Best Practices for Safety Action Review Boards

Transcription

1 Best Practices fr Safety Actin Review Bards By Brian Hughes, Vice President f Slgic A versin f this article appeared in the May 2011 issue f Prfessinal Safety magazine. Many safety departments I wrk with are gd at prcessing safety incident investigatins. They recgnize when an incident requires investigatin. They check the right bxes, fill in the right descriptins, admnish the guilty in a timely fashin and file the reprt in the right flder, where it may never be referenced again. Metrics are tracked t ensure that the prcess stays n target. Hw many incident investigatins are pened? In prcess? Hw many clsed? N safety manager wuld deny that reprt thrughput is imprtant, but the mst imprtant scre t watch is risk reductin. Withut a significant rganizatinal emphasis n utput quality, risk reductin is left t the individual cmpleting the investigatin. Sme d a terrific jb, but many d nt. S, hw d yu measure the quality f safety reprts in a meaningful methd that truly results in risk reductin? Creating and implementing a safety review bard (SRB), based n the cncept f a crrective actin review bard (CAB) that is frequently used in the area f quality, can make a big difference in safety reprt quality. An SRB als will help disseminate imprtant imprvement ideas acrss the rganizatin. A CAB in quality r prcurement is made up f a small, yet diverse grup f managers and is chartered with the task f reviewing significant quality investigatins. Its gal is t cultivate an verall reductin in risk. A CAB reviews: key aspects f the investigatin t ensure that key quality milestnes are met; the crrective actins suggested by the investigatin team; systemic causes uncvered by the investigatin. Based n reviews, the CAB: suggests imprvements given t the investigatin team; apprves f crrective actins; cmmunicates systemic pprtunities fr imprvement t ther parts f the rganizatin. This mdel culd be equally effective in the area f safety Washingtn Street, Midland, MI slgic.cm

2 SRB Review Prcess Key Elements Assessing Investigatin Quality When a CAB reviews an investigatin fr quality, it must incrprate a standard scre sheet and prvide space t add qualitative cmments fr each sectin. The scre sheet fsters cnsistency and cmpleteness. Every investigatin shuld include a prblem statement, causal analysis, reprt summary, crrective actin plan, identificatin f systemic causes and remaining actins. Prblem Statement A cmplete prblem statement explains the prblem, when and where it happened, and its effect n the rganizatin. If the investigatin was triggered by a predefined threshld exceedance, the reprt shuld nte this. An example f a safety threshld exceedance used by many cmpanies is an OSHA recrdable injury. The SRB shuld cnsider predefined threshlds. Are they wrking as intended? Are they t lw r t high given the investigative resurces allcated by the cmpany? Shuld threshlds r investigative resurces be adjusted? These are imprtant prgram cnsideratins int which the SRB has visibility. SRB input can be crucial t effectively balancing the expectatins placed n the safety prgram with the resurces allcated tward achieving these expectatins. Causal Analysis The SRB shuld review the causal analysis because this is the basis fr the team's cnclusins. There are many methdlgies fr causal analysis; sme are better than thers. The rganizatin shuld als select a single methdlgy and stick t it s that everyne cnducting investigatins fllws the same prcess and generating reprts that are accurate and cnsistent. Any rt cause analysis (RCA) prvider either has, r will be willing t help a site develp a list f key elements t include in the review. Reprt Summary The summary statement is essentially the causal analysis cnverted int narrative frm. Is the reprt summary cmplete and thrugh? Is it accurate? Is it readable? When the reprt is distributed, this is likely where mst readers will get their infrmatin. A well written summary statement is crucial t accurate disseminatin f this infrmatin. Reprt writing is nt everyne's specialty. Cnsider designating an internal resurce t edit widely distributed reprts. Crrective Actin Plan Crrective actins derive frm causes. The SRB needs t ensure that the crrective actins recmmended by the team are supprted by the analysis. The SRB als needs t practice basic prtfli management with respect t crrective actins. The best crrective actin plans include a multiprnged attack n causes rather than just a single rt cause. The SRB shuld cnsider the verall risk reductin ffered by the cmbinatin f crrective actins. The SRB als needs t review the actual implementatin plan. Has the team cmpleted a plan that is achievable in a reasnable time frame? What barriers might prevent implementatin that the Washingtn Street, Midland, MI slgic.cm

