A Human Factors Approach to Root Cause Analysis:
|
|
- Harvey Taylor
- 5 years ago
- Views:
Transcription
1 A Human Factors Approach to Root Cause Analysis: The Human Factors Analysis and Classification System (HFACS) Douglas A. Wiegmann, PhD University of Wisconsin-Madison
2 Human Error and Adverse Events Medical error is the 3 rd leading cause of death in the U.S. When such errors and events happen, a Root Causes Analysis (RCA) is conducted to determine why it happened and how it can be prevented from happening again. However, the causes of errors are manifold and often include complex human factors issues rather than individual incompetence. Therefore, any RCA of a patient harm event cannot be considered thorough and credible unless it effectively examines the human factors that underlie errors.
3 What is Root Cause Analysis (RCA)? RCA is a commonly used process and set of tools for discovering the underlying factors that contribute to accidents or injuries. Goal is to figure out what happened, why did it happen, and how can it be prevented from happening again? Process involves several major steps: Gathering information Analyzing information Drawing Conclusions Making Recommendations Implementing Changes Evaluating Outcomes
4 General RCA Process Event, hazard, system vulnerability Near-Miss Investigation Process Minor Event Risk-based prioritization Major Event RCA Tools HFACS Lite What happened? Fact finding and flow diagramming What happened? Development of causal statements Why did it happen? Identification of solutions and corrective actions Implementation How can it be prevented from happening again? Measurement Feedback Adapted from NPSF (2015). RCA 2 Improving Root Cause Analyses and Actions to Prevent Harm
5 What is RCA? Traditional RCA was developed as an engineering method for discovering the causes underlying equipment and material failures. Engineers in the aerospace industries, such as NASA developed RCA tools for gathering information to understand why a piece of technology (like a rocket engine) may have failed and caused a spaceship to crash. They developed these tools based on their knowledge of the basic physical sciences, such as physics and chemistry, as well as mathematics. These tools help investigators frame their thinking about causality, ask the right questions about why things failed, gather important engineering data relevant to answering these questions, and analyzing findings in a systematic and reliable fashion based on science. This is where many of our RCA tools today come from, such as fault trees, as well as our assumptions about root causes and the 5 Whys heuristic.
6 Does RCA Work? RCA is an effective engineering method for discovering the causes underlying equipment and material failures. However, current RCA methods and tools were NOT designed to identify human factors causes of errors. (They are based on the physical sciences not the human sciences. ) Hence, they do NOT help investigators to frame their thinking about causality, ask the right questions about why errors occurred, gather important human factors data relevant to answering these questions, and analyzing findings in a systematic and reliable fashion based on science. Thus, when RCA methods are used to investigate medical error-related events, they typically produce superficial results, often focusing on who did what. Any attribution of cause is often only speculative or subtly veiled blame. The results from such reports identify few opportunities for implementing substantive change. Consequently, RCA has NOT been an effective method for analyzing and correcting human factors issues that produce errors and lead to patient harm.
7 What do we do now? 1. Discard RCA altogether and try something else. 2. Continue using traditional RCA tools even though they don t work well. 3. We can try to come up with our own tools based on personal preferences or opinions. 4. We can adopt RCA Tools that are based on human factors science.
8 Redesigning RCA The Human Factors Analysis and Classification System (HFACS) and the Human Factors Intervention Matrix (HFIX) were designed to transform RCA into an effective error analysis and prevention technique. Organizational Influences Organizational Culture Operational Process Resource Managemen t Supervisory Factors Inadequate Supervision Planned Inappropriate Failure To Correct Operations Known Problem Supervisory Violation Preconditions for Unsafe Acts Situational Factors Individual Factors Team Factors Tools/Techn ology Mental State Physiological State Leadership Task Physical Environment Fitness for Duty Communication Coordination Unsafe Acts Errors Violations Decision Errors Skill-Based Errors Perceptual Errors Routine Violations Exceptional Violations
9 HFACS-RCA Process Event, hazard, system vulnerability Near-Miss Investigation Process Minor Event Risk-based prioritization Major Event HFACS Lite What happened? Fact finding and flow diagramming HFACS-RCA Development of causal statements Identification of solutions and corrective actions HFIX Implementation Measurement Feedback (Adapted from NPSF (2015). RCA 2 Improving Root Cause Analyses and Actions to Prevent Harm)
10 HFACS HFACS was originally designed to facilitate the investigation of human errors in aviation. HFACS has now been applied in variety of industries including mining, construction, petrochemical, and healthcare. Numerous studies have demonstrated its usability, comprehensiveness, and reliability.
11 Swiss Cheese Model ORGANIZATIONAL INFLUENCES SUPERVISORY FACTORS PRECONDITIONS FOR UNSAFE ACTS UNSAFE ACTS
12 Swiss Cheese Model Key Points: 1. Holes represent a failure or absence of safety barriers. 2. Not every failure will lead to an accident (holes may be inconsequential or plug themselves). 3. Multiple failures (holes) can occur at each level, not just a single hole. 4. Not every accident will have organizational roots (but you must look for them). 5. Failures across levels interact and follow a logical sequence (no tier jumping). 6. The farther down the system a hole is plugged, the more localized the fix will be. 7. The farther up the system a hole can be plugged, the broader impact it will have a safety. But what are the holes in the cheese?
13 Unsafe Acts Errors Violations Decision Errors Skill-Based Errors Perceptual Errors Routine Violations Exceptional Violations
14 Unsafe Acts Errors Violations Decision Errors Skill-based Errors Perceptual Errors Routine Violations Exceptional Violations Decision Errors These thinking errors represent conscious, goal-intended behavior that proceeds as intended, yet the plan proves inadequate or inappropriate for the situation. These errors typically result from a lack of information, knowledge or experience.
