Upload
others
View
1
Download
0
Embed Size (px)
Citation preview
© Copyright 2019, Great Systems, All Rights Reserved
2019 TapRooT® Summit
Montgomery, TX
March 2019
Kevin McManus
Chief Excellence Officer
Great Systems
www.greatsystems.com
Systems
Culture
Behaviors
BeliefsR
General JHA
General JHA
General JHA
General JHA
General JHA
Task Specific
JHA
FLRA / Pre-Job
FLRA / Pre-Job
FLRA / Pre-Job
Practice-Based
Training
Walk Through
Task Specific
JHA
Task Specific
JHA
Task Specific
JHA
Walk Through
© Copyright 2019, Great Systems, All Rights Reserved
Here is Edward Bear,coming downstairs now,bump bump bump
on the back of his head, behind Christopher Robin.
It is, as far as he knows, the only way of coming down stairs, but sometimes he feels that there
really is another way, if only he could stop bumping for a moment and think of it.
© Copyright 2019, Great Systems, All Rights Reserved
Weak people-focused fix
When we write a corrective action against a human error or equipment failure:
Human error or equipment failure
Strong systems-focused fix
When we write a corrective action against a systemic root cause:
Human error or equipment failure
Systemic root causes of problem
© Copyright 2019, Great Systems, All Rights Reserved
We don’t know our real error rates, costs, and risk levels
We are not evaluating and improving our existing safeguards
We are not closing the ‘big holes’ in our error-prone work systems
We often underestimate what it takes to sustain human behavior change
How do you know if your safeguards are effective?
© Copyright 2019, Great Systems, All Rights Reserved
If leaders knew the cost of the errors that occur EACH DAY …
They would make VERY DIFFERENT decisions!
© Copyright 2019, Great Systems, All Rights Reserved
Safeguard Effectiveness
Rate
of
Hum
an E
rror
LOW
HIGH
HIGH
2015
2016
20172018
1 out of 200
1 out of 2,000
1 out of 20,000 1 out of
200,000
A six sigma level of quality allows for 1
defect out of 294,118 opportunities
© Copyright 2019, Great Systems, All Rights Reserved
Degree that work environment shiftsDegree that scope of work shiftsShifts in team experience levelsAmount of blame culture that exists
Your HEPI consists of five factors …
HEPI = Human Error Potential Index
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
O
HEPI = 18 / 25 – 72%
As your HEPI increases, process waste levels also increase
OO
ODegree of task complexity 1 2 3 4 5O
© Copyright 2019, Great Systems, All Rights Reserved
RISK ASSESSMENT MATRIX
Consequence / Severity
Likelihood Negligible Marginal Major Critical Catastrophic
Frequent 5 10 15 20 25
Occasional 4 8 12 16 20
Seldom 3 6 9 12 15
Remote 2 4 6 8 10
Unlikely 1 2 3 4 5
Does Your Potential Fix Impact equal the POTENTIAL Severity of the problem?
© Copyright 2019, Great Systems, All Rights Reserved
© Copyright 2019, Great Systems, All Rights Reserved
© Copyright 2019, Great Systems, All Rights Reserved
© Copyright 2019, Great Systems, All Rights Reserved
To what degree are these factors used to minimize error potential in your organization?
© Copyright 2019, Great Systems, All Rights Reserved
Safeguard Effectiveness
Risk
of
Hum
an E
rror
HIGHER
LOWER
HIGHLOW
Each process should be evaluated and improved
at least annually
General JHA
General JHA
General JHA
General JHA
General JHA
Task Specific
JHA
FLRA / Pre-Job
FLRA / Pre-Job
FLRA / Pre-Job
Practice-Based
Training
Walk Through
Task Specific
JHA
Task Specific
JHA
Task Specific
JHA
Walk Through
© Copyright 2019, Great Systems, All Rights Reserved
Formal shakedown meetings are held prior to trek departure
A trek shakedown checklist specifically lists what to bring (and not bring)
A guided walkthrough is used to verify each backpack’s contents
The Philmont trek shakedown process uses multiple safeguards
to help minimize errorsWalkthrough is led by a formally certified ranger
© Copyright 2019, Great Systems, All Rights Reserved
Minimize Risk of Process
Errors
Human Factors Engineering
Policies and Procedures
Job Design / Organizational
Ergonomics
High Practice Competency-based
Training
Which safeguards are the most effective?
