I understand how crucial it is to investigate incidents thoroughly and uncover root causes. Adopting Human and Organizational Performance (HOP) principles can transform the way you approach post-incident investigations, leading to more meaningful improvements and better safety outcomes. Let me show you how HOP can enhance your incident analysis process.
Incorporating HOP into incident investigations shifts the focus from blaming individuals to understanding system weaknesses and human factors that contributed to the incident. This approach helps uncover the underlying causes of safety incidents, leading to sustainable improvements and preventing future occurrences.
Shifting Focus from Blame to Learning with HOP
Human and Organizational Performance (HOP) offers a significant departure from traditional safety management approaches. Instead of focusing on the individual who made an error, HOP emphasizes learning from the incident by analyzing the conditions and systems that contributed to the error.
When you incorporate HOP into your incident investigations, you prioritize understanding how work is actually performed (“work as done”) rather than how it was expected to be done (“work as imagined”). This shift allows investigators to gain a clearer picture of the real challenges workers face, leading to better solutions that can be integrated into your safety management system.
A major component of successful investigations is moving away from a “blame culture” and developing a “learning culture.” Studies indicate that organizations that promote a culture of learning, openness, and reporting create a safer environment. A systemic approach to learning can help avoid recurring incidents by addressing the root causes, including latent system weaknesses that often go unnoticed (Irawati & Astoro, 2024).
The Benefits of HOP in Post-Incident Analysis
- Uncovering Systemic Weaknesses
Traditional investigations tend to focus on human error, often stopping at the point where someone made a mistake. HOP digs deeper, asking why that mistake occurred and what aspects of the system allowed or even encouraged it. For example:- Did the procedures in place provide enough clarity and guidance?
- Were the tools or equipment used adequate for the job?
- Were workers trained and supported effectively?
By focusing on these questions, HOP can identify systemic weaknesses that may not be obvious at first glance. Moreover, ensuring psychological safety among employees allows them to contribute valuable insights to the investigation, as they feel secure in sharing their experiences (Alashram, Hamouda, & Yaseen, 2024).
- Encouraging Proactive Problem-Solving
HOP promotes a forward-looking approach to incident investigations. Instead of simply identifying what went wrong, it encourages organizations to ask how they can design better systems that reduce the likelihood of human errors. This leads to proactive solutions, such as improving work processes, enhancing communication, and designing safer environments. This strategy is critical for healthcare organizations, where proactive changes can significantly reduce adverse outcomes (Alashram et al., 2024). - Fostering a Learning Culture
Incorporating HOP into incident investigations shifts the focus from assigning blame to learning from mistakes. When employees know that their mistakes won’t be met with punishment but instead used as learning opportunities, they are more likely to report near misses and safety concerns. This is particularly true in industries like healthcare, where creating a learning culture is essential for improving patient outcomes (Irawati & Astoro, 2024). - Better Engagement from Workers
Workers often have the best insights into the practical challenges they face on the job. HOP encourages their active involvement in incident investigations, ensuring that their perspectives are heard and integrated into the problem-solving process. This engagement not only leads to more practical solutions but also enhances workers’ trust in the organization and its safety culture (Alashram et al., 2024).
Applying HOP Principles in Incident Investigations
Incorporating HOP principles into your incident investigations requires a structured, yet flexible approach. Here are some steps to guide you through this process:
- Focus on Work as Done
When investigating an incident, begin by exploring how the work was actually performed rather than how it was supposed to be performed. Workers often develop “workarounds” to cope with challenges in the system, and understanding these adaptations can provide valuable insights into system weaknesses. By understanding the real-world conditions workers face, you can identify where your processes may need improvement (Irawati & Astoro, 2024). - Ask the Right Questions
In a HOP-based investigation, the goal is not to pinpoint who made a mistake but to uncover why that mistake occurred. Focus on asking questions like:- What was the context of the incident?
- Were there any environmental factors that influenced behavior?
- How did existing processes or equipment contribute to the event?
- What can we do to prevent this from happening again?
These questions help steer the investigation towards learning and system improvement rather than blame.
- Engage Workers in the Investigation
HOP encourages workers’ participation in the investigation process because they have firsthand knowledge of the day-to-day realities of their jobs. Conduct learning teams or post-incident discussions where workers can openly share their experiences without fear of blame. This collaboration ensures that the solutions developed are practical and grounded in the actual work being performed (Alashram et al., 2024). - Focus on System Improvements
Once the root causes have been identified, focus on improving systems rather than modifying individual behavior. For example, if an incident occurred because of unclear procedures, revising the procedures and providing additional training is a more sustainable solution than simply telling workers to “be more careful” next time. Implementing systemic improvements can prevent future incidents and create a more resilient safety system.
Conclusion
Incorporating Human and Organizational Performance (HOP) into incident investigations transforms the process from one focused on blame to one centered on learning and improvement. By uncovering systemic weaknesses, encouraging proactive problem-solving, and engaging workers in the process, HOP leads to better safety outcomes and fosters a culture of continuous improvement. The result? Safer workplaces, fewer incidents, and stronger safety cultures.
References
Alashram, H. M., Hamouda, G. M., & Yaseen, M. (2024). Nurses’ perception toward the relationship between just culture and patient safety activities: A literature review. Journal of Health, Medicine and Nursing, 10(2), 18-33. https://doi.org/10.47604/jhmn.2499
Irawati, S., & Astoro, A. B. (2024). From blame culture to learning culture in healthcare services: A literature review. Formosa Journal of Science and Technology, 3(6), 1195-1216. https://doi.org/10.55927/fjst.v3i6.9712