15 Unsafe Acts Errors Violations Decision Errors Skill-based Errors Perceptual Errors Routine Violations Exceptional Violations Skill-based Errors Highly practiced behavior that occurs with little or no conscious thought. These doing errors frequently appear as attention failures, memory failures, or errors associated with the technique with which one performs a task.
16 Unsafe Acts Errors Violations Decision Errors Skill-based Errors Perceptual Errors Routine Violations Exceptional Violations Perceptual Errors These errors involve the five senses: seeing, hearing, touching, tasting, and smelling. It is not unusual for these senses to become inaccurate or confused in sensory impoverished environments or degraded simply due to normal aging.
17 Unsafe Acts Errors Violations Decision Errors Skill-based Errors Perceptual Errors Routine Violations Exceptional Violations
18 Unsafe Acts Errors Violations Decision Errors Skill-based Errors Perceptual Errors Routine Violations Exceptional Violations Routine Violations Often referred to as bending the rules, this type of violation tends to be habitual by nature, engaged in by others, and is often enabled by a system of supervision and management that tolerates such departures from the rules.
19 Unsafe Acts Errors Violations Decision Errors Skill-based Errors Perceptual Errors Routine Violations Exceptional Violations Exceptional Violations Isolated departures from the rules, neither typical of the individual nor condoned by management.
20 Preconditions for Unsafe Acts Situational Factors Individual Factors Team Factors Tools/Technology Mental State Physiological State Leadership Task Physical Environment Fitness for Duty Communication Coordination
21 Preconditions for Unsafe Acts Situational Factors Individual Factors Team Factors Tools/Technology Mental State Physiological State Leadership Task Physical Environment Fitness for Duty Communication Coordination Mental State Psychological/mental conditions that negatively affect performance such as mental fatigue, pernicious attitudes, misplaced motivation, and cognitive states such as distraction, mental workload, and confusion.
22 Preconditions for Unsafe Acts Situational Factors Individual Factors Team Factors Tools/Technology Mental State Physiological State Leadership Task Physical Environment Fitness for Duty Communication Coordination Physiological State Medical/physiological conditions that preclude safe operations such as illness, intoxication, and the myriad of pharmacological and medical abnormalities known to affect performance.
23 Preconditions for Unsafe Acts Situational Factors Individual Factors Team Factors Tools/Technology Mental State Physiological State Leadership Task Physical Environment Fitness for Duty Communication Coordination Fitness for Duty Off-duty activities that negatively impact performance on the job such the failure to adhere to sleep/rest requirements, alcohol restrictions, and other off-duty mandates.
24 Preconditions for Unsafe Acts Situational Factors Individual Factors Team Factors Tools/Technology Mental State Physiological State Leadership Task Physical Environment Fitness for Duty Communication Coordination
25 Preconditions for Unsafe Acts Situational Factors Individual Factors Team Factors Tools/Technology Mental State Physiological State Leadership Task Physical Environment Fitness for Duty Communication Coordination Tools/Technology This category encompasses a variety of issues including the design of equipment and controls, displays/interface characteristics, checklist layout, and automation.
26 Preconditions for Unsafe Acts Situational Factors Individual Factors Team Factors Tools/Technology Mental State Physiological State Leadership Task Physical Environment Fitness for Duty Communication Coordination Task Refers to the nature of the activities performed by individuals and teams including such things as the complexity, criticality, and consistency of assigned work.
27 Preconditions for Unsafe Acts Situational Factors Individual Factors Team Factors Tools/Technology Mental State Physiological State Leadership Task Physical Environment Fitness for Duty Communication Coordination Physical Environment This category includes the setting in which the individual performs their work and consists of such things as lighting, layout, noise, clutter, and workplace design.
28 Preconditions for Unsafe Acts Situational Factors Individual Factors Team Factors Tools/Technology Mental State Physiological State Leadership Task Physical Environment Fitness for Duty Communication Coordination
29 Preconditions for Unsafe Acts Situational Factors Individual Factors Team Factors Tools/Technology Mental State Physiological State Leadership Task Physical Environment Fitness for Duty Communication Coordination Leadership The team leader s performance of his/her responsibilities such as the failure to adopt a leadership role or model/reinforce principles of teamwork.
30 Preconditions for Unsafe Acts Situational Factors Individual Factors Team Factors Tools/Technology Mental State Physiological State Leadership Task Physical Environment Fitness for Duty Communication Coordination Communication The sharing of information among team members including providing/requesting information and the failure to provide two-way (positive confirmation) communication.
31 Preconditions for Unsafe Acts Situational Factors Individual Factors Team Factors Tools/Technology Mental State Physiological State Leadership Task Physical Environment Fitness for Duty Communication Coordination Communication The sharing of information among team members including providing/requesting information and the failure to provide two-way (positive confirmation) communication.
32 Supervisory Factors Inadequate Supervision Planned Inappropriate Operations Failure To Address Known Problem Supervisory Violation
33 Supervisory Factors Inadequate Supervision Planned Inappropriate Operations Failure To Address Known Problem Supervisory Violation Inadequate Supervision Oversight and management of personnel and resources, including training, professional guidance, and operational leadership.
34 Supervisory Factors Inadequate Supervision Planned Inappropriate Operations Failure To Address Known Problem Supervisory Violation Planned Inappropriate Operations Management and assignment of work including aspects of risk management, staff assignment, work tempo, scheduling, etc.