How do you measure safeguard effectiveness?
What error rate do you want to sustain?
What is the current process error rate?
Audits and Inspections
In-Hand Work Instructions
Daily Job Preparation
Supervision and Team Dynamics
© Copyright 2019, Great Systems, All Rights Reserved
COUNT INDEX ALGORITHMRATIO
How many times does
this happen?
How is the performance area doing?
How do different variables affect the outcome?
How often does this happen?
Counts are the most used, and least effective, type of metric
Algorithms are the foundation of predictive analytics
All counts can be turned into ratios by using time, cost, or percent of total
© Copyright 2019, Great Systems, All Rights Reserved
Three Bears Scale
Likert 5-Point Scale
Likert 7-Point Scale
Top Box Scale
LOW MEDIUM
Tailboard meetings are consistently effective
Tailboard meetings are rarely effective
Tailboard meetings are effective some of the time
HIGH
1 3 542
1 4 752 3 6
SD AD SAAD
Strongly Agree
Strongly Disagree
Sometimes Agree or Disagree
AgreeDisagree
In all cases, survey response rate is the KEY survey effectiveness metric!
© Copyright 2019, Great Systems, All Rights Reserved
“If I could reduce my message to management to just a few words, I’d say it all has to do with reducing variation.”
– W. Edwards Deming
Most processes are normally distributed – look like bell curves
Variation must be reduced in order to improve the mean
Standard deviation measures variation – more variation equals more waste
© Copyright 2019, Great Systems, All Rights Reserved
How effective are your safeguards at reinforcing the desired on-the-job behaviors?
Systems
Culture
Behaviors
BeliefsR
© Copyright 2019, Great Systems, All Rights Reserved
Buffalo Fields Region
Construction Business Unit
How well deployed are your safeguards?
Alpine Ridge Region
Diamond Flats Region
Swampy Mesa Region
Task Specific JSA
Daily Toolbox
TalksTraining
Completion %Monthly
Audit Score
Above Goal
On the fence
Danger Zone
© Copyright 2019, Great Systems, All Rights Reserved
Preferred Sensing Modality
Visual
What are your preferences?
Auditory
Kinesthetic
Preferred Thinking Style
Preferred Mode of Expression
Visual
Auditory
Kinesthetic
Serial
Parallel
© Copyright 2019, Great Systems, All Rights Reserved
1. Works with me to define the expectations of my job
2. Helps us find ways to do our jobs better
3. Is willing to spend time listening to my concerns
4. Lets me know when I have done a good job
5. Asks for my ideas about things affecting our work
6. Treats me with respect and dignity
7. Keeps me informed about things I need to know
8. Lets me do my job without interfering
9. Makes an effort to understand my point of view
10. Keeps favoritism from being a problem in our workgroup
11. Makes sure that continuous improvement is part of my daily job
My manager or supervisor …
SA A AD D SD
SA A AD D SD
SA A AD D SD
SA A AD D SD
SA A AD D SD
SA A AD D SD
SA A AD D SD
SA A AD D SD
SA A AD D SD
SA A AD D SD
SA A AD D SD
LI = 45%
Which leaders should be measured with an index?
How long should we tolerate ‘poor performance’?What minimum score should be considered acceptable?
LI = 45%
© Copyright 2019, Great Systems, All Rights Reserved
The Foundational Power of Paper
Systems
Culture
Behaviors
BeliefsR
Positive, Purpose Driven Culture
Using Processes to Guide People
Perfect Practice Makes Perfect
Be Prepared
© Copyright 2019, Great Systems, All Rights Reserved
Chunking and mnenomics, such as HOMES
Rehearse, teach the concept to others
Meaningful organization
Visualize and relate
Engage multiple senses
EbbinghausForgetting Curve
Hermann Ebbinghaus, 1885
# of Days
% In
form
atio
n Re
tain
ed
None
100%
721
When we first hear new information
One day later without reinforcement
Two days later without reinforcement
0 3
60%
40%
Use visual and auditory cues
How do we use our memory to minimize human error?
