Human Organizational Performance

Human and Organizational Performance (HOP) is a system of thinking about errors and accidents in the workplace developed in the mid-20th century by industrial thinker W. Edwards Deming. The idea is that 90% of events in the workplace are caused by something other than just the individual worker.

In many workplaces, when something goes wrong, the tendency is to focus on the individual and what that worker may have done or not done to cause that incident.

While it does not remove the accountability of the the individual worker, HOP also calls for investigators to look at the system under which the individual is working. As Deming noted: “A bad system will beat a good person every time.”

The assumption is that most people want to do a good job. Things other than people that contribute to errors:

• Programs – written operating procedures.

• Processes – things inherent to the task that can get out of control.

• Work environment – conditions in the workplace that can contribute to errors such as weather or busy periods.

• Organization – other people who can contribute to an error.

• Equipment – faulty tools and machines.

Errors and Violations

Human error is any action or inaction that unintentionally:

• Results in an undesirable or unwanted condition.

• Leads a task or system outside of limits.

• Deviates from a set of rules, standards, or expectations.

An error is not a choice. Humans are error-making machines.

Resources – Consultant
Fisher Improvement Technologies, Concord, NC; 888-246-0119; improveWithFIT.com.

Books
• Todd Conklin, “5 Principles of Human Performance.”
• Sidney Dekker: “The Field Guide to Understanding Human Error.”
• James Reason: “Managing the Risks of Organizational Accidents.”

Podcast
Todd Conklin: “Pre-Accident Investigations.”

Youtube
Sidney Dekker: “Safety Differently.” youtube.com/user/sidneydekker.

Many errors do not impact performance. Many employees become experts at identifying when an error has occurred and correcting it before something bad can happen. It can be like running a stop sign. Nine out of 10 times, no one else is in the intersection, so there are no consequences. It’s that 10th time that creates the incident.

Unlike an error, a violation is an action or inaction that intentionally deviates from a set of rules or expectations. There is a conscious intent to violate.

For workers to commit a violation, they must know that a rule or standard exists, that the rule or standard applies to them, and consciously decide to deviate from the rule or standard.

That sounds bad, but again, it is rare for someone committing a violation to intend harm. A company’s systems may create situations that force workers to violate. These include goal conflicts, procedures that conflict with other procedures, and local customs that conflict with other company expectations.

Safety Pyramid

Figure 1 depicts a commonly used concept of the safety pyramid. The steps of the pyramid begin with a wide step signifying an error or violation that results in no consequences. As you climb the pyramid, the steps get narrower and the consequences more severe, until you get to a fatality at the top.

To prevent an error or violation from becoming a harmful incident, there are three lines of defense:

• Engineering controls. These are things like safety designs and guarding. Once they are in place, the worker should not have to think about them when at task.

• Administrative controls. These include training, written instructions, and personal protective equipment (PPE). The worker does have to think about these and follow instructions consciously.

• Individual controls. These are a matter of communication before a task begins and the worker’s own behavior.

If you rely on workers to do a task safely with just individual controls, eventually a mistake will happen, possibly resulting in an incident. This is the last and least effective line of defense. If this is all you have, you need more layers.

An example of how this works is when automobiles first appeared on the road at the start of the 20th century. At first, everyone relied on the driver to operate the vehicle safely, which was individual controls.

Next came administrative controls, such as traffic laws, signage on the road, and police trained to enforce the rules.

Finally, automotive engineers created engineering controls over time – bumpers, horns, turn signals, antilock braking, seat belts, etc.

Guiding Principles for HOP

• People make mistakes. People are fallible, even the best of them.

• Error-likely situations are preventable. You can predict them and manage them.

• Individual behavior is influenced by organizational processes and values.

• Positive reinforcement builds trust. People achieve high performance because they are encouraged and reinforced by leaders, peers, and subordinates.

• We learn from past incidents. Events can be avoided through an understanding of the reasons mistakes occur and lessons learned.

• Deviations are rarely malicious. Rather, they are well-meaning behaviors intended to get the job done.

• How leaders respond to mistakes and deviations matters.

In the workplace, look for activities that have the potential to result in serious injuries and fatalities (SIF). HOP thinking can help with these:

• Identify systemic drivers and weaknesses.

• Look for single-point vulnerabilities.

• Verify the presence and capacity of the controls that keep us safe.

• Learn how well we support our employees and contractors performing high-risk work.

Performance Modes

Research dating back to the 1970s has identified three performance modes while workers are engaged in a task. Understanding these can reduce the potential for error.

1. Skill-based performance mode. These refer to things we do out of habit or routine using little or no conscious thought. There have been 50 to 100 successful completions. The task consists of less than seven to 15 discrete steps. Error rate is 1 in 1,000.

2. Rule-based performance mode. The worker refers to a written or standard operating procedure to get the task accomplished. He or she may look something up on Google or YouTube. There may be unwritten rules that everyone knows. Error rate is 1 in 100.

3. Knowledge-based performance mode. This is where you don’t know what you don’t know. It’s a new task. It may be problem solving, troubleshooting, a confusing situation, or just having unanswered questions before you start. You may need research to find a rule. You may need to hire a technician. Error rate is 1 in 2 to 1 in 10.

Some workers love these situations; others become paralyzed. You have a higher rate of failure, but you learn from those failures. Eventually you have a rulebook for performing the task. Getting there usually requires more than one person, and they need to work out a game plan.

Takeaways

Author Sidney Dekker notes that “people do what they do, at the time they do it, for reasons that make sense to them at that time.”

If we want to understand a person’s decision, we must understand the information the person had when the decision was made, and the situation that was developing around the person at that time.

The words we use influence the context and culture of our organization. Shift from asking “why” to asking “how.” Asking why too early can cut learning short, because people try to draw conclusions or causes from limited data. Asking how opens the door to deeper, more impactful learning.

Blame fixes nothing. Watch and listen for these blame-type statements:

• “Employee failed to follow procedure.”

• “SOP was not used as directed.”

• “Team failed to recognize a risk/hazard/issue.”

Learning and improving rather than blaming is a deliberate strategy that requires reinforcement and demonstration. This idea, however, does not remove individual accountability.

Ed Zdrojewski, editor