35 Supervisory Factors Inadequate Supervision Planned Inappropriate Operations Failure To Address Known Problem Supervisory Violation Failure to Correct Known Problems Those instances when deficiencies among individuals or teams, problems with equipment, or hazards are known to the supervisor but are allowed to continue unabated.
36 Supervisory Factors Inadequate Supervision Planned Inappropriate Operations Failure To Address Known Problem Supervisory Violation Supervisory Violation The willful disregard for existing rules, regulations, instructions, or standard operating procedures by management during the course of their duties.
37 Organizational Culture Organizational Influences Operational Process Resource Management
38 Organizational Culture Organizational Influences Operational Process Resource Management Organizational Culture The shared values, beliefs, and priorities regarding safety that govern organizational decision making, as well as the willingness of an organization to openly communicate and learn from adverse events.
39 Organizational Culture Organizational Influences Operational Process Resource Management Operational Process Refers to how an organization plans to accomplish its mission, as reflected by its strategic planning, policies/procedures and corporate oversight.
40 Organizational Culture Organizational Influences Operational Process Resource Management Resource Management Refers to the support provided by senior leadership to accomplish the objectives of the organization including the allocation of human, equipment/facility and monetary resources.
41 Organizational Culture Organizational Influences Operational Process Resource Management Supervisory Factors Inadequate Supervision Planned Inappropriate Operations Failure To Correct Known Problem Supervisory Violation Preconditions for Unsafe Acts Situational Factors Individual Factors Team Factors Tools/Technology Mental State Physiological State Leadership Task Physical Environment Fitness for Duty Communication Coordination Unsafe Acts Errors Violations Decision Errors Skill-based Errors Perceptual Errors Routine Violations Exceptional Violations
42 HFACS-RCA Process Event, hazard, system vulnerability HFACS Interviewing Guide Near-Miss Investigation Process Minor Event Risk-based prioritization Major Event HFACS Lite What happened? Fact finding and flow diagramming HFACS-RCA Development of causal statements HFACS Analysis Tools Identification of solutions and corrective actions HFIX-RCA Implementation HFACS Data Analytics Measurement Feedback HFIX Tool Kit (Adapted from NPSF (2015). RCA 2 Improving Root Cause Analyses and Actions to Prevent Harm)
43 HFACS-RCA Process Event, hazard, system vulnerability HFACS Interviewing Guide Near-Miss Investigation Process Minor Event Risk-based prioritization Major Event HFACS Lite What happened? Fact finding and flow diagramming HFACS-RCA Development of causal statements HFACS Analysis Tools Identification of solutions and corrective actions HFIX-RCA Implementation HFACS Data Analytics Measurement Local Feedback HFIX Tool Kit (Adapted from NPSF (2015). RCA 2 Improving Root Cause Analyses and Actions to Prevent Harm)
44 HFACS-RCA Process Event, hazard, system vulnerability HFACS Interviewing Guide Near-Miss Investigation Process Minor Event Risk-based prioritization HFIX-Global Major Event HFACS HFACS Lite Lite What happened? Fact finding and flow diagramming HFACS Trends Development of causal statements HFACS-RCA HFACS Analysis Tools Identification of solutions and corrective actions HFIX-RCA System Feedback HFACS Data Analytics Implementation Measurement HFACS-FMEA HFACS Observations HFACS Latent Factors Survey Closed-claim Cases/Prior RCAs Other sources Local Feedback HFIX-RCA Tool Kit (Adapted from NPSF (2015). RCA 2 Improving Root Cause Analyses and Actions to Prevent Harm)
45 HFACS-RCA Process Event, hazard, system vulnerability Near-Miss Investigation Process Minor Event Risk-based prioritization HFIX-Global Major Event HFACS HFACS Lite Lite Never Happens HFACS Trends System Feedback HFACS Data Analytics HFACS-FMEA HFACS Observations HFACS Latent Factors Survey Closed-claim Cases/Prior RCAs Other sources (Adapted from NPSF (2015). RCA 2 Improving Root Cause Analyses and Actions to Prevent Harm)
46 HFACS-RCA Process Event, hazard, system vulnerability HFACS Interviewing Guide Near-Miss Investigation Process Minor Event Risk-based prioritization Major Event HFACS Lite What happened? Fact finding and flow diagramming HFACS-RCA Development of causal statements HFACS Analysis Tools Identification of solutions and corrective actions HFIX Implementation HFACS Data and Analytics Measurement Local Feedback HFIX Tool Kit (Adapted from NPSF (2015). RCA 2 Improving Root Cause Analyses and Actions to Prevent Harm)
47 What can happen RCA Teams Acquire the ability to perform a more in-depth analysis of actual systemic or root causes of events Experience a greater feeling of ownership and commitment to the RCA process Greater conviction and satisfaction with their findings and recommendations Those involved in event: Heightened sense that their voices have been heard Improved attitude about the RCA Process Leadership Less scrutiny of analysis and findings and greater focus on solutions Increased buy-in of operational owners of the required changes Organization Transformation of culture from one of blame to one of a learning and just culture. Improved patient care and satisfaction Increased provider moral and professional pride in your healthcare system.