© Copyright 2019, Great Systems, All Rights Reserved
How much time does it take to use the procedure?What grade level is the procedure written at?
Procedures are used for high risk to minimize risk
How easy is the procedure to access?How do procedure users rate the effectiveness of the procedure?
How many procedure steps contain only one action?
How often is the procedure used when it is required?
0 points 2 points 4 points
Total Score
© Copyright 2019, Great Systems, All Rights Reserved
Identified all high risk tasks that should require ‘instructions in hand’?
Written all procedures at a grade six or lower reading level?
To what degree have you …
Used technology, such as video, to help ensure procedures are easy to access?
Surveyed procedure users about ease of use and trended the results?
Ensured all procedures contain only one action per step?
Monitored and enforced the effective use of procedures when they are required?
© Copyright 2019, Great Systems, All Rights Reserved
Be specific, quantitative, and clear
Write instructions at a 5-6 grade level
Use check boxes and initial lines to increase accountability
Limit of one action per step
Instructions are used DURING work to reduce the risk of relying on memory
Use small words and short sentences
Specify instruction use requirements on the document
© Copyright 2019, Great Systems, All Rights Reserved
Checklist in hand
How much do you rely on memory to minimize human error?
Instructions in notebook
Instructions in PDA
Instructions on job aid
Ease of retrieval is improved
Memory loss impact is reduced
© Copyright 2019, Great Systems, All Rights Reserved
Verbal work instructions only
Daily instructions written to grade
6-8 level
Instructions exist, but not part of work
package
Part of daily pre-shift work review
General review of tasks at orientation
Crisp, single action steps with signoffs
Includes safety JSA and risk assessment
Reviewed annually as part of development
planning
Get the instructions close to the workCreate simple, picture-based instructions
Involve users in work package improvement
Effective Work Package Building Codes
Make special instructions OBVIOUS!
© Copyright 2019, Great Systems, All Rights Reserved
Work packages contain the necessary information to understand and do the job?
Tailboard meetings contain all necessary content and keep the team engaged?
Rate the degree that…
Technology is used to make the work easier to understand and remember?
Team members provide feedback about daily job preparation effectiveness?
Walkthroughs identify key hazards and actions that must be taken?
Regular reviews and improvements to job preparations practices occur?
© Copyright 2019, Great Systems, All Rights Reserved
Have a plan – use some form of agenda to guide the meeting
Provide everyone with a visual agenda
Involve everyone – assign an agenda item to each participant
Use emotion and humor appropriately to provide emphasisUse questions and repeat back to help ensure the message is understood
If jobs change scope, take time to hold a new briefing
Job preparation approaches help reduce memory reliance and increase rule enforcement
© Copyright 2019, Great Systems, All Rights Reserved
Meeting ContentTo what extent do your work group meetings …
Include a review of performance against key measures 1 2 3 4 5
Use graphs to make trends more visible 1 2 3 4 5
Include a variety of agenda topics 1 2 3 4 5
Include a review of the key project list and a project status update 1 2 3 4 5
Provide you with a chance to add new projects to the list 1 2 3 4 5
Include a review of things that have happened elsewhere in the company 1 2 3 4 5
Make a good use of the time that is invested to hold the meeting 1 2 3 4 5
Include brief training sessions on job skills or procedures 1 2 3 4 5
Include some fun exercises at time to help build teamwork 1 2 3 4 5
