What Is Human and Organizational Performance? (H&OP)
Human and Organizational Performance (H&OP)
If an Organization has created an imperfect System where an Individual can inevitably make a mistake that might cause serious injury or death... Then how does the Organization change the System to fail safely when an inevitable human error occurs?Human & Organizational Performance (H&OP) is about building organizations that can tolerate inevitable human errors in such a way that no serious injuries or fatalities (SIFs) occur in the workforce nor the organization's customers. Organizations that practice H&OP are always learning organizations that learn from both their failures and their successes. These H&OP Organizations fail just like every other Organization, but when H&OP Organizations fail, they fail safely.
H&OP is a "red queen" dynamic that learning Organizations use to protect themselves and their customers from harm as hazards change and evolve. These Organizations continuously adapt their systems to tolerate human error in order to keep up with the constantly evolving hazards that will not tolerate human error. H&OP requires a combined a safety scaffolding of: Just Culture, Safety Culture and Safety Management an Organization (or even an entire industry) uses H&OP to continuously protect itself and its customers 24/7. Just Culture is the most important part of the safety scaffolding that H&OP sits on because blame increases risk and reduces trust both of which will eliminate any H&OP effort. An Organization that is skilled in practicing H&OP uses it as a language to efficiently communicate risk based thinking and build trust. Every hazard, every irreversible critical step, every event, every near miss is taken into account by every person in the Organization, from the CEO to the last person hired. Zero SIFs is a shared common vision which everyone communicates by practicing H&OP as a language to build a zero SIFs Organization. Everyone matters.
Aviation Flight Operations ModelThe aviation industry has successfully been practicing H&OP for decades. For aviation, H&OP provides a safety management approach that assumes that flight crews will naturally make mistakes and encounter risky situations during operations. Rather than try to avoid errors, the Organization's primary focus is to teach flight crews to manage these issues so they do not impair safety. The goal is to maintain safety margins by enabling leaders and crews to detect and respond to mistakes that are likely to cause harm.
Ref: "Threat and error management" Wikipedia
Simply put: Performance = Behavior + Results
A person can not outperform the Organization (O). Even if they are the "safest" person in the Organization. Why? The Organization's Behavior (Ob) can still get the person injured or killed even if the Organization's Results ( Or) are achieved with safety "compliant" behavior. For example: Even the safest driver on the road can NOT be safer (outperform) than all the drivers who make up a local area.
but it is not that simple...
Op = Ob + Or
An Organization's Performance is the combination of Behavior + Results (the organization's systems drive its behavior)
Ref: "DOE Standard Human Performance Improvement Handbook" U.S. Department of Energy Vol-1, Ch-1, pg-12, June 2009
It is great to be the safest person in the company, but in the U.S. it is far safer to be the safest person working for the safest company. The safest Organizations far exceed the safety compliance regulations that are required for them to opererate. As dangerous as landing a commercial airliner is, every day in the U.S. commercial pilots make tens of thousands of safe landings. Pilots don't get killed doing a dangerous job, yet the same can not be said for electrical lineman working on the grid who die at a rate of one every week in the U.S.. The difference is not the job. The difference is the Performance of the Organization - in this case the industries as a whole.
On average a person dies in the workplace every two hours. Most of these 4000+ workplace deaths every year are preventable.
Ref: "Work related fatality trends 1992-2019" Injury Facts®
What is driving this trend? Profits. To survive Organizations must be relentlessly competitive. Experienced CEOs with experienced management teams know how to compete without degrading the organization's behavior. They know that safety is a core value that drives profit. For example, While many management teams "imagine" the way work gets done, top performing teams get out from behind their desks and they learn how the work is really getting done. This approach raises the bar for Organizational behavior, creates more efficient communications and builds trust across the Organization. The message must be clear, everyone matters.
The Safest Organizations know that Profit and Safety is Not a Binary ChoiceThey know that safety is a core value that drives profit. Because they invest and build a safety scaffold of Just Culture, Safety Culture, Safety Management and practice H&OP these Organizations:
- Pay lower insurance premiums
- Have fewer accidents
- Have less waste
- Have higher profits
- Have more a more engaged work force
- Have higher customer satisfaction
This enables these companies to invest more money in their safety scaffold, make "long term" investments in their production or service lines and pay higher salaries to get the best people. These investments then go on to save them even more money. It is a circle that spirals upward compared to companies who see production and safety as a binary choice.
What About Human Error?Glad you asked, we almost forgot! Humans are fallible and that is one of the great things about being human. Human error is universal, human error is inevitable and most importantly unintentional human error is not the cause of a serious injury or fatality (SIF). Blaming individuals for their errors is useless for an Organization that is working to get to zero SIFs. But individuals must he held accountable for their errors, right? Not if it was unintentional.
No one uses human error to describe the conduct of a drunk driver or a suicide bomber.
In fact blaming individuals for making unintentional errors actually increases because it creates a culture where nobody will discuss evolving hazards and how they can be removed or made to not cause harm when the inevitable human error occurs. It should also not go unnoticed that human error occurs in many successes. The behavior of Learning Organizations is such that they plan for failures and learn from failures, just as much as they plan and learn from their successes.