48 What can happen When we showed the Joint Commission our HFACS-RCA report, they said that it was the most thorough and credible RCA they had ever seen! J. Hood (ASHRM 2017 Annual Meeting)
49 Thank you! Douglas A. Wiegmann, Ph.D. (608)
3. RELATED CIVIL AVIATION SAFETY REGULATIONS. Civil Aviation Safety Regulations (CASR):
3. RELATED CIVIL AVIATION SAFETY REGULATIONS. Civil Aviation Safety Regulations (CASR): a. Part 91, General Operating and Flight Rules; b. Part 121, Certification And Operating Requirements : Domestic,
More informationAdvisory Circular. Subject: Guidance on Acceptable and Unacceptable Behaviour Date: 1 January 2013
Cooperative Development of Operational Safety and Continuing Airworthiness Programme COSCAP - SOUTH ASIA International Civil Aviation Organization Advisory Circular Subject: Guidance on Acceptable and
More informationOriginal: February 2002 Module Four Page 1 of 7
MODULE 4 OBJECTIVE: TRAINING TIME: KEY TEACHING POINTS: : The participant will be able to describe the Human Factors Analysis and Classification System (HFACS). 30 Minutes ERROR CLASSIFICATION LATENT CONDITIONS
More informationMETHOD. Development of HFACS-MI
The Development of an Accident/Incident Investigation System for the Mining Industry Based on the Human Factors Analysis and Classification System (HFACS) Framework Jessica Patterson Graduate Research
More informationRCAs in Action - Approaches and Tools to Maximize Your Effectiveness as a Risk Manager
RCAs in Action - Approaches and Tools to Maximize Your Effectiveness as a Risk Manager 2015 The Year of the RCA Spring of 2015 The National Patient Safety Foundation (NPSF) released its white paper - RCA
More informationHuman Factors & Medicines Information Errors
Human Factors & Medicines Information Errors Dr Hannah Family, Lecturer, Department of Pharmacy & Pharmacology @errorgirlblog A story of 4 parts Memory & Attention Error Theory Workload & Errors Work design
More informationData Collection Systems
Data Collection Systems David Embrey PhD Managing Director Human Reliability Associates Ltd 1. An Overview of Data Collection Systems The function of this document is to provide an overall framework within
More informationSystems-Based Approaches for Effective Problem Solving
Systems-Based Approaches for Effective Problem Solving James P. Bagian, MD, PE Director Center for Healthcare Engineering and Patient Safety Professor, Department of Anesthesiology and Engineering University
More informationSTPA: A New Hazard Analysis Technique. Presented by Sanghyun Yoon
STPA: A New Hazard Analysis Technique Presented by Sanghyun Yoon Introduction Hazard analysis can be described as investigating an accident before it occurs. Potential causes of accidents can be eliminated
More informationAccident Investigation Procedures for Supervisors
Accident Investigation Procedures for Supervisors ACCIDENT defined: An accident is "an undesired event that results in personal injury and/or property damage. Being "undesired" makes it something that
More informationThe Common Language of Nuclear Safety Culture (and how it affects you!) 8/13/2012. The Problem: The Uncommon Language of Nuclear Safety
The Common Language of Nuclear Safety Culture (and how it affects you!) Tom Houghton Certrec Corporation The Problem: The Uncommon Language of Nuclear Safety NRC looks at inspection results using cross
More informationE & B Oilfield Services Inc.
Chapter 1 Company Safety Policy and Procedures E & B Oilfield Services Inc. 1798 W 3250 N. Roosevelt Utah 84066 Danny Abegglen is the designated Company Safety Coordinator. Safety & Health Policy Statement
More informationAnalysis of Accidents Involving Machines and Equipment Using the Human Factor Analysis and Classification System Method (HFACS)
Analysis of Accidents Involving Machines and Equipment Using the Human Factor Analysis and Classification System Method (HFACS) Anastacio Filho (&), Thais Berlink, and Tales Vasconcelos Federal University
More informationIncident Investigation Process
Incident Investigation Process Introduction An incident is an unplanned or undesired event that adversely affects a company s work operations. Incidents include work-related injuries, occupational illnesses,
More informationWorkplace Violence. Workplace Violence. Work Safe: Preventing Injuries and Workplace Violence. Gene R. La Suer Davis Brown Law Firm
Work Safe: Preventing Injuries and Gene R. La Suer Davis Brown Law Firm What is workplace violence? Workplace violence is any act or threat of physical violence, harassment, intimidation, or other threatening
More informationBCPE CORE COMPETENCIES
BCPE CORE COMPETENCIES The following Core Competencies is the exam specification, listing the critical tasks necessary for an early career professional (minimum 3 years of experience) to show competence
More informationManagerial Competency Guide
Managerial Performance Evaluation and Reappointment Recommendation Managerial Competency Guide Division of Human Resources Competency List: I. Accountability II. III. IV. Communication Skills Customer
More informationManagerial Competency Guide
Managerial Performance Evaluation and Reappointment Recommendation Managerial Competency Guide Division of Human Resources Competency List: I. Accountability II. III. IV. Communication Skills Customer
More informationIncident Investigation
Incident Investigation What does a thorough incident investigation look like and what purpose does it serve? Michelle Schlefstein Definition Incident: unplanned or unintended occurrence that caused or
More informationInjury Investigation Process. Using Root Cause Analysis
