2019 TapRooT® Summit Montgomery, TX March 2019 · 2019 TapRooT® Summit Montgomery, TX March 2019 Kevin McManus Chief Excellence Officer Great Systems Systems Culture Behaviors R

© 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


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.


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


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?


If leaders knew the cost of the errors that occur EACH DAY …

They would make VERY DIFFERENT decisions!


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


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


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?





To what degree are these factors used to minimize error potential in your organization?


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


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


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


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


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!


“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


How effective are your safeguards at reinforcing the desired on-the-job behaviors?

Systems

Culture

Behaviors

BeliefsR


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


Preferred Sensing Modality

Visual

What are your preferences?

Auditory

Kinesthetic

Preferred Thinking Style

Preferred Mode of Expression

Visual

Auditory

Kinesthetic

Serial

Parallel


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%


The Foundational Power of Paper

Systems

Culture

Behaviors

BeliefsR

Positive, Purpose Driven Culture

Using Processes to Guide People

Perfect Practice Makes Perfect

Be Prepared


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?


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


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?


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


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


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!


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?


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


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 #


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


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


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


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


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


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?


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?


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


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


Total Score


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


Total Score


Bar Coding

Easy to use app interfaces

Quick Response Codes

ImplantsRFID Bands


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


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


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


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


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


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


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!

Documents

2019 TapRooT® Summit Montgomery, TX March 2019 · 2019 TapRooT® Summit Montgomery, TX March 2019 Kevin McManus Chief Excellence Officer Great Systems Systems Culture Behaviors R