Closing the Gap

To start closing the gap, it's good to get a few people into a room and discuss the examples that you have witnessed or heard about. The end goal is a shared and detailed picture of the task under different circumstances, and agreement about the documentation (rules, guidelines, checklists, etc.) that will best support the execution in practice. It seems only logical to involve the people that are affected by the rules in their design, as well as domain experts. 24

In the example of the work instructions for the filter change, we held a workshop with team members and central engineering staff. It took a while for the front-line operators to have a voice, initially everyone was happy for the staff members to do all the talking. But after some coaxing the operators chipped in, and we were able to define the critical check points that we (collectively) considered to be so important that we wanted them signed off. We also considered which guidance material might be useful for an operator that was doing the change for the first time, taking into account that they would always be accompanied by a more experienced colleague. The end result of this workshop was a procedure that was agreed by all and less than half in length than the original. It was implemented successfully and in fact a few months later the regulator got to hear about the new procedure and indicated their support for the approach and the result.25

Our approach assumes that there is enough trust and respect between parties to enable this discussion. The safety department can be called upon to not just add their expertise, but also facilitate the discussion, and help to strike the right equilibrium between the required detailing of the rules and the autonomy to adapt to varying circumstances. If staff and management are up to it - that is to say they will not judge motives - they can be included to learn and understand. However, you may find that they will quickly fall into the trap of defending the current rules, procedures, checklists, standards, job descriptions and management systems, rather than taking Work-as-Done as the reference and seeing where Work-as-imagined falls short of helping to achieve a particular purpose in a particular context. So in that case, you will need to remind them of this.. ,26

When we have a common understanding of the reasons that practice deviates from paper, we can make a start with closing the gap. We strive for agreement about the extent to which task formalisation is required versus autonomy for the operators to cope with process and external variances. We want the gap between paper and practice to be balanced between organisational needs and the variances encountered in practice - and that this gap is defendable against external scrutiny such as audits. This balance may vary between locations or teams: one size does not necessarily fit all. On the one hand, a set of procedures is needed to help people remember the steps under challenging circumstances, to educate and train people for their jobs, to ensure that people can cooperate effectively, for design and planning purposes, and as a means to identify variances in behaviour. On the other hand, we should not excessively restrict people to cope with the variances that they routinely encounter in practice; that is, exemptions to the rules should be justified and limited in number. The appropriate level of detail will vary from context to context and is dependent on several factors. More detail in the rules will support the organisational needs (help people remember the steps and cooperate, training of operators, for design and planning purposes, and for the identification of variances) but will increase the number of exceptions to be managed, particularly if these tasks occur in strongly differing conditions. As an organisation matures and the operators become more competent, we migrate to framework rules within which the professional has freedom to execute his tasks (we sometimes call this freedom in a frame). If the workforce is expanded or rejuvenated, we may need to revert back to more detailed work descriptions. Note that there may be other solutions for aligning Work-as-Done with procedures than just changing the procedures. We may be able to add physical barriers, redesign the workplace or change the way that tasks are allocated across a group of people. In fact, these redesigns are generally preferable to the limited efficacy of written instructions to support people in executing a task.27

A useful process for aligning paper with practice is given in Figure 3.1. (1) We start by having a really good understanding how work is done in practice. Feedback from the front line allows us to comprehend where the rules and procedures are working, and where they need to be improved. (2) As suggested before, the monitoring of the use of the rules should not evolve from a requirement for compliance but a real need to learn. In evaluating whether a rule is currently satisfactory or needs to be changed, we need to understand

Existing processes and rules

New or existing processes needing rules

FIGURE 3.1

Flow chart for rules management. (Adapted from Haie and Borys (2013b).)

how work is done in practice and how the rules support the front line in varying conditions. (3) The rules might be too detailed for the variance that occurs in practice and the maturity of the workforce (like the extensive step-by-step filter instructions were not compatible with North Sea weather), so that (parts of) rules are superfluous and need to be scrapped. This also allows us to redesign and reword rules so that they are more suitable for the tasks they are intended to support. (4) There may be other solutions for aligning Work-as-Done with procedures than just changing the procedures that need to be considered. (5) The need for new rules requires us to draw them up for the first time, possibly considering alternatives to rules as well. (6) The implementation of rules requires us to first test them (see, for instance, Chapter 4), then approve them and ensure that they are stored and made available through some sort of organisational memory system. (7) Appropriate implementation of rules is necessary to ensure that those that we expect to apply the rules know about them - and ideally buy into them as well. We need to communicate the changes to the rules and train people in their use - including how we expect them to manage exceptions when they feel they cannot abide by them. (8) Only when we have communicated the new rules and achieved buy-in can we expect our employees to apply the rules and deal satisfactorily with exceptions.28

Some good guidelines for drafting the procedures are as follows:

  • • Use 'swim lanes' (one per accountable role) to depict the process and its associated rules in a flow chart. Try to limit each process to a flow chart on a single page. Details of the process steps and constraints can be added as text on additional pages. If the flow chart doesn't fit on a single page, split the process into multiple flows.
  • • Ensure that the enforcers of the procedures (those that determine the compliance) are not the makers. Definitely include their input but ensure that they do not feel so much ownership for the procedures that they cannot kill their darlings or consider every divergence from the rules a violation rather than an exception.
  • • Consider that every task (and therefore its description) needs to satisfy multiple goals. Integrate these goals into the process description, and ensure that a task is not subject to multiple, possibly contradictory descriptions. Don't let your workforce identify and solve inconsistencies on the spot.
  • • When considering (an update to) a procedure, ensure that obsolete rules are eliminated. Technology or policy changes can make the existing rules irrelevant - or worse, counterproductive. Rule creep may have occurred if rules have been given a broader application than their original intent.
  • • Include the reporting and monitoring requirements in the procedure, and ensure a balance between organisational needs and the disruption that is caused by reporting. Eliminate duplication.
  • • Contemplate alternatives to rules and procedures to improve performance and reduce risks, such as specific tooling, redesign of processes and physical barriers. Also consider the use of 'nudges' to ensure more compliance with good practice, unwritten cultural rules or written instructions. For example, to reduce shipping damages, an up-market bicycle manufacturer printed a television on their boxes.
  • • Pilot the new rules before giving the final go and keep monitoring their use even after this.
  • • If you find that you are continuously coping with exceptions, then the procedures are too detailed. If you find that the organisational needs (memory aid, training, collaboration, design and planning and monitoring behaviour) are not met, then further detailing is warranted. Getting the balance right is the challenge.
  • • Some organisations put a 'next review' date on procedures to ensure that they are revisited regularly. We find that this rarely achieves its aim but rather burdens valuable resources needlessly. Some rules will require frequent reconsideration even before the review date, whereas others can remain unchanged for much longer. Other triggers such too many exemptions or not meeting organisational needs are more effective in identifying the requirement for improved rules.

Of course, in drafting the procedures, the people that actually execute the work are in the lead, as they understand Work-as-Done. Staff members such as safety professionals contribute by helping to identify and analyse risks and suggesting measures to mitigate these. In most companies, operational management has the final say regarding the procedures, taking into account the proposal from the shop floor and the recommendations of the safety staff. Hopefully, there is a shared understanding that the final version of the rules (paper) balances risks with workability and variation with traceability - and so best meets the various objectives and multiple instances of practice.

 
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