Injury Investigation Process Using Root Cause Analysis 1 Objectives Review why injury investigations & multiple root cause analysis are important. Discuss the elements of an effective injury investigation
More informationINTEGRITY MANAGEMENT CONTINUOUS IMPROVEMENT. Foundation for an Effective Safety Culture
INTEGRITY MANAGEMENT CONTINUOUS IMPROVEMENT Foundation for an Effective Safety Culture June 2011 Foundation for an Effective Safety Culture describes the key elements of organizational culture and business
More informationParks & Recreation Programming & Operations Manager #02975 City of Virginia Beach Job Description Date of Last Revision:
Parks & Recreation Programming & Operations Manager #02975 City of Virginia Beach Job Description Date of Last Revision: 06-19-2013 FLSA Status: Exempt Pay Plan: Administrative Grade: 15 City of Virginia
More informationLearning from Risk Management Integrating Root Cause Analysis and Failure Mode & Effect Analysis into Your Compliance Program
Learning from Risk Management Integrating Root Cause Analysis and Failure Mode & Effect Analysis into Your Compliance Program Health Care Compliance Association 2005 Compliance Institute Margaret Hambleton,
More informationEMPOWERING WORKERS TO SHARE SAFETY CONCERNS: WHAT MANAGERS NEED TO KNOW AND DO. Joe McGuire, PhD, CRH Emily J. Haas, PhD, NIOSH
EMPOWERING WORKERS TO SHARE SAFETY CONCERNS: WHAT MANAGERS NEED TO KNOW AND DO Joe McGuire, PhD, CRH Emily J. Haas, PhD, NIOSH IMAGINE a workplace where everyone truly cares about coworkers safety all
More informationSelf Assessment Guide for a Great Safety Culture
Self Assessment Guide for a Great Safety Culture Overview: Safety culture is in an intrinsic part of organization culture. Safety culture refers to the shared values, beliefs, and attitudes that influence
More informationAccountability in a Safety Culture. Berry Bairrington, OHST
Accountability in a Safety Culture Berry Bairrington, OHST OUTLINE Who is responsible for safety at your organization? Safety Culture: Are your leaders engaged? Principals for leaders to foster safety
More informationJob Description: Operations Manager September 2017
Job Description: Operations Manager September 2017 Title: Operations Manager Reporting to: Executive Director Purpose As a senior member of the Management Team, the Operations Manager is responsible for
More informationIndiana Safety & Health Conference
Indiana Safety & Health Conference 3/13/18 Beyond Compliance (Breaking Through to the Next Level of S, H & E Excellence) Presented by: Michael Topf MA Topf Initiatives Wayne, Pa. 19087 Beyond Compliance:
More informationGuidelines for Establishing a Safety Management System on Aerodromes. DASS Publication 11/2006-A APPENDIX 9 HUMAN FACTORS 1,2 AND THE SHELL MODEL
APPENDIX 9 HUMAN FACTORS 1,2 AND THE SHELL MODEL A9.1 In a high-technology industry such as aviation, the focus of problem solving is often on technology. However, the accident record repeatedly demonstrates
More informationGuide to Defining Performance Levels
Guide to Defining Performance Levels This guide lists the performance factors and performance levels in the College s Goals and Performance Evaluation for Staff. It is a reference tool to help you write
More informationSAS Conference 5 November 2018
Supporting Patent Safety- Team Resource Management & Human Factors and Ergonomics SAS Conference 5 November 2018 Professor Pramod K Luthra Associate Dean HEE NW Visiting Professor MMU & EHU Safety Safety
More informationROOT CAUSE ANALYSIS AND THE AUDIT LIFE CYCLE
1 ROOT CAUSE ANALYSIS AND THE AUDIT LIFE CYCLE DEREK BUTLER SENIOR MANAGER GRANT THORNTON LLP +1 443.414.3257 DEREK.BUTLER@US.GT.COM AHIA 35th Annual Conference September 11-14, 2016 www.ahia.org Agenda
More informationLEADERSHIP PRINCIPLES
LEADERSHIP PRINCIPLES 1. Know yourself and seek self-improvement. a. Evaluate yourself by using the leadership traits and determine your strengths and weaknesses. b. Work to improve your weaknesses and
More informationDeveloping a logic model
Developing a logic model A depiction of a program showing what the program will do and what the program is to accomplish A series of if-then relationships that, if implemented as intended, lead to the
More informationCoaching for Talent Development and Employee Engagement
Coaching for Talent Development and Employee Engagement If you wish to improve the skills of your employees, you must plan to observe them (or their results) and provide them with feedback. If you re like
More informationA Guide to Competencies and Behavior Based Interviewing
A Guide to Competencies and Behavior Based Interviewing 9.14.2015 HR Toolkit http://www.unitedwayofcolliercounty.org/maphr 2015 Competence is the ability of an individual to do a job properly. Job competencies
More informationFatality Prevention/Risk Management
The persistence of high severity events suggests a new approach rooted in safety management systems is needed in order to have different mine safety outcomes. The backbone of this effort is the risk management
More informationWINTER. Safety Culture High Reliability Strategies for High Consequence Professions. Who Else? Socio-Technical Systems. Template
WINTER Template Safety Culture High Reliability Strategies for High Consequence Professions Much of the information in this presentation is protected by copyrights and Standards of Use contracts with the
More informationModule 1: Making the Transition from Social Worker to Supervisor
Module 1: Making the Transition from Social Worker to Supervisor Day One 9:00 9:45 Welcome And Introductions 9:45 11:15 Leadership Style And Its Impact On Performance 11:15 12:00 What Makes An Effective
