HUMAN PERFORMANCE IMPROVEMENT HANDBOOK
NOT MEASUREMENTSENSITIVEDOE-HDBK-1028-2009DOE STANDARDHUMAN PERFORMANCEIMPROVEMENT HANDBOOKVOLUME 1: CONCEPTS ANDPRINCIPLESU.S. Department of EnergyWashington, D.C. 20585AREA HFACDISTRIBUTION STATEMENT A. Approved for public release; distribution is unlimited.
Available on the Department of EnergyTechnical Standards ProgramWeb site athttp://tis.eh.doe.gov/techstds/
DOE-HDBK-1028-2009VOLUME 1: CONCEPTS AND PRINCIPLESPREFACE . vReading The Handbook . viCHAPTER 1 - INTRODUCTION TO HUMAN PERFORMANCE.1-1OVERVIEW. 1-1Perspective on Human Performance and Events. 1-10Human Performance for Engineers and Knowledge Workers . 1-11The Work Place. 1-11Individuals, Leaders, and Organizations . 1-12HUMAN PERFORMANCE. 1-12Behavior . 1-13ANATOMY OF AN EVENT . 1-14Event .1-14Initiating Action. 1-14Flawed Controls . 1-15Error Precursors. 1-15Latent Organizational Weaknesses. 1-15STRATEGIC APPROACH FOR HUMAN PERFORMANCE . 1-16Reducing Error . 1-16Managing Controls . 1-17PRINCIPLES OF HUMAN PERFORMANCE . 1-19REFERENCES. 1-21CHAPTER 2 - REDUCING ERROR .2-1HUMAN FALLIBILITY (Essential Reading) . 2-1Common Traps of Human Nature . 2-1Unsafe Attitudes and At-Risk Behaviors . 2-4Slips, Lapses, Mistakes, Errors and Violations. 2-8Active Errors. 2-8Latent Errors . 2-9Violations. 2-10Dependency and Team Errors . 2-11Equipment Dependencies . 2-11i
DOE-HDBK-1028-2009Team Errors . 2-12Personal Dependencies . 2-15PERFORMANCE MODES (Essential Reading) . 2-16Information Processing, Memory, and Attention. 2-16Generic Error Model System (GEMS) . 2-20Skill-Based Performance. 2-21Examples of Skill-Based Activities . 2-22Skill-Based Error Mode – Inattention. 2-22Rule-Based Performance . 2-23Examples of Rule-Based Activities. 2-23Rule-Based Error Mode . 2-24Knowledge-Based Performance. 2-25Examples of Knowledge-Based Activities . 2-26Knowledge-Based Error Mode . 2-26How Performance Modes Can be Used . 2-27Mental Models.2-28Assumptions. 2-29Mental Biases – Shortcuts. 2-29Conservative Decisions. 2-30ERROR-LIKELY SITUATIONS (Essential Reading). 2-30Error Precursors. 2-31Common Error Precursors . 2-32ERROR-PREVENTION TOOLS. 2-33ATTACHMENT A – ERROR PRECURSORS. 2-35ATTACHMENT B – COMMON ERROR-PRECURSOR DESCRIPTIONS . 2-39REFERENCES. 2-45CHAPTER 3 - MANAGING CONTROLS .3-1Controls. 3-1Severity of Events . 3-3The Organization’s Role in Controls. 3-3Defense Functions . 3-4Reliability of Controls . 3-4DEFENSE-IN-DEPTH . 3-5Engineered Controls . 3-5Administrative Controls . 3-6Cultural Controls – Values, Beliefs, Attitudes . 3-8ii
DOE-HDBK-1028-2009Work Group Norms . 3-9Leadership Practices. 3-10Common Flaws with Cultural Controls . 3-10Oversight Controls . 3-10Senior Management Team Focus on Human Performance . 3-11Performance Improvement Processes . 3-11Human Performance Improvement Plans . 3-12PERFORMANCE MODEL . 3-12Organizational Effectiveness. 3-13Organizational Factors . 3-14Job-Site Conditions . 3-14Worker Behaviors. 3-15Plant Results . 3-15MANAGING CONTROLS – PERFORMANCE IMPROVEMENT MODEL. 3-15METHODS (Tools) FOR FINDING LATENT ORGANIZATIONAL CONDITIONS . 3-17Self-Assessments . 3-18Behavior Observations . 3-18Problem Reporting . 3-19Benchmarking . 3-19Performance Indicators and Trending . 3-20Operating Experience . 3-20Independent Oversight . 3-21Problem Analysis . 3-22Management Oversight . 3-23Surveys and Questionnaires . 3-23Corrective Action Program . 3-23Change Management. 3-24APPENDIX A: WARNING FLAGS—FACTORS THAT DEFEAT CONTROLS . 3-25REFERENCES. 3-27CHAPTER 4 - CULTURE AND LEADERSHIP .4-1ORGANIZATIONAL CULTURE. 4-1SAFETY CULTURE .4-2How Organizations Process Information . 4-5LEADERSHIP . 4-11Leader’s Role . 4-11Production and Prevention: Competing Purposes. 4-12iii
DOE-HDBK-1028-2009KEY LEADERSHIP PRACTICES . 4-13Facilitate Open Communication . 4-13Promote Teamwork. 4-13Reinforce Expectations . 4-14Eliminate Latent Organizational Weaknesses . 4-16Value the Prevention of Error . 4-17BEHAVIOR ENGINEERING MODEL (BEM) . 4-17CREATE A JUST CULTURE. 4-23The Blame Cycle. 4-23Categories of Violations . 4-23The Foresight Test . 4-24The Substitution Test . 4-25The Culpability Decision Tree . 4-25ATTACHMENT A – PERFORMANCE GAP ANALYSIS . 4-27ATTACHMENT B – CULPABILITY DECISION TREE . 4-29ATTACHMENT C – ESTABLISHING A REPORTING CULTURE . 4-31REFERENCES. 4-33CHAPTER 5 - HUMAN PERFORMANCE EVOLUTION .5-1INTRODUCTION. 5-1A Perspective on Organizations . 5-1FACTORS THAT IMPACT ORGANIZATIONS. 5-2Production . 5-2Quality Management . 5-3Human Factors and Ergonomics. 5-4Organizational Development . 5-6Learning Organizations . 5-8Human Performance Technology. 5-10Error Management . 5-11Mindfulness and Performance. 5-12High Reliability Organizations . 5-12Resilience Engineering . 5-16Organizational Resilience. 5-17Performance Improvement In the Work Place. 5-18REFERENCES. 5-21GLOSSARY . iCONCLUDING MATERIAL . xiiv
