Incident management is not a simple function. The process consists of reacting to an incident, finding its root causes, creating procedures around reporting and investigation, and based on these, implementing corrective actions. The aim is to inspire an all-encompassing safety culture that revolves around learning and facts; ‘learning’ being an important concept here.
It has been widely discussed how companies should avoid a blame culture where employees are frankly just too afraid to report an incident in anticipation of the blame that will be cast.
However, shifting from blaming to learning is easier said than done. For many, challenge lies in reducing mistakes whilst trying not to point the finger. How do you maximize safety, and motivate personnel to avoid mistakes without correcting the culprit?
In my opinion, what needs to be cultivated in this context is responsibility. When the culture in a workplace revolves around responsibility, all parties are encouraged to remain honest and adhere to procedures. This kind of mentality can also lead to increased focus on the overall incident rather than the subject.
Inspired by these thoughts, I have gathered 3 aspects that can help to shape workplace culture built on “no blame, no fear, learn”.
Statistics are always a good place to start.
Globally, there are over 317 million accidents every year, of which 2.3 million lead to the death of an employee. To reduce these numbers, it is paramount for every organization to build solid procedures around their incident management. This meaning that in the event of an incident, a clear step by step guide should be formulated to explain the journey from reporting to action.
Procedures help to take attention away from the “culprit”, and place it on the facts instead.
Reporting should be made simple and standardized so that all incidents can be reported without an extra layer of bureaucracy.
Forms for reporting incidents should be easily accessible and should capture all necessary information of the situation. The report should also be automatically forwarded to the assigned manager of the site, or routed to the appropriate person based on the type of incident at play.
A good reporting system tends to be tailored to the needs of a company, and it supports the entire process from reporting to data storage to analysis. These are some of the benefits when using Incident Management for SharePoint, for example. Since SharePoint works as a storage, sharing platform and communication channel, it enables all functions to be managed via the same system. When combined with a thorough reporting capacity, the company can fully maximize the benefits of their EHS system.
After reporting, it is imperative to have clear follow-up actions in place. Roles should be assigned to those in charge, and everyone should be notified of the actions they are required to take.
At this point, it is also time to delve deeper into the data.
Finding the root cause of an incident is about reversing the events and discovering the initial causes leading to it. The findings can reveal why a safety procedure was skipped, or that the site fell short on a safety policy, for example.
It is generally advised to ask many questions along the way, and especially the 5 WHYs are considered useful. The WHY questions allow us to open up the reasons behind the event, point to the root causes and improve conditions accordingly.
The next phase of the process is the corrective actions that prevent the incident or something similar from happening again in the future.
An example of a corrective action could be an extra step in safety procedures or a physical safety measure, such as new personal protective equipment (PPE). All personnel must be aware of the steps and procedures involved in your company’s overall incident management plan.
Additionally, it must be acknowledged that the incident report itself is not the key, but rather a facilitator towards a healthier culture. It is the content of the report and the action following it that matters the most.
D. Rebbitt on EHS Today makes a sarcastic yet an on-point comment about our general habit of filling in facts based on pre-identified information. Rebbitt says:
“Once we gather a few facts, we automatically know what probably happened. Our amazing brain fills in the rest and assumptions become facts; the report almost writes itself. That is the focus after all right?”
This is obviously not the case. This kind of thinking should be substituted with rational analysis that results from thorough investigation and analysis of data.
At the bottom of the pyramid, if you like, is culture. Culture is what influences workers' approach to safety.
There has been a lot of discussion within the medical industry about how doctors and nurses are influenced by this so-called blame culture. Blame nurtures fear, which leads to reduced confidence and safety amongst staff.
Medicine is an applicable example of an industry where culture is undergoing change. Management in many medical organizations have put a heavy focus on learning. This has resulted in less focus on the personnel associated with the incident, and a heavier weight is put towards investigating the flaws within the organizational system.
Another sign of a healthy culture is the cultivation of equality. Management taking equal responsibility for their actions communicates responsibility and fair treatment.
If management is transparent about their mistakes, and demonstrate equal treatment of everyone no matter their seniority, this encourages staff to report incidents when they happen and feel comfortable doing so. Furthermore, focusing on responsibility and equality will also nurture higher commitment to general health and safety, and will likely reduce the number of incidents overall.
Finally, organizations should come up with an Incident Investigation Program that states the roles, responsibilities, and relevant training of all personnel (guide for employers by OSHA). This guide provides employers with “a systems approach to help them identify and control the underlying or root causes of all incidents in order to prevent their recurrence”.
In the end it all comes down to how an incident is being dealt with in practice.
The 3 suggestions of this article include maintaining procedures that guarantee the implementation of proper reporting, investigation and corrective actions for every incident and near miss. Second, cultivating a culture that emphasizes facts and responsibility over blame. And, finally, formulating a formal incident management program, and training, that provides the concrete steps for the process.
Hence, the overall aim of incident management system is to detect the reasons leading to the incident, implement corrective actions and prevent similar incidents from happening again by learning from the case at hand.
Ultimately, with lax Incident Management procedures the personnel might change, but if the root causes are not properly corrected, the underlying problem will remain.
I mean, you can’t fix a broken leg with a plaster.