What is the typical strategy for eliminating errors? Most of the time it’s whack-a-mole; find out who made the mistake, knock ‘em over the head, hope everyone else gets the message, and wait for the next error to pop up. Surely, the other workers saw the pain and suffering endured by the offending party and are going to tighten up. Problem solved, now where’s the next problem? It’s a strategy that’s reactionary and doesn’t fix the underlying problem; a lack of error defenses.
As discussed in a previous blog, the active error by an individual is just part of the equation. Workers are more often than not “set up” to make mistakes when latent organizational weaknesses (LOW) exist. Simply put, LOWs are unaddressed deficiencies in an organization that contribute to worker errors. LOWs can be found in the policies, procedures, work control, training, work environment, norms, values, beliefs, physical environment, equipment, resource allocation… almost anywhere. Since LOW’s can be found in so many places, identifying and eliminating them is a continuous effort; and it can be daunting. Because of this, we typically react to an error very superficially by addressing “who did it?” instead of asking “how did they get there?”
When an error or accident occurs, there are immediate actions that need to take place to ensure the health and safety of the employees and facility. Once things have stabilized and the dust has settled, rather than looking for who to whack, leadership should do a quick Substitution Test. The Substitution Test is pretty simple, but pretty profound. You simply ask: If I removed the person that made the mistake and replaced them with an equally qualified person, could they (could, not would) make the same choices. If the answer is “yes”, then it’s not a person problem; it’s a process problem and LOWs are present. If we don’t address the LOWs then we are using “hope” as a strategy. “I hope everyone got the message, I hope the next person can work around existing organizational deficiencies, and I hope this doesn’t happen again.”
Addressing LOWs is the ED portion of REMEDY: Error Defenses. LOWs can be found everywhere if the organization is willing to look for them. However, this doesn’t mean that you are off the hook and it’s the “organization’s” problem. The “organization” is all of us. If you are the frontline worker, you need to identify the items that make it hard for you to perform your job as described and report it up. If you are the manager, you need to work within your corrective action system to eliminate the LOWs. Both of you need to follow through to ensure the LOW is fixed and it doesn’t remain a workaround for the next person.
The full quote, from Rudy Giuliani, is “…change is not a destination, just as hope is not a strategy”. The more we can change for the better, the less we need to hope for no errors or accidents.