DOE-HDBK-1028-2009PREFACEThis Human Performance Improvement Handbook is a reference for anyone working in theDepartment of Energy (DOE) community who wants to learn more about human performanceand how it can be improved. The handbook consists of five chapters entitled: “An Introductionto Human Performance,” “Reducing Error,” “Managing Controls,” “Culture and Leadership”,and “Organizations at Work.” The handbook addresses the roles of individuals, leaders, and theorganization in improving performance. Principles of human performance, outlined in Chapter1, are the foundation blocks for the behaviors described and promoted in the handbook. Thestrategic approach for improving performance is to reduce human error and manage controls soas to reduce unwanted events and/or mitigate their impact should they occur. For the purposes ofthis handbook, an event is an undesirable change in the state of structures, systems, orcomponents or human/organizational conditions (health, behavior, controls) that exceedsestablished significance criteria.Human performance improvement (HPI) as addressed in this handbook is not a program per se,such as Six Sigma, Total Quality Management, and the like. Rather, it is a set of concepts andprinciples associated with a performance model that illustrates the organizational context ofhuman performance. The model contends that human performance is a system that comprises anetwork of elements that work together to produce repeatable outcomes. The systemencompasses organizational factors, job-site conditions, individual behavior, and results. Thesystem approach puts new perspective on human error: it is not a cause of failure, alone, butrather the effect or symptom of deeper trouble in the system. Human error is not random; it issystematically connected to features of people’s tools, the tasks they perform, and the operatingenvironment in which they work. A separate volume, Human Performance ImprovementHandbook Volume II: Human Performance Tools for Individuals, Work Teams, andManagement, is a companion document to this handbook. That volume describes methods andtechniques for catching and reducing errors and locating and eliminating latent organizationalweaknessesThis volume is an introductory summary document that addresses a human performanceimprovement approach as was initially introduced within DOE in recent years. The content andthe approach to the topic are based on concepts and practices found useful in the commercialnuclear power industry and similarly adopted by other industries. The Institute of Nuclear PowerOperations (INPO) generously provided assistance in helping the Department roll out its humanperformance courses, which were patterned on the INPO model. This handbook reflects heavilyon the human performance research and practical applications so expertly chronicled in INPO’sHuman Performance Fundamentals Course Reference (2002) and its later revision of thematerial in Human Performance Reference Manual, INPO 06-003 (2006). The Department isgreatly appreciative of this outstanding assistance and support. It is just one more recentexample of a long-standing collaborative relationship between these two organizations that spansmore than two decades.The concept of high reliability organizations (HRO) has captured the interest of manyorganizational leaders in recent years. HROs provide real examples of organizations that operatesuccessfully while almost never experiencing an unwanted event. HROs by definition operateunder very trying conditions all the time and yet manage to have very few accidents. (Anaccident is an unfortunate mishap, especially one causing damage or injury.) Examples of HROsv
