Good Decision Making
TASK MANAGEMENT - OUR RESPONSE TO UNANTICIPATED CHALLENGES
1. Identify workload performance problems (overload/under-load, distractions, & stress)
2. Develop methods to respond to those problems
This trap comes into play when someone with a significant amount of experience in one area is transitioning to a new job or one this person has not accomplished for a considerable amount of time. Typically, this person is given a very accelerated checkout on the new position because, with so much experience on “X”, this person can certainly handle “Y”! The halo of expertise and the rush to get the person on line blinds everyone to the need for more extensive training.
Once on the job, coworkers may be impressed by the vast experience of this person and tend not to speak up about problems they see, even though they may have more experience, or more recent experience on that particular job. The individual involved should make a conscious effort to ensure that they get the training they need and people don’t give them special treatment because of their experience or seniority.
The decision making process integrates many of the basic elements that are crucial in preventing human error. When making a decision, it is important to pull together all the resources available to achieve "synergy," where the results of the whole team's effort is greater than the sum of the individual efforts. Synergy is easier to achieve in an environment of good communication and good leadership. Normally, there is enough time to make a good decision, but there may not be enough time to recover from a bad decision.
Decision making based on the QPIDR Model creates a synergistic effect because it encourages decisions that are the result of a coordinated group effort rather than an isolated person working with less than complete information.
Judgment is the total mental process used to arrive at a decision. It is normally based on our previous experiences. We can improve our own judgment by studying the errors committed by others that led to a mistake or an accident. This is why discussing case studies plays such a vital role in preventing error.
Decision making is the act of rendering a solution to a problem using your judgment. Often, the value of a decision cannot be determined until the outcome is known.
The first step is to seek all the information, data, and ideas that will help make a good decision. It is typically the responsibility of the PIC to initiate this process. However, everyone shares the responsibility for ensuring that each step of the formula is used, and for speaking out assertively about information that enhances the judgment of the PIC. Be sure to encourage open discussion, use AESOP™ to avoid preoccupation with minor details (tunnel vision), and use all available resources.
Once all the ideas are on the table, it is time to narrow the options. Some of the ideas or plans presented during the questioning process may be in conflict. Open discussion of such conflict not only leads to a synergistic decision, but it gets everyone behind the resulting plan.
The PIC is responsible for resolving any disagreement between two or more points of view. At the same time, it is important for the PIC to test proposed courses of action to see which offers the best results. Everyone is responsible for assertively promoting their own ideas while remaining flexible and open to the ideas of others.
The PIC makes the final decision or delegates that authority to someone. In virtually all circumstances, it is critical to preserve the authority of command. A company is not a democratic organization, and strong leadership is critical to the success of any endeavor. On the other hand, if the PIC does not involve the appropriate people in the decision making process through the use of QPIDR, they may feel alienated and may not have a full commitment to the project.
Once the decision is announced, the PIC uses AESOP™ to ensure everyone understands what is intended, what their tasks and priorities are, and to check for unanticipated risks one final time. If an optimum solution has not been achieved, repeat QPIDR as many times as necessary.
Define Task Concept / Learn to respond to unanticipated challenges
The goal of planning is to develop a Task Concept that is shared by everyone on the team. The Task Concept consists of all elements and factors of the job, including the duties and responsibilities of each team member. Unless the PIC has a specific Task Concept, which is shared with all team members, much of the advantage of thorough planning is lost.
The original Task Concept rarely remains static throughout a project. Eventually something happens that was not anticipated. This is called a challenge to the Task Concept. The Challenge/Response Cycle provides a framework for response to these unanticipated challenges.
Break the Chain
There are 3 steps you can use to break the Error/Accident Chain.
1. Realize you are close to the edge.
Nobody has a perfect life. The Error/Accident Chain starts growing every day as problems occur in our personal life and at work. Every day people do what they have to do to get the job done. This makes it very difficult for people to realize when the current situation is getting close to their personal limit of what they can handle. Be on the alert for the following warning flags mentioned throughout this seminar.
Warning signs of loss of situational awareness
Symptoms of high/low workload
2. Verbalize your concern
Once you recognize that a chain of problems and/or poor decisions is occurring and may be reaching the danger point, verbalize your concern using the Assertive Statement and, if necessary, “This is Stupid!”
3. Use AESOP and QPIDR
Once a problem or poor decision is recognized, determine if it is the only one currently affecting the project, by using AESOP™ to identify all hazardous situations. Then use QPIDR and the Conservative Response Rule™ to determine the best course of action.
You Can Make a Difference
Helen Keller said, “You can’t change the whole world, but you can change the world where you are.” Nothing is going to happen unless you make the decision to start using these error prevention techniques. If you believe this information can help you and your team be more effective, start using it today to:
Open lines of communication
Help people learn and use the Traps & Tools of Error Prevention
Recognize and avoid or deal with traps and pitfalls
"Have your radar on" for better ways to operate
Recognize problems and conflicts before they cause problems
Operate more effectively individually and as part of your team
Break the Error/Accident Chain / Implement Error Prevention
We have repeatedly stressed during this seminar that there are no easy answers. The Traps and Tools™ can alert us to problems and help us deal with them, but it is still up to each person to use their own judgment in ultimately deciding what to do. One final concept that helps to pull everything together is called the Error/Accident Chain.
Mistakes and accidents don't just happen. They generally involve a chain of risk factors and poor judgments, sometimes stretching back days, weeks, months, or even years before the actual incident. Each risk factor brings that person or team closer to the mistake or accident. Each poor judgment increases the availability of false information, which may then negatively influence decisions that follow. As the chain grows, situational awareness becomes impaired and the alternatives for getting the project back on track decrease.
Error/Accident Chain Drawing