More informationPOWERPOINT HANDOUT. Supervisor Core - Module 4 Ohio Child Welfare Training Program
Supervisor Core - Module 4 Ohio Child Welfare Training Program 1 Participants can miss no more than 15 minutes during the entire workshop, not per day. If you miss more than 15 minutes, you will be unable
More informationA Guide to Competencies and Behavior Based Interviewing. HR Toolkit
A Guide to Competencies and Behavior Based Interviewing HR Toolkit 2015 Competency models help make transparent the skills an agency needs to be successful. Start by identifying competencies that predict
More informationHarbisonWalker International. Core Competencies
HarbisonWalker International Core Competencies HWI Core Competency Model 1 TABLE OF CONTENTS Core Competencies Accountability/Drive 3 Innovation 4 Collaboration 5 Customer Focus 6 Adapting to Change 7
More informationElements of an Effective Safety and Health Program
Elements of an Effective Safety and Health Program Voluntary Safety and Health Program Management Guidelines 10/11 1 Effective Safety and Health Programs It has been found that effective management of
More informationCORE COMPETENCIES. For all faculty and staff
SELF-AWARENESS & PROFESSIONALISM Being mindful of one s impact on others and managing thoughts, feelings and actions in an effective manner. INTEGRITY Conducting oneself and activities according to the
More informationORGANIZATIONAL BEHAVIOR & WORKPLACE SAFETY: PROMOTING A SAFETY CULTURE
ORGANIZATIONAL BEHAVIOR & WORKPLACE SAFETY: PROMOTING A SAFETY CULTURE Eng Raed Al-Marzooqi Head-Occupational Health and Safety Section Health & Safety Dept. Dubai Municipality PRESENTATION OBJECTIVES
More informationTANZANIA CIVIL AVIATION AUTHORITY SAFETY REGULATION
Page 1 of 7 1.0 PURPOSE This Advisory Circular is promulgated to provide guidelines to Aerodrome Operators in adopting policies and procedures on human factors principles in the provision of Aerodrome
More informationTrouble-Shooting: Questions
Trouble-Shooting: Questions For wraparound supervisors: These are individuals who are hired or will be hired to provide handson oversight, direction and coaching to staff members who work directly with
More informationJust Culture. Leading Through Shared Values and Expectations
Just Culture Leading Through Shared Values and Expectations Objectives Understand the concepts of Just Culture Identify three predictable behaviors Understand a Just Culture investigation Describe the
More informationPAGE 1 OF 5 HEALTH, SAFETY & ENVIRONMENTAL MANUAL PROCEDURE: S085 Hazard Recognition Program REV
PAGE 1 OF 5 PURPOSE The Hazard Recognition program is geared towards pre-loss identification and treatment of potential hazard exposures than inspections and job safety analyses. It involves several layers
More informationHuman Failure. Overview. People are never 100% reliable. Andy Brazier. Types of human failure Slips Mistakes Violations
Human Failure Andy Brazier Tel: (+44) 01492 879813 Mob: (+44) 07984 284642 andy@abrisk.co.uk www.abrisk.co.uk 1 Overview Types of human failure Slips Mistakes Violations Causes of human failure Things
More informationIndividual Development Plan for UCSF Faculty
Individual Development Plan for UCSF Faculty Individual Development Plans (IDPs) provide a planning process that identifies both professional development needs and career objectives. Furthermore, IDPs
More informationThe School District of Lee County Division of Operations
The School District of Lee County Division of Operations District Based Administrator Evaluation System 2013-2014 Academic Year Table of Contents District Based Administrator Evaluation System Overview...
More informationAccountant III #01800 City of Virginia Beach Job Description Date of Last Revision:
City of Virginia Beach Job Description Date of Last Revision: 03-01-2016 FLSA Status: Exempt Pay Plan: Administrative Grade: 13 City of Virginia Beach Organizational Mission & Values The City of Virginia
More informationCertified Clinical Supervisor (CCS) APPENDIX A
Certified Clinical Supervisor (CCS) APPENDIX A Performance Domains & Job Tasks APPENDIX A Certified Clinical Supervisor Performance Domains and Job Tasks Domain 1: Counselor Development Build a supportive
More informationSTAMP Applied to Workplace Safety
STAMP Applied to Workplace Safety Emily Howard, Ph.D., Senior Technical Fellow Lori Smith, EHS Deputy Chief Engineer March 21, 2016 The Team Dr. Emily Howard, Human Factors Engineering, Boeing Senior Technical
More informationSafety from an Executive s Point of View: Turning Complaints into Efficiencies
Session No. 785 Safety from an Executive s Point of View: Turning Complaints into Efficiencies Todd Britten, M.S., CSP Senior Consultant CoreMedia Portland, OR Introduction and Background The late guru
More informationQueen's University Environmental Health & Safety. 1. Introduction
1 1. Introduction The Joint Health & Safety Committee (JHSC) Workplace Inspection Standard Operating Procedure was developed by the Department of Environmental Health & Safety in accordance with the University
More informationINPO s Approach to Human Performance in the U.S. Commercial Nuclear Industry
INPO s Approach to Human Performance in the U.S. Commercial Nuclear Industry Tony Muschara Principal Program Manager Hu Institute of Nuclear Power Operations INPO s Mission to promote the highest levels
More informationUnderstanding Human Error and Improving Human Performance
Understanding Human Error and Improving Human Performance Facts about Human Error It thrives in every industry It is a major contributor to events and unwanted outcomes It is costly, adverse to safety
More informationInternal Audit Policy and Procedures Internal Audit Charter
