Corrective action and change management programs secure the proportionate, prioritized close-out of actions arising from monitoring, investigations, audits, and safety management system reviews.
Taking from the “Five Themes for Excellence in Safety Management Systems (SMS),” we can look at a facility’s approach to its Corrective Action Plans (CAP) process through this lens of excellence and measure the maturity of the safety culture. To recap the progression, here are the five (5) levels:
- Ad-Hoc
- Managed
- Standardized
- Predictable
- Excellence
Using an organization’s approach to it’s CAP process, we can see where they lie on the path to SMS Excellence.
Ad-Hoc – Culture of acceptance of non-completion of corrective actions
- Monitoring, audits, and reviews result in little or no change because none are carried out or followed up.
- No systematic process for ensuring corrective actions are completed.
- The organization does not know if lessons are being learned from incidents and cannot demonstrate continuous improvement or a learning culture.
- No application of legal or other standards.
- No sharing of lessons learned with collaborators
Managed – Inconsistent completion of corrective actions. Completion depends on the individuals involved and is not system driven.
- Corrective actions address only the immediate causes or those which are quick and simple to implement and rarely address underlying causes.
- Actions are owned but not always by the individual best placed to implement them effectively.
- There is some tracking of corrective action to completion by senior managers, but NOT CONSISTENTLY.
- Corrective actions are not prioritized consistently based on risk.
- Inconsistent sharing of lessons learned during collaborative ventures.
Standardized – Individuals understand the importance of completing corrective actions, and the organisation can demonstrate a LEARNING CULTURE.
- Underlying causes are routinely identified, and corrective actions are appropriate to the potential risk.
- The right people are tasked with owning actions to ensure effective implementation.
- Corrective action will be at any level of the SMS, and all actions are tracked to closure.
- Corrective actions are actioned in a timely fashion that is proportionate to the risk addressed by the action.
- The system for addressing corrective actions includes those affecting or arising from collaborative ventures.
Predictable – CAPs are recognized as opportunities to implement improvements to risk management in the organization.
- Corrective actions are linked to objectives set out in the safety management system to deliver the greatest benefit possible.
- The board and executive leadership actively support and resource the delivery of corrective actions.
- Corrective actions are considered part of the continous improvement process within the SMS.
- Corrective actions are verified and validated proportionately to ensure effective risk control.
Excellence – Individuals can and do identify actions from outside the organization to improve the organization’s risk management.
- The organization monitors reports from its industry and other industries to identify and implement corrective actions that improve risk management.
- The board and executive leadership can provide evidence of how corrective action has supported continuous improvement.
- Corrective actions are sought and shared from national and international organizations.
- There is a highly effective systematic approach and demonstrable improvements to risk management.
- Effective collaboration ensures that corrective actions are shared and adopted by organizations with shared or similar risks.
Source: RM3, 2019 – The Risk Management Maturity Model (UK’s HSE)