When learning Organizations investigate their failures they don't stop the investigation when they find human error because all this will do is cause reoccurrences of the same failure. Instead they ask their safety professionals to: get to the systems, and human choices, behind the human errors.
Ref: "Human Error is NEVER the Root Cause – REVISITED" by David Marx, The Just Culture Company, "What We Believe" series.
In learning Organizations, reducing the frequency and severity of human errors does play a significant role in Organizations that practice H&OP. But the individuals who are at the touch points doing the work are only part of the Organization. The crown jewel of H&OP is for the Organization's behavior to be such that the Organization as a whole continuously evolves and adapts to ensure that when the inevitable human error is made, then zero humans and customers will be seriously injured or killed.
Asset –– [risk] –– Hazard
This requires the executive team and management to always be in synch with the workers who continuously encounter and discover new places that can cause a SIF if a human error is made. Simply put, Management must constantly be managing and adapting error defenses (engineering, processes and procedures). Managing error defenses means that the Organization must constantly adapt by discovering and removing newly evolved hazards. For built in hazards which cannot be removed nor substituted, the Organization must constantly manage its defenses by adapting its engineering, processes and procedures so that the built in hazards do not evolve to cause harm when a human error is made.
-- W. Edwards Deming
How? Start with this: An Organization cannot change what it cannot see. Therefore an Organization must map every hazard, map every irreversible critical step, democratize event reports across the Organization and facilitate anonymous near miss reporting. Use the knowledge acquired from these four elements of the Safety Spectrum to build an Organization that can tolerate human error without harm as the first line of defense. Use error reduction and managing defenses (engineering, processes and procedures) as the second line of defense. Personal protective equipment (PPF) is not really a line of defense, it is there as a last resort when an Organization's lines of defense break down.
James Reason originally proposed a model of what happens when an Organization's lines of defense break down. Reason called his model: "The Swiss Cheese Model of Defences". This model helps to visualize and explain the randomness of SIFs. H&OP has advanced since 1997. For the purposes of the way H&OP is being practiced in the twenties we propose slight modifications to Reason's model when used to discuss H&OP:
- Layer 1: Organization fails to mitigate all removable hazards and fails to"wrap" inherent hazards to tolerate human error by failing to a safe state.
- Layer 2: Safety Culture and Safety Management fails. (e.g. supervision)
- Layer 3: Error Reduction and Managing Defenses fails.
- Layer 4: Human Error inevitably occurs.
When the "holes line up"...the person's only hope to escape SIF is the PPE they are wearing.
Ref: "Managing the Risks of Organizational Accidents" by James Reason, Published by Routledge, Ch-1, pg-9, December 1997
Hunam Factors?Human factors is a discipline with a design focus (especially on ergonomics) that is concerned with the performance of the system. For example some planes in WWII had the flap controls and landing gear controls side by side and ergonomically almost the same. It was easy to make a mistake even during a calm day landing never mind at night, exhausted after a mission and sometimes wounded. Human factors engineers and phycologists recognized this as a design flaw and ever since the two controls are now located in separate locations with ergonomic differences.
H&OP is interdisciplinary with a focus on behavior. Modern H&OP is highly focused on the behavior of the Organization as a whole. When Human Factors is unable to remove, substitute or engineer safety into the hazard then the Organization must administratively control the hazard. However as shown by James Reason's Swiss cheese model the holes will eventually line up and inevitable the human error will be made. H&OP uses an interdisciplinary approach of behavior and learning to make sure that the Organization continuously learns how to protect itself from the hazard.
Ref: "‘Human Factors and Human Performance: What’s the difference?" by Steven Shorrock, Feb-04 2019
Well...You Made it all the Way to Here!As a Safety Professional, you probably do not agree with everything above used to explain what H&OP is in the context of safety. That is a good thing because safety professionals care deeply about the people they are protecting. Before an Organization adds H&OP to the existing safety scaffolding the Organization must be sure H&OP will add more protection to the workforce and the customers.
Remember, H&OP is a red queen dynamic. Organizations need this dynamic because they have to continuously adapt and evolve thier protection as new hazards evolve or else the Organization will fail its way into extinction. Safety Professionals who are hugely outnumbered by hazards and ever growing work place complexities understand clearly that protecting the workforce and customers is an arms race. This means that by definition, the dynamic H&OP approach of a learning Organization is going to initially clash with Organizations that have static or outdated "reactive protections".
More importantly H&OP will not work without the scaffolding of Just Culture, Safety Culture and Safety Management. Without those three H&OP will not thrive in an Organization. If an Organization does not have that scaffolding in place then H&OP may be colliding with the current mental model of safety in an Organization...and that's ok. On this journey to Zero SIFs we start with compliance and then we go beyond compliance.
Human & Organizational Performance (H&OP) PrinciplesError Makes Us Human • Blame Increases Risk • Organizations Learn to Fail Safely • Organizational Systems Drive Behavior • How an Organization Responds to Failure Matters
Ref: "The 5 Principles of Human Performance" Todd E. Conklin PhD, Ch: 2-6 January 2019