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System or program?

Management systems were all the rage in the 1990s and like many things since then, the meaning of “safety management system” has changed. These days we see the possibility of a new ISO 45001 standard for safety management systems, which has reignited the discussion.

Management systems are simply a structured set of documents to guide the execution of a system. It really is way to force an activity into more rigor and produce repeatable and auditable processes that drive results. Of course all that is management speak for providing an outline and specific instructions on how to perform a function like safety. It is a framework for operating the safety system.

After all that we had the ISO 14000 Environmental Management System and the ISO 9000 Quality Management System. These had at least some of their roots in the British Standards Institute (BSI). Then there was BSI 8800. This standard was destined not to become an ISO standard and the bid for ISO 18000 was not successful. Countries developed their own standard for a safety management system that bore strong resemblance to ISO 14000. The United States came out with ANSI Z10 and in Canada the CSA came out with Z1000.

With ISO 45001 on the horizon. I am sometimes asked what a management system is. After all, we did start with safety programs and then there was some sort of mysterious change and everyone has a management system. “Management system” has become a slogan. With a group, it makes for an interesting discussion.

I know everyone is now thinking plan do check act (PDCA). I must admit that this is a simplistic view of a management system. In a group I will often ask who thinks they have a management system. Almost everyone indicates they do, truth be told, there is seldom one who will say they don’t. So, we need to compare to really find out who has a management system and who a program.

Programs and systems look the same

A safety program has long been the mainstay and, a management system is not for everyone. In fact, for companies with less than 250 employees they may be overkill, wasteful and even counterproductive. Strangely, programs look very similar to management systems. There is a rather large binder and it contains a policy or policies relating to the overall program and other things of importance (if you live in the small policy world). Management systems stress a single overarching policy and document hierarchy.

Programs contain standards, processes and even specific instructions along with a variety of forms. In both cases these guidance documents even spell out the all-important training and orientation that workers, supervisors, and even managers must receive.

Of course, with the implementation, that means that we must measure compliance against the system or program and this is normally done through audits in both cases. This is the check in PDCA which is followed by acting on what was found, perhaps an action plan for the year.

Overall this looks very similar. A program is almost indistinguishable from a system and yet I am sure that almost everyone who reads this will still be thinking they have a system. It may come as some surprise that in my career, which is not short, I have seen very few companies that I think have a safety management system. Perhaps along with your doubt, I may have grabbed your attention.

Program defined

Management systems are, by their very nature much different from programs and yet appear similar. We expect one particular thing from a management system. That thing is continuous improvement. A management system must improve over time. How is this possible? When stressed it must be a learning system and become stronger instead of weaker when stressed. For example when a hand develops callouses or when bone density increases because the person is carrying heavy weights.

This may seem complicated and it can be but a simple example will suffice to make the point. Safety systems are stressed when there is an incident. As Dan Petersen would have pointed out, incidents are indicators of gaps in the system. So all we need do is an exercise looking at a common incident.

Let us suppose an incident has occurred where the immediate cause is that a worker failed to follow a procedure or instruction. This is a very common cause and sometimes mistaken for a root cause. In safety we seem to take pleasure in measuring outcomes so let’s follow this one through.

The investigator may find that the worker did not follow the procedure. The question logically becomes did he know the procedure? Did the company train him in the task? Was he found competent? These are all good and relevant questions. After all the immediate cause is often an unsafe act and we must work to understand why it occurred.

Following this line of inquiry we are not likely to have a worker admitting he knew the procedure. We may have clear orientation records and even a competency verification showing that the worker demonstrated they knew the procedure. We may conclude he had forgotten or it was a lapse that can occur. In cases where this is a pattern we would certainly ensure some accountability was added to the mix.

We show the company being duly diligent having the records in place to show that training was provided and competency was verified but there was simply a human failure. We may find that the worker was bored, complacent or distracted. A detailed investigation report would be written and the corrective actions would involve retraining the worker in question and reviewing the requirement with other similar workers while sharing the lessons learned across the organization.

You see at the heart of the matter is that the worker failed to comply with a procedure they had been trained and tested on. Almost certainly this was unintentional and ensuring that they understand the requirement and the probable outcomes of failing to adhere to the procedure we have ensured that this incident is unlikely to recur. This is what having a program looks like.

System defined

In a system, those investigating the incident will find exactly the same things and have the same information. They will not ask all he same questions or arrive at the same place. In a system failure is expected and even anticipated. Failure is a learning opportunity and in most cases these opportunities improve the system.

Some different sorts of questions arise from this mindset. Why was the worker not following the procedure? Was the procedure to onerous? Too long? Too complex? Where is the gap in the system that allowed a very human lapse to lead to an incident?

Systems address some of the consequences of what I term “drift.” Once a worker is trained on a procedure and tested, that is the perfect 100 per cent moment in which she meets all requirements. Being human over time, she will look for faster, easier and even better ways to do the job. Complacency encourages drift and so deviations from what is desired become normalized within the workplace.

Getting back to our incident, we see that the investigators having asked somewhat different questions may come to a different conclusion. A program is focussed on compliance. Workers must simply be told what to do and follow the rules and procedures. It is a simplistic way to look at what are complex interactions in the workplace.

In a system, an investigator would look for gaps in the system. Gaps in the layers of controls and checks in place. Most importantly the investigator would also look at the process or procedure that was not followed. The key assumption is that the problem is with the system, not the employee.

The outcome would be that the procedure may be changed, the work may be adjusted or the actual training or evaluation be scrutinized and improved. In this case we can see that the system has been improved, where the program has simply advocated re-establishing compliance with the program.

Programs do not have continuous improvement and systems most definitely do. That is the key difference. A program is fairly inflexible and little changing without some outside stimulus such as a legislative change or major workplace event. A system improves and becomes stronger as it is stressed and as part of strategic planning and analysis.

Building a functioning continuous improvement system is not easy, it takes real focus and significant training. The continually improving systems not only learns from incidents but plans ahead to focus on emerging issues, areas of weakness and targeted areas for improvement.

So, coming full circle I will ask again. Do you have a program or system? In groups and in my classes very few will claim they do, given these definitions.

Dave Rebbitt

Dave Rebbitt is the president of Rarebit Consulting providing services across Western Canada. With almost 30 years in health and safety, Rebbitt has built numerous health, safety, and environment management systems along with some innovative processes and even developed specialized PPE. He is an experienced speaker and writer on a wide variety of topics. He also develops and instructs courses at the University of Alberta OHS program. He can be reached through
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