Mission Statement Internal Audit Policy and Procedures Internal Audit Charter The mission of the Internal Audit Department is to provide independent and objective reviews and assessments of the business
More informationImpact and management tool for identification and reduction of human Errors in pharmaceuticals Industry
7 Impact and management tool for identification and reduction of human Errors in pharmaceuticals Industry Suleman S. khoja 1 *, Sohil S. khoja 1, Farhad S. Khoja 2, Shamim Khoja 2, Narmin Pirani 2 1 Resource
More informationChapter 4 Motivating self and others
Chapter 4 Motivating self and others Defining Motivation Define motivation - The internal and external forces that lead an individual to work toward a goal o Intensity is how hard a person tries o Persistence
More informationIncident [Accident] Investigations
Incident [Accident] Investigations 1. Preserve/ Document Scene 2. Collect Information 3. Determine Root Causes 4. Implement Corrective Actions Objectives for Today Discuss the importance of why all incidents,
More informationRETURN TO WORK Strategies for supporting the supervisor when mental health is a factor in the employee s return to work
ABSTRACT: Factors and strategies to help occupational health nurses assist in supporting the supervisor for return-to-work cases where the returning employee has experienced mental health issues. RETURN
More informationCITY OF JONESBORO Sex Offender Registration Specialist Job Description
CITY OF JONESBORO Sex Offender Registration Specialist Job Description Exempt: No Department: Police Reports To: Captain of CID Location: Police Department 1001 S. Caraway Rd, Jonesboro AR Date Prepared:
More informationHuman Performance, Zero Harm and the Siemens Safety Journey
2014 April Human Performance, Zero Harm and the Siemens Safety Journey Restricted Siemens AG 2013. All rights reserved. One world, one life we care. Greetings from St. Petersburg, Florida Photos courtesy
More informationSafety Competencies. Introduction to Safety Competencies
Safety Competencies Introduction to Safety Competencies 0 Continuing Care Safety Association T: 780.433.5330 www.continuingcaresafety.ca Vision Incident free workplaces. Mission To create safe workplaces
More informationARE WE OBLIVIOUS TO UNSAFE WORKING PRACTICES PETER CORFIELD NASS, DIRECTOR GENERAL
ARE WE OBLIVIOUS TO UNSAFE WORKING PRACTICES PETER CORFIELD NASS, DIRECTOR GENERAL IMPROVING SAFETY PERFORMANCE ADDRESSING HARDWARE ISSUES IMPLEMENTING SAFETY MANAGEMENT SYSTEMS PRODUCE REDUCTIONS IN ACCIDENT
More informationSupervision: the key to Felt Leadership. Kirk Regular, Vale Canada, January 25, 2018
Supervision: the key to Felt Leadership Kirk Regular, Vale Canada, January 25, 2018 Super Vision Chart the course A felt leader sees more than others see, sees farther than others see and sees before others
More informationGeneral Information. 1. What department do you work for? 2. How long have you worked for the City? 3. Supervision: Do you supervise other employee(s)?
General Information 1. What department do you work for? Administrative Services City Attorney Community and Economic Development Community Services Court Executive Human Resources & Risk Management Police
More informationSTAMP and Workplace Safety
STAMP and Workplace Safety Larry Hettinger & Marvin Dainoff Liberty Mutual Research Institute for Safety John Flach Wright State University 1 MIT STAMP/STPA Workshop March 23-26, 2015 2 Liberty Mutual
More informationReducing Hidden Costs and Improving Effectiveness in a Rural Medical Center: CEO s story of his SEAM journey
Reducing Hidden Costs and Improving Effectiveness in a Rural Medical Center: CEO s story of his SEAM journey Rural Health Care Leadership Conference February 7, 2018 7:30 & 9:00 am Dave Dobosenski, John
More informationTALENT DNA REPORT Created by TalentMetrix For Sample. TALENTMETRIX Delivering Insights for Performance
TALENT DNA REPORT Created by TalentMetrix For Sample COMPETENCY ANALYSIS APPROACH TO GROWTH PROJECT APPROACH PRODUCTION APPROACH PROJECT APPROACH: Chooses involvement in the design or invention of a new
More informationDeveloping Frontline Supervisor Competencies Overview
Developing Frontline Supervisor Competencies Overview The City and County of Denver is a vibrant, dynamic city that requires strong leaders at every level of the organization. To ensure that we have strong
More informationCHAPTER 6. Conclusions, Suggestions and Recommendations. 6.1 Conclusions Overview
CHAPTER 6 Conclusions, Suggestions and Recommendations 6.1 Conclusions 6.1.1 Overview An effective training should contribute towards growth and development of employees competencies and motivation. If
More informationSAFETY CULTURES: THE POWER OF A POSITIVE FRAME OF REFERENCE
SAFETY CULTURES: THE POWER OF A POSITIVE FRAME OF REFERENCE DAVE PETERS President, Absolute Change Management Learning Outcomes Understand how to assess the current climate and culture of your organization
More informationATTACHMENT Guidance for Conducting an Independent NRC Safety Culture Assessment
ATTACHMENT 95003.02 Introduction Guidance for Conducting an Independent NRC Safety Culture Assessment The purpose of this assessment is for the NRC to assess the licensee s safety culture. Safety culture
More informationIOSH Branch event 3 rd June Making Behaviour Change Happen in Health & Safety. Jane Hopkinson, Senior Psychologist, Health and Safety Laboratory
IOSH Branch event 3 rd June 2015 Making Behaviour Change Happen in Health & Safety Jane Hopkinson, Senior Psychologist, Health and Safety Laboratory Objectives What is behaviour and what influences it?