Content DeliveryTo what extent do your work group meetings …
Allow for plenty of two way communication 1 2 3 4 5
Involve more than one person as a presenter or trainer 1 2 3 4 5
Use visual aids to help illustrate key points and trends 1 2 3 4 5
Avoid simply reading information - focus is on discussion instead 1 2 3 4 5
Avoid arguments and complaining - focus is on improvement 1 2 3 4 5
LOW ----------------------- HIGH
LOW ----------------------- HIGH
Circle the appropriate #
Circle the appropriate #
© Copyright 2019, Great Systems, All Rights Reserved
Clock in and start working
Team pre and post briefings
Start of Shift Toolbox Talks
Position specific JHA and FLHA
Task specific JHA and FLHA
Daily Schedule
Step by step walkthroughs
Pre-Task Toolbox Talks
Work order for each job
Interactive Toolbox Talks
Team lead keeps the big picture in mind
Match prep style to team skill mix
Add prep detail and layers as risk increasesDaily Preparation
Building CodesEngage the entire team in planning
© Copyright 2019, Great Systems, All Rights Reserved
HighCourse Delivery EffectivenessLow
Cour
se C
onte
nt E
ffect
iven
ess
Rank your most common ‘training packages relative to their effectiveness
Hazardous materials training
Facilitation Skills training
Supervisor Development trainingLock out / tag
out training
Fall Protection training
High
Six Sigma Black Belt training
‘Smith System’ Driving Skills training
Hazard Awareness training
Forklift Certification training
TapRooT® Root Cause Analysis Training
Group Dynamics and Teambuilding training
© Copyright 2019, Great Systems, All Rights Reserved
Identify what needs to be 100% committed to memory
Use Position Observation Checklists to gauge skill proficiency
Require time on job to demonstrate expected work behaviors
Link certification requirements to EACH job description
Certifications are used to help emphasize the need for demonstrated skill success
Minimize use of lecture in favor of practice time
Use computer-based training (CBT) for compliance or awareness needs only
© Copyright 2019, Great Systems, All Rights Reserved
Self Study Certification Process
Lecture / Classroom
Interactive with Skill Testing
Skill Practice in Field
Read and Sign Training
Step by step walkthroughs
Pre-Task Toolbox Talks
Web-based Training
Skill Practice with Coach
Team lead keeps the big picture in mind
Match prep style to team skill mix
Add prep detail and layers as risk increasesTraining System Building Codes
Engage the entire team in planning
© Copyright 2019, Great Systems, All Rights Reserved
Define Policy
Communicate Policy
Enforce Policy
Review and Improve Policy
All key rules must be
reinforced regularly
AuditsFormal recognitionInformal recognitionPre-job briefsTraining
Letters and e-mails
One-on-one coaching
Work package contentsSigns, labels, and alarms
Discipline
© Copyright 2019, Great Systems, All Rights Reserved
Policies are designed in a manner that makes them easy to understand?
Policies are communicated in a timely and effective manner to key personnel?
Rate the degree that…
Inspections and audits are conducted in a manner that catches key process gaps?
Corrective actions are reviewed for effectiveness and timeliness?
Inspections and audits are designed to monitor key process requirements?
Regular reviews and improvements to policy / oversight practices occur?
© Copyright 2019, Great Systems, All Rights Reserved
POSI
TIVE
INFORMAL
Daily, consistent, positive, and
meaningful thank you / feedback
NEG
ATIV
E
FORMAL
Monthly Give Aways, 100 Point
Clubs, Profit Sharing
Beratement, no positive feedback,
limited communication
Discipline for errors, poor job
assignments, pay cuts / layoffs
Which square contains the most effective enforcement strategies?
What % of your enforcement actions fall into each square?
How was your current enforcement culture shaped over time?
How can leaders learn to enforce rules differently?
