81: SMS Pt 2 – Systems Thinking, Continuous Process Improvement, PDCA

Safety Management System

In this episode, I continue my series breaking down Safety Management Systems (SMS) and will talk about Continuous Process Improvement. Before I can do that, we need to understand something else about SMS – In episode 80 of The SafetyPro Podcast, Safety Management System (SMS) Defined, I talked about how you need to move away from individual programs and toward a systems approach to safety management. Well, there is something called systems thinking, and we are going to get into what that is and how you can shift not only the way you look at managing safety but also how your organization can make the shift from managing programs to integrating safety within the rest of the business by using systems thinking.

I recently came across an interesting article over at The Systems Thinker written by Micheal Goodman, and I thought it would help safety pros better understand what system thinking is all about. Michael is an internationally recognized speaker, author, and practitioner in the fields of Systems Thinking, Organizational Learning, and Leadership. The article is called SYSTEMS THINKING: WHAT, WHY, WHEN, WHERE, AND HOW? He writes:

“The discipline of systems thinking is more than just a collection of tools and methods – it’s also an underlying philosophy. Many beginners are attracted to the tools, such as causal loop diagrams, in hopes that these tools will help them deal with persistent business problems. But systems thinking is also a sensitivity to the circular nature of the world we live in; an awareness of the role of structure in creating the conditions we face; a recognition that there are powerful laws of systems operating that we are unaware of; a realization that there are consequences to our actions to which we are oblivious.

Systems thinking is also a diagnostic tool. As in the medical field, effective treatment follows a thorough diagnosis. In this sense, systems thinking is a disciplined approach for examining problems more completely and accurately before acting. It allows us to ask better questions before jumping to conclusions.

Systems thinking involves moving from observing events or data, to identifying patterns of behavior over time, to surfacing the underlying structures that drive those events and patterns.”

So you can see how this sets us up for moving away from merely managing programs toward a systems approach to safety. We need to understand the relationships the individual safety programs have with other areas of the business – how people think, feel, and behave when interacting with them.

It is also essential to understand that when we use the term system, it implies that the entire business is a single system and composed of many related subsystems. An accident occurs when a human or a mechanical part or multiple parts of the system fails or even just malfunctions. The system safety approach reviews the accident to determine how and why it occurred and what steps could be taken to prevent a recurrence. The goal of a systems approach is to produce, you guessed it, a safer system.

Therefore, at a minimum, a safety system is a formal approach to eliminate or control hazardous events through engineering, design, education, management policy, and supervisory oversight and control of conditions (environment) and practices, the organizational policies, practices, and overall organizational culture, etc. Notice I included the human and organizational aspects? Yes, traditional systems safety does address these areas.

In episode 80 of this podcast, I also talked about how SMS is a continuous improvement process that reduces hazards and prevents accidents. So what is a Continuous Improvement Process exactly? And how does it help us improve safety? Simply put, it is an ongoing effort to improve products, services, or processes. Or put another way; a recurring activity or activities to enhance performance. Typically, the goal is for “incremental” improvement over time and, in some cases, significant improvements all at once.

So once again, I will use Lean principles to explain this concept. First, I want to start with some structure, which will lead to this concept of continuous improvement. There is a term known to Lean practitioners; Kaizen. The Japanese word kaizen simply means “change for better” and refers to any improvement, either a one-time deal or a continuous process, either large or small, in the same sense as the English word “improvement.” So when you hear the phrase “Kaizen Event” – that simply means an improvement event.

The most well-known example of a Kaizen approach is the Toyota Production System, or TPS, where everyone is expected to stop their moving production line in case of any abnormality and, along with their supervisor, suggest an improvement to resolve the abnormal issue. This will initiate a cycle of activity aimed at not merely fixing that one issue, but instead improving the overall process to prevent the issues from repeating. This cycle can be defined as: “Plan → Do → Check → Act.”

PDCA (Plan-Do-Check-Act) is a scientific method of problem-solving and involves a 4-stage, iterative cycle for improving processes, products or services, and for resolving problems. It involves systematically testing possible solutions, assessing the results, and implementing the ones that have shown to work. It is a rather simple and effective approach for solving problems as well as for managing change.

This is because it enables businesses to develop hypotheses about what needs to change, test these hypotheses in a continuous feedback loop, and gain valuable learning and knowledge. Again, the value here is that you are testing improvements on a small scale before trying to apply them company-wide. The PDCA cycle consists of four components and can be applied to safety management systems as follows:

Plan – Identify and assess risks and opportunities to establish objectives and processes needed to solve them. There are 3 steps to this part:

  1. Problem Identification – verify you identified the right problem, determine its impact, who will it benefit?
  2. Problem Analysis – what information is needed to understand the problem and its root cause fully? What do we already know about the problem? What do we need to collect to understand the problem further? Who needs to be involved in this process? Once we get a full understanding, is it even feasible to solve the problem?
  3. Run Experiments – What are all possible solutions (think of 3 options)? Who will “own” which options to test? How will we measure expected outcomes? Can we run a small test? Will the small-scale results scale up?

Do – Here is where we develop and implement our tests and gauge their effectiveness. Again, this should be done on a small-scale to allow us to learn quickly, adjust as needed, and are typically less expensive to undertake. It also lessens any potential negative impact on the business. Think of the phrase, “fail small.” It also will have a less negative impact on the culture as a large-scale test, and failure might make workers feel defeated or that no solutions are coming. And be sure to collect all data needed so you can objectively decide which ones are best.

Check – Here is where we confirm the results through before-and-after data comparison. What worked? How can you tell? Also, look at what did NOT work – this may help you look back at your planning stage to see what you missed or did not consider. Remember, this is a cycle, even between the stages. So try not to think of this linearly. You may discover that the solution is no longer viable, or that there are simpler ones you had not considered.

Act – Here is where you will document the results and make recommendations for future PDCA cycles. If the solution was successful, implement it. If not, tackle the next problem and repeat the PDCA cycle. Remember, you can always stop and back up a step or go to the beginning. Learning is the objective here. So now you can start to ask what resources are needed to blow up the solutions company-wide? What impact will there be on production? Things like retraining, replacing equipment, parts, etc. Closing a part of a building, or the area will all need to be considered as well.

This PDCA process is critical to safety management systems for obvious reasons. Kaizen focuses on applying small, everyday changes that result in significant improvements over the long run if done correctly. The PDCA Cycle gives you the framework and structure needed for identifying improvement opportunities and evaluating them objectively. So when you hear folks talk about a systems approach to safety management, and the need to apply a process of continuous improvement, this is it.

In doing so you will be able to create this culture of problem-solvers, critical thinkers and folks that step up to tackle issues; willing to take on the accountability because the process to do it is easy and yields results by taking the focus off the person and on the process when it comes to problems that arise. Improvement ideas can be tested on a small scale, analyzed, tweaked, and repeated until solved.

By going through this process, and understanding systems thinking, you can start to see that you need to look at both individual components of your safety program and also the interactions with other areas of the business – the system as a whole. You cannot just do one. What I am saying is that yes, you need to find root causes to mechanical failures, “why” it occurred, but you also cannot ignore the “how” it was able to occur organizationally as well. If you reverse this thinking, start with “how” as some of these gurus want you to believe, it will still require you to find out the “why.” You need to be able to both.

So, in the next episode, I will continue to break down safety management systems by answering the question; What is Root Cause Analysis or RCA? I will explain how it is critical to support systems thinking, a systems approach to safety, and even talk about how it has been redefined by some in our industry to sell books, training courses and prop themselves up as thought leaders when in reality, it’s all the same stuff.

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