Learning the lessons from WMSDs: A framework for reporting and investigation Dr Natassia Goode with Professor Paul Salmon, Dr Sharon Newnam, Professor Sidney Dekker, Erin Stevens, Dr Michelle Van Mulken
Dr Natassia Goode • Senior Research Fellow within the Centre for Human Factors and Sociotechnical Systems • Theme leader for Organisational Safety • PhD in cognitive psychology, full time research in HF for the past 6 years • Key areas: Organisational behaviour, accident analysis, workplace safety • Theoretical approach to accident causation: systems thinking
Background • WMSDs still a major burden on individuals, organisations and the healthcare system in Australia. • Considerable evidence that WMSDs are caused by a complex system of factors (e.g. individual, work design, sociocultural factors + physical risks) • Significant literature on accident causation and learning from incidents • Have these advances been translated into practice? Are current reporting and investigation systems optimized for learning from WMSDs?
Aims Aim: Develop a practical framework for optimising learning from reports and investigations into WMSDs, which provides guidance on: • The organisational resources required • The processes that need to be implemented • The types of contributing factors and countermeasures to consider Learning: the capability to extract experiences from incidents and convert them into measures and activities which will help to avoid future similar incidents and improve safety overall.
Development of the framework Stage 1: Literature review on contemporary theory regarding accident causation and learning from incidents, identifying: • A best practice model of accident causation • A model of learning from incidents • The conditions required to optimise learning from incidents Stage 2: Systematic review on the evidence regarding the risk factors associated with WMSDs Developed a prototype taxonomy of the contributing factors involved in • WMSDs Stage 3: Study of reporting and investigation practices in 19 large Australian organisations (Interviews with 38 safety managers, documentation review, analysis of incident and investigation reports) Factors that facilitate or act as barriers to implementing the conditions • identified as best practice in the framework
Framework for reporting and investigation Reporting and investigation process Incident management policy Data collection: reporting and investigation Taxonomy of Data contributing Analysis collection factors for tools WMSDs Organisational resources Recommendations Decision-making Database for Training on storing reporting/ learning investigation Follow-up and evaluation Model of accident causation
Accident causation models What-you-look-for-is-what-you-find What-you-find-is-what-you-fix
Sequential models
Epidemiological models
Best practice: Systems models Current practice Barriers • The majority of safety Real, invisible, safety boundary managers did know about Economic failure accident causation models boundary (22/38). Adverse events • Reasons’ Swiss cheese (12/38) • Use of inconsistent Unacceptable workload boundary methods/models. Boundary defined by Facilitators official work practices • Integrated into all organisation documents (1 organisation).
Framework for reporting and investigation Reporting and investigation process Incident management policy Data collection: reporting and investigation Taxonomy of Data contributing Analysis collection factors for tools WMSDs Organisational resources Recommendations Decision-making Database for Training on storing reporting/ learning investigation Follow-up and evaluation Model of accident causation
Organisational resources Incident management policy Taxonomy of Data contributing collection factors for tools WMSDs Organisational resources Database for Training on storing reporting/ learning investigation
Incident management policy Best Practice Facilitator(s) Barrier(s) Clear definitions of what Include examples in Lack of clarity around should be documentation definitions e.g. “all incidents” reported/investigated or “all near misses” Define who is responsible and Senior management have Lack of skill sets involved in each stage of the specific responsibilities Lack of power to implement learning cycle. changes
Taxonomy of contributing factors Best Practice Facilitator(s) Barrier(s) Domain specific taxonomy Integrated into all aspects of Unclear/overlapping reporting and investigation categories
Taxonomy – the literature Government Regulatory bodies and associations Company Supervisor Supervisory Co-worker Efforts & Organisational Work Management Job Design Breaks support methods support rewards change scheduling General General health, prior Worker strain and Health Individual Worker perceptions Staff Demographics health pain and co- opportunities for behaviours psychological factors job security characteristics morbidities recovery Ambient Work Equipment Postures Task factors conditions
Taxonomy + current practice Government funding and Government priorities Expense of changes Regulatory Expense of Equipment to work WHS regulations bodies and equipment standards environment associations Co-operation Approval process Long term Company Safety Senior between different OHS funding and Policies / OHS for funding and monitoring management Company work groups in the resources procedures recommendations strategies resources systems attitudes safety organisation Senior management accountability Silos within the Safety culture and responsibility for OHS outcomes organisation Management and Staff Communication of OHS Team power direct supervisor workloads risk controls measures and responsibiltiy attitudes to safety Management Supervisor Supervisory Co-worker Efforts & Organisational Work Job Design Breaks support methods support rewards change scheduling General General health, prior Worker strain and Health Individual Worker perceptions Staff Demographics health pain and co- opportunities for behaviours psychological factors job security characteristics morbidities recovery Maintenance of Dynamic work Nature of the equipment and Ambient Work Postures Task factors Equipment environment work work conditions environment
Database for storing learning Best practice: Database used to store all reports and investigation findings Facilitators Barriers • Software accessible online • Difficult to enter reports e.g. fields do not match paper form, system is slow, • Simplicity of questions interface confusing • Automatic email reminders • Multiple systems for different types of • OHS Team can modify questions incidents, hazards and near misses • Multiple people can add information • Investigation findings not recorded about an incident • Difficult to extract data for analysis • Search function does not allow you to identify clusters of incidents • Managers can delete reports they don’t perceive as important
Data collection tools Best Practice Facilitator(s) Barrier(s) Incident forms collect Forms collect info from Forms encourage selection of information required to support multiple people single contributory factor decision making around investigation Free text boxes for detailed Forms time consuming description of events/conditions, cont factors, Lack of space for incident recommendations description and contributory factors Confusing categories Range of standardised Interview questions Informal chats investigation tools available that target data around levels Previous risk assessments Reliance on single tool of Rasmussen’s framework Same tools used in all WMSD Tool use based on personal investigations preferences
Training Best Practice Facilitator(s) Barrier(s) All staff receive appropriate Considers different skill sets, One off training training on incident reports education levels, and access to computers Training embedded in other OHS compliance training Annual All lead investigation staff Opportunity to reflect on Online training receive appropriate formal investigation practice training Training not specific to org Evaluation of investigation context reports Training focuses on compliance Lack of opportunity for feedback False sense of authority
Framework for reporting and investigation Reporting and investigation process Incident management policy Data collection: reporting and investigation Taxonomy of Data contributing Analysis collection factors for tools WMSDs Organisational resources Recommendations Decision-making Database for Training on storing reporting/ learning investigation Follow-up and evaluation Model of accident causation
The process – the learning cycle Reporting and investigation process Data collection: reporting and investigation Analysis Recommendations Decision-making Follow-up and evaluation
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