3 SRB can help vercme? Has the team cnsidered imprtant management f change issues t help ensure that its recmmended slutins d nt cause ther prblems? Systemic Opprtunities Areas f systemic rganizatinal risk ften can be fund in any analysis. Examples f systemic prblems include a high turnver rate, a bias tward prductin and a reactive maintenance prgram. Such high level causes increase the risk f incidents t everyne in the rganizatin. The SRB is uniquely suited t identify these causes and help elevate their visibility in the rganizatin t a level that can make a difference. Remaining Actins Mst investigatins have utstanding actin items t be cmpleted. The SRB shuld review these utstanding items t ensure that all lse ends are tied up in a timely fashin. The scre sheet nly tells part f the stry. Ensure that SRB members have the ability t cmment qualitatively as well. CAB Pitfalls CABs are planned with the best intentins, but implementatin can present sme pitfalls. Thse pitfalls include selecting the wrng peple as CAB members, failing t take return n investment int accunt, being unable t vercme a quick fix culture and deficiencies in RCA prgram implementatin. Optimal Membership Thse chsen as CAB/SRB members shuld have bth the ability and the incentive t participate effectively. Effective participatin requires that the SRB member have a slid knwledge f the RCA prcess, as well as the supprting prblem management prgram. All members need t knw the steps invlved in an RCA. They need nt be card carrying RCA facilitatrs, but such knwledge certainly des nt hurt. This experience prvides them with the ability t understand what is being presented as well as hw the infrmatin was generated. This allws the SRB team t prvide credible, meaningful feedback and mentrship t the RCA facilitatr. Participating effectively als requires a certain level f pwer within the rganizatin. CAB/SRB members need t set pririties and assign resurces. This pwer culd be inherent in the CAB r SRB member's title, r culd be bestwed frm executives fr the purpses f the CAB/SRB. CAB/SRB members als need t have the incentive t participate. They must have a stake in the successful utcme f the investigatin and f the prblem management prgram itself. They need t see hw the prgram nt nly aligns with the metrics by which they themselves are measured at their perfrmance reviews, but als hw it is actually a critical cmpnent f their jb functin. Their gals and the gals f the prblem management prgram are ne and the same Washingtn Street, Midland, MI slgic.cm

4 Quantifying Return n Investment Many safety prgrams d nt take return n investment (ROI) int accunt. This mistake is ften made with the best intentins; n cmpany wants t be perceived as acting n safetyrelated prblems nly when it experiences a certain financial utcme. This is understandable, but there are gd reasns t take int accunt the financial impact f safety prblems, nt t mentin the nnfinancial ROI calculatins. ROI is an imprtant way t keep scre fr the prgram. If dne prperly, it can shw the prgram's value in bth qualitative and quantitative terms. It helps t invlve finance in this calculatin. Many safety prfessinals may nt knw hw t build an ROI mdel that is accurate and meaningful. The finance department shuld be able t help. Quick-Fix Culture Often, the fcus f an RCA prgram is incident management versus prblem management. The purpse f incident management is t get business back up and running as sn as pssible. Hwever, when the fcus is slely n getting back t wrk, the prcess verlks imprtant systemic risk factrs that will leave the rganizatin at risk fr recurrences. The SRB shuld be tuned fr prblem management, which brings mre thrugh RCA int the issue. The SRB can help shck a quick fix culture int taking a mre lng term apprach t significant prblems, but it als can reinfrce the quick fix culture. Prgram Implementatin Prblems Many RCA prgrams have gaps that can lead t an ineffective SRB prcess. These include: failure t define prgram gals and bjectives; failure t define apprpriate threshld criteria; training the wrng peple as investigatrs; nt implementing recmmended crrective actins; failure t develp effective prgram metrics. A well planned SRB is nly ne element f a successful prblem management prgram. The ther pillars listed als must be in place in rder t achieve ptimal results Washingtn Street, Midland, MI slgic.cm

5 Building an Effective SRB A Quick Checklist 1. Chse the right SRB members. Members shuld be knwledgeable in the cmpany's RCA prcess. Members shuld pssess rganizatinal pwer. Members shuld have a persnal incentive fr the success f the SRB. 2. Develp a cnsistent review prcess. Use a scre sheet. Cmment qualitatively. Prvide cnstructive feedback. Reward high quality wrk publicly. 3. Rt ut systemic risk. Learn t recgnize systemic prblems/causes. Make sure t cmmunicate with ther parts f the rganizatin. 4. Ensure that actin items are cmpleted. Verify that all actins are n track. Validate that actins did in fact reduce the risk f recurrence. Brian Hughes is vice president f Slgic, a prvider f rt cause analysis cnsulting, training and sftware, an affiliate f Artemis Investigatins. Hughes has led significant incident investigatins, including thse related t majr explsins, chemical releases, cnsumer prduct cntaminatin, manufacturing defects and supply chain prcesses. Fr mre infrmatin, visit r cntact Hughes at brian.hughes@slgic.cm; (989) Washingtn Street, Midland, MI slgic.cm