culture

  • Principles of Human Performance

    • People are fallible, and even the best people make

    mistakes

    • Error-likely situations are predictable, manageable,

    and preventable

    • Individual behavior is influenced by organizational

    processes and values

    • People achieve high levels of performance because

    of the encouragement and reinforcement received

    from leaders, peers, and subordinates

    • Events can be avoided through an understanding of

    the reasons mistakes occur and application of the

    lessons learned from past events or errors

    3

  • 12 Most Common Causes of Human Error

    • Lack of Communication

    • Lack of Teamwork (No Peer Caring)

    • Norms (Culture)

    • Pressure (Shortcuts)

    • Complacency

    • Lack of Knowledge (Unconscious Incompetence)

    • Lack of Awareness

    • Lack of Resources

    • Distraction

    • Lack of Assertiveness (Courage to speak up)

    • Fatigue

    • Stress

  • Information Word Game

    ✓ Bed

    ✓ Rest

    ✓ Awake

    ✓ Snooze

    ✓ Nap

    ✓ Drowsy

    ✓ Pillow

    ✓ Wake

    ✓ Tired

    ✓ Blanket

    ✓ Slumber

    ✓ Peace

    ✓ Yawn

    ✓ Doze

  • Error Precursors (Error Traps)

    • Task Demands

    – Time pressure

    – High workload

    – Simultaneous tasks

    – Repetitive tasks

    – Monotony

    – Unclear goals

    – Unclear standards

    • Individual Capabilities

    – Unfamiliarity with task

    – Lack of knowledge

    – Poor communication

    – Inexperience

    – Illness / Fatigue

    – Unsafe attitude

    – Major life event

  • Error Precursors (Error Traps)

    • Work Environment

    – Distractions

    – Interruptions

    – Departure from routine

    – Work-arounds

    – Personality conflicts

    – Shift changes

    – Production

    overemphasis

    – Physical climate

    • Human Nature

    – Stress / Mental strain

    – Habits / Biases

    – Assumptions / Mindset

    – Complacency

    – Overconfidence

    – Inaccurate risk

    perception

    – Limited memory

    – Circadian rhythm

  • Unsafe Attitudes / At-Risk Behaviors

    • Pride

    – “Don’t tell me what to do”

    • Heroic

    – Custer at Little Big Horn, “Here I come to save the day”

    • Fatalistic

    – Predetermined, Inevitable, “Let the chips fall where they may”

    • Invulnerability

    – “Nothing will happen to me”

    • Pollyanna

    – “All is well”, “What can go wrong”, “It’s routine”

    • Bald Tire

    – “We’ve always done it this way”

    9

  • Team Errors

    • Halo Effect

    – Blind trust due to experience or education

    • Pilot / Co-pilot

    – Reluctance of subordinate to question senior person

    • Free Riding

    – Taking passive role

    • Groupthink

    – Reluctance to question group opinion

    • Diffusion of Responsibility

    – Spread the blame

    10

  • Error Likely Situations

  • Moving to a Just Culture

    • Manage your state and habits of mind

    • Pay attention to what stories you tell yourself

    • Be aware of your mental biases

    – Invincibility / Invulnerability

    – Fundamental Attribution Error

    – Outcome Bias

    – Hindsight Bias

    – Confirmation Bias

  • Why We Do What We Do

    • Antecedent

    – Prompts a Behavior

    • Behavior

    – Specific muscle movement

    • Consequence

    – What happens to us

    19

  • Behavioral Consequences

    20

    R+ positive reinforcement

    R- negative reinforcement

    P+ Punishment

    P- Penalty

  • Behavioral Consequences

    • Determine the probability of a behavior re-occurring

    • Will be either:

    – Positive or Negative

    – Immediate or Future

    – Certain or Uncertain

    21

  • Establish and Maintain a Just Culture

    • An open, honest, reporting culture

    • Look at the intent, not just the consequence

    – Get away from fault and blame

    • Recognize the difference between errors and

    violations

    – Errors are unintentional slips or lapses

    – Violations are intentional

    • Balanced accountability is the key

    • Just Culture begins with Trust

  • Five Dysfunctions of a Team

    • Inattention to Results

    • Avoidance of Accountability

    • Lack of Commitment

    • Fear of Conflict

    • Absence of Trust

    23 From “The Five Dysfunctions of a Team” – Patrick Lencioni

  • Strategic Approach for Human Performance

    • Anticipate, prevent, catch, and recover from active

    errors at the job site

    – Preparation

    – Performance

    – Feedback

    • Identify and eliminate latent organizational

    weaknesses that provoke human error and degrade

    controls against error and consequences of error

    – Control hazards by elimination or substitution

    – Engineered Features

    – Administrative Provisions

    – Cultural “Norms”

    – Oversight

    24

  • Human Performance Tools

    • Task Preview

    • Job-site Review

    • Questioning Attitude

    • Stop when Unsure

    • Procedure Use and

    Adherence

    • 3-way Communication

    • Phonetic Alphabet

    • Pre-job Briefing

    • Post job Review

    • Concurrent Verification

    • Independent Verification

    • Place-keeping

    • Validating Assumptions

    25

  • Principles of Human Performance

    • People are fallible, and even the best people make

    mistakes

    • Error-likely situations are predictable, manageable,

    and preventable

    • Individual behavior is influenced by organizational

    processes and values

    • People achieve high levels of performance because

    of the encouragement and reinforcement received

    from leaders, peers, and subordinates

    • Events can be avoided through an understanding of

    the reasons mistakes occur and application of the

    lessons learned from past events or errors

    26

  • Universal Sign of Commitment

  • References

    • DOE Human Performance Improvement Handbook

    Vol. 1

    • DOE human Performance Improvement Handbook

    Vol. 2

    • Crucial Conversations – Joseph Grenny, David

    Maxfield, Kerry Patterson

    • The Five Dysfunctions of a Team – Patrick Lencioni

    • Bringing Out the Best in People – Aubrey Daniels

  • 29