To Err is Human (Factors)

Working with air traffic control, other external bodies and senior colleagues to introduce Human Factors to:

• improve the investigation and resolving of quality incidents

• make NHSBT a safer and nicer place to work

• tailor responses to HSW improvements when they are being addressed

With the central understanding that "nobody comes to work to purposefully do a bad job" we used Human Factors methodology to ascertain why things "still go wrong" when our policies and procedures were extremely comprehensive and clear.

It turned out that our policies and procedures were so detailed that it made them too large and nobody actually read them and they seemed to only be applied to "punish" people!

After workshops, meetings with managers, staff and unions and online research we came up with the following actions:

1. Slash the size of policies to 1-3 pages, and support them with online frequently asked questions. This resulted in far more of the policies being read by a wider variety of staff.

2. Educate all managers in Human Factors with regards to the health, safety and wellbeing of their teams - encouraging the reporting and local addressing of near misses and poor practice. This resulted in a reduction in the "walk past culture" for hazards, near-misses and accidents.

3. Applying TBO technique (trigger-behaviour-outcome) to halt poor and dangerous practices within individual teams. This allowed team to investigate why they displayed particular behaviours and help to formulate plans for changing that behaviour.

4. the introduction of a just-blame culture when investigating quality incidents and replacing blame with errors (slips, lapses, rule-based mistakes and knowledge-based mistakes) and violations (routine, situational, exceptual, optimizing and individual). As staff are getting used to this approach they are, at all levels, becoming more honest about reporting incidents and the part they played in them, enabling more accurate reporting and better-informed solutions.

5. Just being introduced are Human Factor observations of processes - early days but we are beginning by training a cohort of staff to be expert observers and understand the philosophy underpinning the practice - the beginning of a long journey.

The important aspect of introducing Human Factors as an approach in the workplace is that all managers and leaders support it, both verbally and (more importantly) their actions. They must "walk the talk".