Replying to LO28958 --
Good question Chris. Will be interested in seeing the responses.
It seems the quality movement addresses business results from a much
"harder" bottomline perspective as compared to the "softer" field of LO.
Maybe many/most organizations have value in something before there will be
interest in measuring it. ??
The field of Human Performance seems to be making progress with the softer
side in the nuclear industry, perhaps because it has been integrated into
existing work practices such as like critiques, pre-job briefs, etc, which
are ripe for benefiting from LO principles. Haven't thought about what
measures might be of help in assessing the difference it makes, but will
give it some thought. James Reasoner's books are a good source for this
area of human performance. Below is a summary.
Principles of human performance
1. People are fallible, and even the best people make mistakes.
2. Error-likely situations are predictable, manageable, and preventable.
3. Individual behavior is influenced by organizational processes and
values.
4. People achieve high levels of performance largely because of the
encouragement and reinforcement received from leaders, peers, and
subordinates.
5. Events can be avoided through an understanding of the reasons mistake
occur and application of the lessons learned from past events (or errors).
Brief summary of "Human Error"
Author: James Reason
Issue: March 18, 2000
The human error problem can be viewed in two ways: the person
approach and the system approach. Each has its model of error causation
and each model gives rise to quite different philosophies of error
management. Understanding these differences has important practical
implications for coping with the ever present risk of mishaps in clinical
practice.
Person approach
The longstanding and widespread tradition of the person approach
focuses on the unsafe acts--errors and procedural violations--of people at
the sharp end: nurses, physicians, surgeons, anesthetists, pharmacists,
and the like. It views these unsafe acts as arising primarily from
aberrant mental processes such as forgetfulness, inattention, poor
motivation, carelessness, negligence, and recklessness. Naturally enough,
the associated countermeasures are directed mainly at reducing unwanted
variability in human behavior. These methods include poster campaigns that
appeal to people's sense of fear, writing another procedure (or adding to
existing ones), disciplinary measures, threat of litigation, retraining,
naming, blaming, and shaming. Followers of this approach tend to treat
errors as moral issues, assuming that bad things happen to bad
people--what psychologists have called the just world hypothesis.[1]
System approach
The basic premise in the system approach is that humans are
fallible and errors are to be expected, even in the best organizations.
Errors are seen as consequences rather than causes, having their origins
not so much in the perversity of human nature as in "upstream" systemic
factors. These include recurrent error traps in the workplace and the
organizational processes that give rise to them. Countermeasures are based
on the assumption that though we cannot change the human condition, we can
change the conditions under which humans work. A central idea is that of
system defenses. All hazardous technologies possess barriers and
safeguards. When an adverse event occurs, the important issue is not who
blundered, but how and why the defenses failed.
--Geof
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