DOE-HDBK-1028-2009include aircraft carriers, air traffic controllers, power grid dispatch centers, nuclear submarines,airline cockpit crews, nuclear power plants, and offshore platforms, among others. HPI is oneapproach toward achieving the attributes evident in HROs. (see Chapter 5)This handbook is not a human factors manual. HPI is not a substitute for, nor is it intended toimpinge upon in any way on, the workings of human factors professionals to improveorganizational and individual effectiveness. Neither is it the intent of this handbook to modifyany requirements of other health, safety, and security regulations and obligations. The principlesof HPI can be used to enhance the value of these programs.Reading The HandbookIndividuals will approach the reading of this handbook either from a personal interest in thesubject matter or from a practical need to know the information contained in it. HPI trainers andpractitioners are likely to read it cover to cover, highlight sections, dog-ear certain pages andmake it one of their valued references. Managers, supervisors, and performance improvementleaders wanting to learn about HPI with the goal of implementing it in their workplace willapproach reading in a somewhat different vein than persons who read it for their personal use.The following guidance is intended to help users focus their PI LeadersHPI TrainersHPI PractionersChapter 1: Introduction to HPIXXXChapter 2: Reducing Error*XXXpp.1-17XXXXRecommended Reading by UserGroups XChapter 3: Managing ControlsChapter 4: Culture and LeadershipChapter 5: HPI EvolutionX* Selected sections in Chapter 2 only are designated as “essential reading.”Readers may come across unfamiliar terms while reading this handbook. If the term is notdefined in the text the first time it is used, refer to the glossary at the end of handbook for thedefinition.Both footnotes and endnotes are used in this document. The convention for footnotes is anasterisk (*) followed by a number. Footnotes appear at the bottom of the page. Endnotes areintended to reference source material. The convention for endnotes is a superscript number.Endnotes are listed at the end of each chapter.vi
Department of EnergyHuman Performance HandbookChapter 1 IntroductionCHAPTER 1 - INTRODUCTION TO HUMAN PERFORMANCEOVERVIEWIn its simplest form, human performance is a series of behaviors carried out to accomplishspecific task objectives (results). Behavior is what people do and say—it is a means to an end.Behaviors are observable acts that can be seen and heard. In the Department of Energy (DOE)the behaviors of operators, technicians, maintenance crafts, scientists and engineers, wastehandlers, and a myriad of other professionals are aggregated into cumulative acts designed toachieve mission objectives. The primary objective of the operating facilities is the continuoussafe, reliable, and efficient production of mission-specific products. At the national laboratories,the primary objectives are the ongoing discovery and testing of new materials, the invention ofnew products, and technological advancement. The storage, handling, reconfiguration, and finalrepository of the legacy nuclear waste materials, as well as decontamination, decommissioning,and dismantling of old facilities and support operations used to produce America’s nucleardefense capabilities during the Cold War are other significant mission objectives. Improvinghuman performance is a key in improving the performance of production facilities, performanceof the national laboratories, and performance of cleanup and restoration.It is not easy to anticipate exactly how trivial conditions can influence individual performance.Error-provoking aspects of facility*1 design, procedures, processes, and human nature existeverywhere. No matter how efficiently equipment functions; how good the training, supervision,and procedures; and how well the best worker, engineer, or manager performs his or her duties,people cannot perform better than the organization supporting them.1 Human error is caused notonly by normal human fallibility, but also by incompatible management and leadership practicesand organizational weaknesses in work processes and values. Therefore, defense-in-depth withrespect to the human element is needed to improve the resilience of programmatic systems and todrive down human error and events.The aviation industry, medical industry, commercial nuclear power industry, U.S. Navy, DOEand its contractors, and other high-risk, technologically complex organizations have adoptedhuman performance principles, concepts, and