Wednesday, 22 July 2009

Human Factors

At first sight there is not much similarity between working in child protection and flying a passenger jet. However, it has been recognised that more than 70% of aviation accidents are due to human factors rather than straightforward technical failures. Accordingly the airline industry has developed approaches to safety to look specifically at how members of an airliners' crew, technical and other ground staff work together.

Now mandatory in all US and European airlines, Human Factors (HF) approaches aim to develop staff skills in areas such as communication, assertiveness, situational awareness, decision-making, workload and task prioirtisation, leadership and teamwork, personality types, behaviour and conflict management. The focus is on improving generic skills in identifying where and how errors arise during the course of work, how these can be minimised and mitigated, and generating a learning culture. In recent years HF approaches have been adapted to medical settings such as surgery, anaesthesia and intensive care.

There are some strong similarities here with the concept of Kaizen which I discussed in an earlier post. Like Kaizen, HF approaches are about creating a workplace situation in which all employees are constantly learning about ways to reduce the possibility of failure. This requires the creation of a culture in which error is seen as something which is an inevitable, indeed normal, part of complex working practices. Broadly organisations must adopt a non-punitive approach by encouraging employees to identify the sources and nature of error in the workplace. A person who has committed an error often knows how they did so. Their knowledge can be an invaluable asset in taking steps to ensure that the probability of other people committing the same mistake is reduced.

Conducting a de-briefing after a significant piece of work is a straightforward technique taught in HF training. This involves briefly discussing what went well and what went not-so-well. Team members are encouraged to suggest improvements for next time and to reflect on whether the right tools were available to do the job well. Follow-up roles and responsibilities are assigned.

You only need to read a detailed report into a child protection disaster (such as the Laming report into the death of Victoria Climbie) to see how a human factors approach might have helped avoid the tragedy. Instances of poor communication occur throughout Victoria's story. There were occasions on which those who felt that the child's need for protection was not being met were unwilling or unable to speak out. Key individuals lost situational awareness, ignoring evidence of non-accidental injuries and so assigning Victoria mistaken low prioirty. There was poor leadership and team work, with inter-personal and inter-agency conflict and disagreement. Some practitioners and managers seemed unaware of the ways in which their personalities impacted negatively on others, resulting in mistakes going unremarked.

Like aviation and medicine, child protection is a safety critical activity. The consequences of a chain of errors can be a death or serious injury. Child protection agencies need to learn how to become high reliability organisations. Professor James Reason (BMJ, vol 320, 18th March 2000) tells us that this type of organisation is one in which "They expect to make errors and train their workforce to recognise and recover them". Adapting Human Factors techniques could be an important milestone in child protection's journey to this end.