Human Performance Improvement (HPI) is the systematic process of determining desired performance, continually monitoring performance, discovering and analyzing performance gaps, designing and developing effective interventions, implementing these interventions, and continually evaluating the results of improvement interventions within performance monitoring to ensure that the improvement process takes place. The goal of excellence in human performance is to attain event-free performance at the nuclear facility. By proactively managing human performance and strengthening the facility’s defenses, the performance of individuals, processes, and the organization will be optimized, errors will be minimized, and events will be eliminated.
The underlying principles that form the basis for excellence in human performance were first clearly identified by INPO in human performance and later elaborated on in the INPO human performance reference Manual and the USDoe human performance improvement handbook. These underlying principles, when considered together, can be viewed as the foundation for the HPI model.
1) People are fallible, and even the best make mistakes.
People will make errors, and no amount of coaching, training, or punishment can eliminate human error.
James Reason, in “Human Error,” writes:
“It is crucial that personnel and particularly their managers become more aware of the human potential for errors, the task, workplace, and organizational factors that shape their likelihood and their consequences. Understanding how and why unsafe acts occur is an essential first step in effective error prevention.”
Systemic errors can be removed by using specific tools such as self-checking. Random errors can be reduced but never eliminated. In the earlier example of tightening a valve, there is always a possibility that people will make a mistake in performing this activity. The question becomes why the mistake is made and trying to take all possible precautions to prevent its occurrence. When a mistake is made, having more than one barrier in place to prevent failure (e.g., procedures, peer checking, and labeling) will minimize the consequence of that mistake.
There is always some likelihood of human error. Therefore, it is vital to create an organizational infrastructure that supports facility programs and processes to identify and to protect from human error before that error leads to a more significant event.
2) Error-likely situations are predictable, manageable, and preventable.
Even though human errors are inevitable, some things can be done to predict, manage, and ultimately prevent systemic errors and most random errors from occurring. Recognizing error traps and proactively communicating these to others help to manage situations and minimize errors. Changing the work situation to prevent, remove or lower the presence of conditions that bring about the error, task, and individual factors in the work environment can minimize the chance for error.
For example, when the worker is sent out to tighten a valve, it may be near another similar valve that could be inadvertently tightened instead of the correct one. it is important to recognize this as an error-likely situation and to take steps such as color coding, clear labeling, caution flags within procedures, and conducting pre-job briefings to prevent that mistake from occurring.
3) Organizational processes and values influence individual behavior.
The processes and values of an organization are developed and fostered to direct the behavior of the individuals in the organization towards meeting the organization’s goals, how work is divided into different jobs, and then coordinated to produce results that provide the best picture of the organization. Management is there to direct the worker’s behaviors towards producing the desired results. Work is accomplished not only through managing individual-based human performance but also within the context of organizational processes, culture, and management systems. These factors contribute to most of the causes of human performance problems and result in facility events.
Suppose that two workers are sent together to work on the valve in the example. It is important that these workers feel comfortable and work at a facility that supports their questioning of the actions of each other if they have reason to believe a mistake may have been or may be about to be made. Facilities that actively support such a questioning attitude are more likely to have fewer mistakes made than those in which a questioning attitude is not as valued by the organization.
4) People achieve high-performance levels based largely on encouragement and reinforcement from leaders, peers, and subordinates.
All behavior, whether good or bad, is reinforced in some manner, either by immediate consequences or by experiences from the past. Behavior is reinforced or challenged by the consequences that an individual experiences when the behavior occurs. The level of safety, reliability, and production of a facility is directly dependent upon the behavior of the individuals who work there. Understanding what happens to an individual when they exhibit certain behaviors is important for improving human performance. Positive and immediate reinforcement for expected behaviors is ideal.
In the example, when tightening a valve, a worker may notice that a label is missing or that the procedure is not written. What would be management’s response if that worker were to bring such a situation to management’s attention? Is that worker praised for making a ‘good catch’, or is that worker treated as someone who delays work by asking too many questions? Employees who work in an organization that positively reinforces workers making a ‘good catch’ will be more likely to bring problems to management’s attention in the future and reduce the likelihood of events.
5) Events may be avoided by an understanding of the reasons why mistakes occur and the application of the lessons learned from past events.
Improvement in human performance has historically resulted from corrective actions derived from an analysis of facility events and problem reports. Corrective actions are generally a reactive method of learning which occurs after the fact, but they are still important for continual improvement. A combination of proactive and reactive learning is needed where the anticipation of how an event or error can be prevented is a more cost-effective means of continual performance improvement.
How often do we hear of facilities where repeat errors are made, sometimes even on the same system or piece of equipment? In the valve example, are prior experiences from tightening that specific valve or tightening other similar valves within the facility, or even from other facilities, shared with workers so they can learn from it?
Do pre-job briefings incorporate this information? Are those involved in planning the work made aware of this information? In organizations where such learning is actively applied and incorporated into the ongoing work management system, error rates are lowered, rework is reduced, and events are minimized.
Adopted from sources @ the U.S. Nuclear Regulatory Commission