{"id":903,"date":"2011-07-16T15:22:51","date_gmt":"2011-07-16T15:22:51","guid":{"rendered":"http:\/\/www.saasoft.com\/blog\/?p=903"},"modified":"2011-07-16T15:22:51","modified_gmt":"2011-07-16T15:22:51","slug":"safety-by-design","status":"publish","type":"post","link":"https:\/\/hcse.blog\/?p=903","title":{"rendered":"Safety-By-Design"},"content":{"rendered":"

\"\"<\/a>The picture is of Elisha Graves Otis demonstrating, in the mid 19th century,\u00a0his safe elevator that automatically applies a brake if the lift cable breaks. It is a “simple” fail-safe mechanical design that effectively created the elevator industry and\u00a0the opportunity of high-rise buildings.<\/p>\n

“To err is human”\u00a0and\u00a0human factors research into how we\u00a0err has revealed\u00a0two parts\u00a0– the Error of\u00a0Intention (poor decision)\u00a0and the Error of Execution (poor delivery) – often referred to as “mistakes” and\u00a0“slips”.<\/p>\n

Most of the time we act unconsciously using well practiced skills that work because most of our tasks are\u00a0predictable; walking, driving a car etc.<\/p>\n

The caveman wetware between our ears has evolved to delegate this uninteresting and predictable\u00a0work to different parts of the sub-conscious brain and this design frees us to concentrate our conscious attention on other things.<\/p>\n

So, if something happens that is unexpected we may not be aware of it\u00a0and we may\u00a0make\u00a0a slip without noticing. This is one way that\u00a0process variation can lead to low quality – and\u00a0these are the often the most insidious\u00a0slips because they go unnoticed.<\/p>\n

It is these unintended errors that we need\u00a0to eliminate using safe\u00a0process design.<\/p>\n

There are two ways – by designing processes to reduce the opportunity for mistakes (i.e. improve our decision making); and then to avoid slips by designing the\u00a0subsequent\u00a0process to be predictable and therefore suitable for delegation.<\/p>\n

Finally, we need to add a mechanism\u00a0to automatically alert us of\u00a0any\u00a0slips and\u00a0to\u00a0protect us from their consequences\u00a0by failing-safe.\u00a0 The sign of good process design is that it becomes invisible –\u00a0we\u00a0are not aware of it because it works at the sub-conscious level.<\/p>\n

As soon as we become aware of\u00a0the design we have either made a slip – or the design is poor.<\/p>\n

\n

Suppose\u00a0we walk up to a door and we are faced with a flat metal plate – this “says” to us\u00a0that\u00a0we need to “push” the door to open it – it is unambiguous design and we do not need to invoke consciousness to make a push-or-pull decision. \u00a0The technical term for this is an “affordance”.<\/p>\n

In contrast\u00a0a door handle\u00a0is an ambiguous\u00a0design – it may\u00a0require a push or a pull – and\u00a0we either need to look for other clues or conduct a suck-it-and-see experiment. Either way we need to switch our conscious\u00a0attention to the task – which means we have to switch it away from something else. It is those\u00a0conscious\u00a0interruptions that cause us irritation and can spawn\u00a0other, possibly much bigger, slips and mistakes.<\/p>\n

Safe systems require safe processes – and safe processes mean fewer\u00a0mistakes\u00a0and fewer slips.\u00a0We can reduce slips through good design and relentless improvement.<\/p>\n

A simple and effective\u00a0tool for this\u00a0is\u00a0The 4N Chart\u00ae\u00a0– specifically the “niggle” quadrant.<\/p>\n

Whenever we are interrupted by a poorly designed\u00a0process\u00a0we experience a niggle – and by recording what, where and\u00a0when those niggles occur we can quickly focus our consciousness on the\u00a0opportunity for improvement.\u00a0One requirement to do this is the expectation and the discipline to record niggles – not necessarily to fix them immediately – but just to record them and to review them later.<\/p>\n

In\u00a0his book “Chasing the Rabbit<\/em>” Steven Spear describes two examples of\u00a0world class safety:\u00a0the US Nuclear Submarine Programme and Alcoa, an aluminium producer.\u00a0 Both\u00a0are potentially dangerous\u00a0activities and, in both\u00a0examples, their\u00a0world class safety record came from setting the expectation that\u00a0all niggles are recorded and acted upon – using a simple,\u00a0effective and efficient niggle-busting process.<\/p>\n

In stark and worrying contrast,\u00a0high-volume high-risk activities\u00a0such as health care\u00a0remain unsafe not because there is no incident\u00a0reporting\u00a0process – but because\u00a0the\u00a0design of the report-and-review process is both ineffective and inefficient and so is not used.<\/p>\n

The risk of\u00a0avoidable death\u00a0in a modern hospital is quoted at around 1:300 –\u00a0if our risk of dying in an elevator were that high\u00a0we\u00a0would take the stairs!\u00a0 This worrying statistic is to be expected though – because\u00a0if we lack the organisational capability to design a safe health care delivery process then we will lack the organisational capability to design a safe improvement process too.<\/p>\n

Our skill gap\u00a0is clear – we need to learn how to improve process safety-by-design.<\/p>\n

\n

Download Design for Patient Safety<\/a> report written by the Design Council.<\/p>\n

Other good examples are the WHO Safer Surgery Checklist, and the story behind this is told in Dr Atul Gawande’s Checklist Manifesto<\/em>.<\/p>\n","protected":false},"excerpt":{"rendered":"

The picture is of Elisha Graves Otis demonstrating, in the mid 19th century,\u00a0his safe elevator that automatically applies a brake if the lift cable breaks. It is a “simple” fail-safe mechanical design that effectively created the elevator industry and\u00a0the opportunity of high-rise buildings. “To err is human”\u00a0and\u00a0human factors research into how we\u00a0err has revealed\u00a0two parts\u00a0– … <\/p>\n

Continue reading “Safety-By-Design”<\/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":[5,9,13,21,22,23,35,42,43,45,46],"tags":[91,177,183,250,257,283],"class_list":["post-903","post","type-post","status-publish","format-standard","hentry","category-4n-chart","category-books","category-chimpware","category-governance","category-healthcare","category-history","category-reflections","category-how","category-why","category-what","category-teach","tag-design","tag-mistake","tag-niggle","tag-safety","tag-slip","tag-the-4n-chart"],"_links":{"self":[{"href":"https:\/\/hcse.blog\/index.php?rest_route=\/wp\/v2\/posts\/903","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=903"}],"version-history":[{"count":0,"href":"https:\/\/hcse.blog\/index.php?rest_route=\/wp\/v2\/posts\/903\/revisions"}],"wp:attachment":[{"href":"https:\/\/hcse.blog\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=903"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/hcse.blog\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=903"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/hcse.blog\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=903"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}