practices to consciously reduce human error andbolster controls in order to reduce accidents and events. However, performance improvement isnot limited to safety. Organizations that have adopted human performance improvement (HPI)methods and practices also report improved product quality, efficiency, and productivity.2 HPI,as described in this handbook and practiced in the field, is not so much a program as it is adistinct way of thinking. This handbook seeks to improve understanding about humanperformance and to set forth recommendations on how to manage it and improve it to preventevents triggered by human error.This handbook promotes a practical way of thinking about hazards and risks to humanperformance. It explores both the individual and leader behaviors needed to reduce error, as well*1 The word “facility” used in this handbook is a generic term. It is recognized that D&D work is accomplished byprojects and that laboratory work is accomplished through experiments, etc. The reader should apply the term“facility” to their recognized unit of work1-1
Department of EnergyHuman Performance HandbookChapter 1 Introductionas improvements needed in organizational processes and values and job-site conditions to bettersupport worker performance. Fundamental knowledge of human and organizational behavior isemphasized so that managers, supervisors, and workers alike can better identify and eliminateerror-provoking conditions that can trigger human errors leading to events in processingfacilities, laboratories, D & D structures, or anywhere else on DOE property. Ultimately, theattitudes and practices needed to control these situations include: the will to communicate problems and opportunities to improve; an uneasiness toward the ability to err; an intolerance for error traps that place people and the facility at risk; vigilant situational awareness; rigorous use of error-prevention techniques; and understanding the value of relationships.INTEGRATED SAFETY MANAGEMENT AND HPIDOE developed and began implementation of Integrated Safety Management (ISM) in 1996.Since that time, the Department has gained significant experience with its implementation. Thisexperience has shown that the basic framework and substance of the Department’s ISM programremains valid. The experience also shows that substantial variances exist across the complexregarding familiarity with ISM, commitment to implementation, and implementationeffectiveness. The experience further shows that more clarity of DOE’s role in effective ISMimplementation is needed. Contractors and DOE alike have reported that clearer expectationsand additional guidance on annual ISM maintenance and continuous improvement processes areneeded.Since 1996, external organizations that are also performing high-hazard work, such ascommercial nuclear organizations, Navy nuclear organizations, National Aeronautics and SpaceAdministration, and others, have also gained significant experience and insight relevant to safetymanagement. The ISM core function of “feedback and improvement” calls for DOE to learnfrom available feedback and make changes to improve. This concept applies to the ISM programitself. Lessons learned from both internal and external operating experience are reflected in theISM Manual to update the ISM program. The ISM Manual should be viewed as a naturalevolution of the ISM program, using feedback for improvement of the ISM program itself. Twosignificant sources of external lessons learned have contributed to that Manual: (1) the researchand conclusions related to high-reliability organizations (HRO) and (2) the research andconclusions related to the human performance improvement (HPI) initiatives in the commercialnuclear industry, the U.S. Navy, and other organizations. HRO and HPI tenets are verycomplementary with ISM and serve to extend and clarify the program’s principles and methods.3As part of the ISM revitalization effort, the Department wants to address known opportunities forimprovement based on DOE experience and integrate the lessons learned from HROorganizations and HPI implementation into the Department’s existing ISM infrastructure. The1-2
