{"id":3030,"date":"2013-05-25T10:25:34","date_gmt":"2013-05-25T10:25:34","guid":{"rendered":"http:\/\/www.saasoft.com\/blog\/?p=3030"},"modified":"2013-05-25T10:25:34","modified_gmt":"2013-05-25T10:25:34","slug":"burn-and-scrape","status":"publish","type":"post","link":"https:\/\/hcse.blog\/?p=3030","title":{"rendered":"Burn-and-Scrape"},"content":{"rendered":"


\n\"telephone_ringing_300_wht_14975\"<\/a>[Ring Ring]<\/strong><\/p>\n

<Bob><\/em> Hi Leslie how are you to today?<\/p>\n

<Leslie><\/em> I am good thanks Bob and looking forward to today’s session. What is the topic?<\/p>\n

<Bob><\/em> We will use your Niggle-o-Gram\u00ae to choose something. What is top of the list?<\/p>\n

<Leslie><\/em> Let me see.\u00a0 We have done “Engagement” and “Productivity” so it looks like “Near-Misses” is next.<\/p>\n

<Bob><\/em> OK. That is an excellent topic. What is the specific Niggle?<\/p>\n

<Leslie><\/em> “We feel scared when we have a safety near-miss because we know that there is a catastrophe waiting to happen.”<\/p>\n

<Bob><\/em> OK so the Purpose is to have a system that we can trust not to generate avoidable harm. Is that OK?<\/p>\n

<Leslie><\/em> Yes – well put. When I ask myself the purpose question I got a “do” answer rather than a “have” one. The word trust is key too.<\/p>\n

<Bob><\/em> OK – what is the current safety design used in your organisation?<\/p>\n

<Leslie><\/em> We have a computer system for reporting near misses – but it does not deliver the purpose above. If the issue is ranked as low harm it is just counted, if medium harm then it may be mentioned in a report, and if serious harm then all hell breaks loose and there is a root cause investigation conducted by a committee that usually results in a new “you must do this extra check” policy.<\/p>\n

<Bob><\/em> Ah! The Burn-and-Scrape<\/strong> model.<\/p>\n

<Leslie><\/em>Pardon? What was that? Our Governance Department call it the Swiss Cheese model.<\/p>\n

<Bob><\/em> Burn-and-Scrape is where we wait for something to go wrong – we burn the toast – and then we attempt to fix it – we scrape the burnt toast to make it look better. It still tastes burnt though and badly burnt toast is not salvageable.<\/p>\n

<Leslie><\/em>Yes! That is exactly what happens all the time – most issues never get reported – we just “scrape the burnt toast” at all levels.<\/p>\n

\"fire_blaze_s_150_clr_618\"<\/a> \"fire_blaze_h_150_clr_671\"<\/a> \"fire_blaze_n_150_clr_674\"<\/a><Bob><\/em> One flaw with the Burn-and-Scrape design is that harm has to happen for the design to work.<\/p>\n

It is all reactive.<\/p>\n

Another design flaw is that it focuses attention on the serious harm first – avoidable mortality for example.\u00a0 Counting the extra body bags completely misses the purpose.\u00a0 Avoidable death means avoidably shortened lifetime.\u00a0 Avoidable non-fatal will also shorten lifetime – and it is even harder to measure.\u00a0 Just consider the cumulative effect of all that non-fatal life-shortening avoidable-but-ignored harm?<\/p>\n

Most of the reasons that we live longer today is because we have removed a lot of lifetime shortening hazards – like infectious disease and severe malnutrition.<\/p>\n

Take health care as an example – accurately measuring avoidable mortality in an inherently high-risk system is rather difficult.\u00a0 And to conclude “no action needed” from “no statistically significant difference in mortality between us and the global average<\/em>” is invalid and it leads to a complacent delusion that what we have is good enough.\u00a0 When it comes to harm it is never “good enough”.<\/p>\n

<Leslie><\/em> But we do not have the resources to investigate the thousands of cases of minor harm – we have to concentrate on the biggies.<\/p>\n

<Bob><\/em> And do the near misses keep happening?<\/p>\n

<Leslie><\/em> Yes – that is why they are top rank\u00a0 on the Niggle-o-Gram\u00ae.<\/p>\n

<Bob><\/em> So the Burn-and-Scrape design is not fit-for-purpose.<\/p>\n

<Leslie>\u00a0<\/em>So it seems. But what is the alternative? If there was one we would be using it – surely?<\/p>\n

<Bob><\/em> Look back Leslie. How many of the Improvement Science methods that you have already learned are business-as-usual?<\/p>\n

<Leslie><\/em> Good point. Almost none.<\/p>\n

<Bob><\/em> And do they work?<\/p>\n

<Leslie> You betcha!<\/p>\n

<Bob><\/em> This is another example.\u00a0 It is possible to design systems to be safe – so the frequent near misses become rare events.<\/p>\n

<Leslie><\/em> Is it?\u00a0 Wow! That know-how would be really useful to have. Can you teach me?<\/p>\n

<Bob><\/em> Yes. First we need to explore what the benefits would be.<\/p>\n

<Leslie><\/em> OK – well first there would be no avoidable serious harm and we could trust in the safety of our system – which is the purpose.<\/p>\n

<Bob><\/em> Yes …. and?<\/p>\n

<Leslie><\/em> And … all the effort, time and cost spent “scraping the burnt toast” would be released.<\/p>\n

<Bob><\/em> Yes …. and?<\/p>\n

<Leslie><\/em> The safer-by-design processes would be quicker and smoother, a more enjoyable experience for both customers and suppliers, and probably less expensive as well!<\/p>\n

<Bob><\/em> Yes. So what does that all add up to?<\/p>\n

<Leslie><\/em> A win-win-win-win outcome!<\/p>\n

<Bob><\/em> Indeed. So a one-off investment of effort, time and money in learning Safety-by-Design methods would appear to be a wise business decision.<\/p>\n

<Leslie><\/em> Yes indeed!\u00a0 When do we start?<\/p>\n

<Bob><\/em> We have already started.<\/p>\n

\n

For a real-world example of this approach delivering a significant and sustained improvement in safety click here<\/a>.<\/p>\n","protected":false},"excerpt":{"rendered":"

[Ring Ring] <Bob> Hi Leslie how are you to today? <Leslie> I am good thanks Bob and looking forward to today’s session. What is the topic? <Bob> We will use your Niggle-o-Gram\u00ae to choose something. What is top of the list? <Leslie> Let me see.\u00a0 We have done “Engagement” and “Productivity” so it looks like … <\/p>\n

Continue reading “Burn-and-Scrape”<\/span><\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[5,6,15,22,29,32,38,40,41,42,43,45,47,48],"tags":[],"class_list":["post-3030","post","type-post","status-publish","format-standard","hentry","category-4n-chart","category-6m-design","category-design","category-healthcare","category-niggle-o-gram","category-productivity","category-safety","category-sfqp","category-stories","category-how","category-why","category-what","category-transactional-analysis","category-trust"],"_links":{"self":[{"href":"https:\/\/hcse.blog\/index.php?rest_route=\/wp\/v2\/posts\/3030","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/hcse.blog\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/hcse.blog\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/hcse.blog\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/hcse.blog\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=3030"}],"version-history":[{"count":0,"href":"https:\/\/hcse.blog\/index.php?rest_route=\/wp\/v2\/posts\/3030\/revisions"}],"wp:attachment":[{"href":"https:\/\/hcse.blog\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=3030"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/hcse.blog\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=3030"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/hcse.blog\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=3030"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}