© Copyright 2019, Great Systems, All Rights Reserved
All leaders must use a consistent approach to rule enforcement
Rules must be clearly, consistently, and regularly communicated
Audits, training, and job prep are also used to reinforce rules
Positive reinforcement works better than negative reinforcement
Multiple approaches to rule enforcement are needed to send a clear, consistent message
Each rule needs to be clearly defined – expectations and consequences
Discipline should only be used for ‘one off’ situations
© Copyright 2019, Great Systems, All Rights Reserved
Effective human factors design is used to minimize control and display usage errors?Effective housekeeping practices are used to keep tools and materials organized
Engineered fixes are the most effective way to minimize risk
‘Engineered fixes’ are consistently pursuedStandardization across equipment helps minimize confusion and mistakes
Ergonomic evaluations and improvements are conducted regularly
Noise, lighting, temperature, and other factors that affect performance are managed
0 points 2 points 4 points
Total Score
© Copyright 2019, Great Systems, All Rights Reserved
Use of personal protective equipment is consistently monitored and improvedUse of physical barriers, as needed, helps reduce target exposure to hazards
Target safeguards are used regularly to help minimize risk
Technology is used to monitor hazard exposureUser feedback is consistently obtained to help improve target safeguard effectiveness
Technology, such GPS and RFID, is used to monitor and manage asset movement
Formal target safeguard improvement plans are developed at least annually
0 points 2 points 4 points
Total Score
© Copyright 2019, Great Systems, All Rights Reserved
Bar Coding
Easy to use app interfaces
Quick Response Codes
ImplantsRFID Bands
© Copyright 2019, Great Systems, All Rights Reserved
Match screen displays to the process / form being transacted
Remove the impact of work environment factors –lighting, temperature, noise
Improve error detection approaches
Reduce task complexity to skill level if possible
The best approach for minimizing human error is to engineer out the risk
Standardize control layouts and shape coding
Use color coding, icons, and creativity to engineer out risk
© Copyright 2019, Great Systems, All Rights Reserved
Error Free TASK
Execution
Engineered Fix
Policies and Procedures
Org Ergonomics
Training
Which fixes are the most effective?
Which fixes are used the most often?
What error rate do you want to sustain?
What is your potential for human error?
Audits and Inspections
© Copyright 2019, Great Systems, All Rights Reserved
Execute GREAT reactive problem solving – learn and improve from your mistakes!
Implement effective corrective and preventive actions
Track, trend, and try to reduce daily ‘at risk’ behaviors at the process level
Use Pareto analysis of observations to identify areas needing improvement
Mistake proof key work systems, including non-standard work
REACTIVE
PROACTIVE
© Copyright 2019, Great Systems, All Rights Reserved
Every process owner should be responsible for tracking and trending
process performance and process waste on a regular basis, and for using that
information to improve those processes.
Use the TapRooT® root cause analysis process daily to analyze your highest risk human errors
© Copyright 2019, Great Systems, All Rights Reserved
Addressing a systemic causal factor typically affects multiple process outcomes!
Each process owner analyzes a consistent number of causal factors per week
Potential impact on risk is used as a primary means of selecting causal factors
As effective fixes are installed, process owners work upstream to find and fix new causal factors Recordable
Incidents
First Aid Incidents
Near Misses / High Risk Behaviors
Process non-conformances
© Copyright 2019, Great Systems, All Rights Reserved
E-mail: [email protected]
Snail mail: 70460 Walker RoadRainier, OR 97048
Phone: 206.226.8913
Website: www.greatsystems.com
Root Cause and Incident Analysis: www.taproot.com
If you like this workshop, you also might enjoy my books -Please check them out on Amazon.com!
@greatsystems
https://www.facebook.com/greatsystems/
https://www.linkedin.com/in/kevin-mcmanus-5138322
© Copyright 2019, Great Systems, All Rights Reserved
Pursuing Process Excellence
Vital Signs Measurement
150 pages of ideas and examples that will help you accelerate and sustain your process improvement efforts
Over 25 examples of ‘best practice’ assessment tools that leaders can use to encourage and support high performance work
12 team exercises that can be used to begin applying each concept as it is learned
128 pages of ideas and examples to help you make your existing measurement systems more meaningful
Over 30 examples of ‘best practice’ measurement tools and techniques that leaders can use to promote high performance work
14 team exercises that can be used to begin applying key concepts as they are learned
Error Proof
162 pages of strategies and dialogue questions to help you stop daily goofs for good
Over 100 proven best practices that you can use to help error proof your key work processes
Can be paired with the 100 page workshop workbook that contains 13 team exercises to help you begin applying key ideas
Available on Amazon.com!