Department of EnergyHuman Performance HandbookChapter 1 IntroductionDepartment wants to integrate the ISM core functions, ISM principles, HRO principles, HPIprinciples and methods, lessons learned, and internal and external best safety practices into aproactive safety culture where: facility operations are recognized for their excellence and high-reliability; everyone accepts responsibility for their own safety and the safety of others; organization systems and processes provide mechanisms to identify systematic weaknessesand assure adequate controls; and continuous learning and improvement are expected and consistently achieved.The revitalized ISM system is expected to define and drive desired safety behaviors in order tohelp DOE and its contractors create world-class safety performance.In using the tools, processes, and approaches described in this HPI handbook, it is important toimplement them within an ISM framework, not as stand-alone programs outside of the ISMframework. These tools cannot compete with ISM, but must support ISM. To the extent thatthese tools help to clarify and improve implementation of the ISM system, the use of these toolsis strongly encouraged. The relationship between these tools and the ISM principles andfunctions needs to be clearly understood and articulated in ISM system descriptions if these toolsimpact on ISM implementation. It is also critical that the vocabulary and terminology used toapply these tools be aligned with that of ISM. Learning organizations borrow best practiceswhenever possible, but they must be translated into terms that are consistent and in alignmentwith existing frameworks.ISM Guiding PrinciplesThe objective of ISM is to systematically integrate safety into management and work
Jun 28, 2006 · performance courses, which were patterned on the INPO model. This handbook reflects heavily on the human performance research and practical applications so expertly chronicled in INPO’s Human Performance Fundamentals Course Reference (2002) and its later revision of the material in Human Performance Reference Manual, INPO 06-003 (2006). The .
Quality Improvement Handbook A Guali tym Epropvape nri Pimtymdopvi yt Hiobnr Comi Sk1nid1 1 About This Handbook The Quality Improvement Handbook is a guide to enhancing the performance of health care systems using evidence-based models derived from improvement science. Primarily intended for program managers and technical staff members of FHI 360
quality improvement essentials—critical elements successful quality improvement programs have in common. This executive report defines quality improvement in healthcare, describes critical quality improvement considerations, components, and tools, and identifies the top five quality improvement essentials: 1.
Nursing Quality and Performance Improvement Plan Purpose Nurse involvement is essential to any significant healthcare improvement initiative (Bosagnano, 2010). The Vanderbilt University Medical Center Nursing Quality and Performance Improvement Plan (NQPIP) establishes a framework for placing nursing on the frontlines of transforming
Process Improvement Handbook A Practical Guide Karl E. Wiegers Process Impact 11491 SE 119th Drive Clackamas, OR 97015-8778 phone: 503-698-9620 fax: 503-698-9680 . Nor is process improvement at odds with the agile software development movement that is popular at present. Agile is simply one strategy for process improvement that com-
Quality improvement in mental health is broadly similar to quality improvement in other health care settings 43 Appendix 1: Quality improvement methods 44 . organisations have embraced quality improvement strategies and what has enabled them to do so. In parti
Continuous improvement is about applying good business practices to ensure the best outcomes for our clients, namely: students, industry and the community. . Strategies for continuous improvement; Section 3 - Gathering the evidence for continuous improvement; Section 4 - Recording the outcomes of continuous improvement; and
Section 1 - Principles of continuous improvement; Section 2 - Strategies for continuous improvement; Section 3 - Gathering the evidence for continuous improvement; Section 4 - Recording the outcomes of continuous improvement; and Section 5 - Useful links and resources. 6
The module scst_user API is de ned in scst_user.h le. 3 IOCTL() functions There are following IOCTL functions aailable.v All of them has one argument. They all, except SCST_USER_REGISTER_DEVICE return 0 for success or -1 in case of error, and errno is set appro-priately. 3.1 SCST_USER_REGISTER_DEVICE