More informationA Guide to Develop Safety Performance Indicators (Draft no.1 22/5/2016)
A Guide to Develop Safety Performance Indicators (Draft no.1 22/5/2016) Yu Pak Kuen Monitoring and measuring performance has always been part of safety management systems. However, such systems frequently
More informationIncreasingly, state agencies are using results from "customer satisfaction surveys"
State Agency Use of Customer Satisfaction Surveys EXECUTIVE SUMMARY Increasingly, state agencies are using results from "customer satisfaction surveys" as one measure of their performance. Some agencies
More informationCORE TOPICS Core topic 3: Identifying human failures. Introduction
CORE TOPICS Core topic 3: Identifying human failures Introduction Human failures are often recognised as being a contributor to incidents and accidents, and therefore this section has strong links to the
More informationSales Personality Assessment Report
Sales Personality Assessment Report Assessment Code: 3v1qo4 Date: Jun23, 2009 Location: 1 Sales Personality Assessment Overview Sales Personality Assessment is developed to assess sales success orientation
More informationElectronic Health Records in a System of Care Setting: Lessons Learned from the Field
Electronic Health Records in a System of Care Setting: Lessons Learned from the Field Spencer Hensley Wraparound Evaluation and Research Team Christine Graham Stars Behavioral Health Group Eric Bruns Wraparound
More informationGulfstream Flight Test Safety Management System. Evaluation Tool Guidance
Gulfstream Flight Test Safety Management System Evaluation Tool Guidance Flight test presents unique hazards and elevated risk levels during the development and certification of aircraft and new systems.
More informationWelcome to Day 3! Please pick up your tent card and sit at your selected table.
Welcome to Day 3! Please pick up your tent card and sit at your selected table. Insanity: doing the same thing over and over again and expecting different results. Albert Einstein, (attributed) Human Factors
More informationChapter 7 Internal Controls
Chapter 7 Internal Controls Establishment of and adherence to internal controls is a major part of managing an organization. Internal controls serve as the first line of defense in safeguarding assets
More informationCHAPTER 3 - ELEMENTS OF A COMPREHENSIVE SAFETY, HEALTH AND ENVIRONMENTAL MANAGEMENT PROGRAM
CHAPTER 3 - ELEMENTS OF A COMPREHENSIVE SAFETY, HEALTH AND ENVIRONMENTAL MANAGEMENT PROGRAM A. INTRODUCTION... 1 B. RESPONSIBILITIES... 1 C. SAFETY PROGRAM ELEMENTS.... 2 D. MANAGEMENT COMMITMENT.... 2
More informationPosition No. Job Title Supervisor s Position. Department Division / Region Community Location Education Corporate Services Iqaluit HQ
1. IDENTIFICATION Position No. Job Title Supervisor s Position 09-12663 Specialist, Education Technology Database Management Manager, Information and Education Technology Department Division / Region Community
More informationGuideline content. Page 1
Guideline content Introduction Scope and objective 1. Incident investigation 2. The incident investigation process 3. The root cause analysis method for logistics operations 4. Corrective Actions 5. Examples
More informationJUST CULTURE : An Algorithm for Accountability Bob Henderson 13 October 2016
JUST CULTURE : An Algorithm for Accountability Bob Henderson 13 October 2016 Human Errors Slips - an unplanned action Lapses - not completing a planned action Mistakes - doing an action incorrectly - applying
More informationIdentify Risks. 3. Emergent Identification: There should be provision to identify risks at any time during the project.
Purpose and Objectives of the Identify Risks Process The purpose of the Identify Risks process is to identify all the knowable risks to project objectives to the maximum extent possible. This is an iterative
More informationGormley Stone Marble & Granite Ltd
2018 & BEYOND Gormley Stone Marble & Granite Ltd OUR VISION FOR HEALTH AND SAFETY The Managing health and safety at Gormley is of paramount importance to us and in order that we protect our employees,
More informationIT Deputy Chief of Enterprise Architecture and Planning - #03142 City of Virginia Beach Job Description Date of Last Revision: 03/26/2018
IT Deputy Chief of Enterprise Architecture and Planning - #03142 City of Virginia Beach Job Description Date of Last Revision: 03/26/2018 FLSA Status: Exempt Pay Plan: Administrative Grade: 20 City of
More informationNBAA SAFETY CULTURE SURVEY
DEDICATED TO HELPING BUSINESS ACHIEVE ITS HIGHEST GOALS. NBAA SAFETY CULTURE SURVEY For effective safety leadership in a business aviation environment, the entire organization must work together to fully
More informationAssessment Practice Standards. A practice development guide to understanding children s needs and family situations
Assessment Practice Standards A practice development guide to understanding children s needs and family situations Forward Bolton can be proud of a long history of effective multi-agency working to safeguard
More informationOFFICE OF HUMAN RESOURCES ADMINISTRATIVE & SUPPORT STAFF PERFORMANCE APPRAISAL
OFFICE OF HUMAN RESOURCES ADMINISTRATIVE & SUPPORT STAFF PERFORMANCE APPRAISAL Purpose Statement: The purpose of the appraisal process is to allow each support and administrative employee, and his or her
More informationIntroduction to the DoD Performance Management and Appraisal Program (DPMAP)
Introduction to the DoD Performance Management and Appraisal Program (DPMAP) DPMAP Rev. 2 Welcome Why we are here: -To learn about the new Defense Performance Management Appraisal Program (DPMAP). -Gain
More informationChronic Sense of Uneasiness Stimulating Risk-Based Thinking
Human Performance Conference Atlanta, Georgia, March 18-20, 2014 Chronic Sense of Uneasiness Stimulating Risk-Based Thinking Tony Muschara, CPT The Certified Performance Technologist (CPT) designation
More informationAWAIR Program MN RULES: CHAPTER Dave Gelhar Todd Osman Daniel Schmid Pam Schmid
AWAIR Program (A Workplace Accident and Injury Reduction Program) MN RULES: CHAPTER 5208 Dave Gelhar 12-19-13 Todd Osman 12-19-13 Dave Gelhar / Date SpecSys President Todd Osman / Date RVI President Daniel
More informationThe Orion Pre-Employment Assessment Program
The Orion Pre-Employment Assessment Program The Role of Orion Assessments Identify critical workplace attitudes and behaviors rarely revealed in other prehire processes or interviews Provide assessment
More information