optimising learning from reports of msds

Optimising learning from reports of MSDs

Dr Natassia GoodeCentre for Human Factors and Sociotechnical Systems

Key questions

• How can we optimise learning from reports of MSDs?

• What are the key barriers to learning in current practice?

• What are the facilitators of learning in current practice?

Learning from incidents

• Understand why your risk controls failed.

• Take action to ensure your risk controls are actually reducing or eliminating the risk of injury.

Requirement to review and revise risk control measures if

“the control measure does not control the risk it was implemented to control so far as is reasonably practicable”

NSW WHS Legislation 2017, Section 3.1

Look up and out, not down and in

Framework for learning from MSDs

• The organisational resources required

• The processes that need to be implemented

• The types of contributory factors to consider during investigations

Development of the framework

• Stage 1: Literature review on contemporary theory regarding accident causation and learning from incidents.

• Stage 2: Development of a taxonomy of contributory factors for investigating MSDs

• Stage 3: Study of reporting and investigation practices in 19 large Australian organisations

Framework for reporting and investigation

Model of accident causation

Reporting and investigation process

Data collection

Analysis

Recommendations

Decision-making

Follow-up and evaluation

Organisational resources

Incident management

policy

Data collection

tools

Training on reporting/ investigatio

n

Database for storing learning

Taxonomy of

contributing factors for

WMSDs

Framework

• Best practice for learning from MSDs

• Barriers to learning in current practice

• Facilitators of learning in current practice

What-you-find-is-what-you-fix

What-you-look-for-is-what-you-find

Accident causation models

Sequential models

Epidemiological models

Best practice: Systems models

Adverse events

Real, invisible, safety boundary

Economic failure

boundary

Unacceptable

workload boundary

Boundary defined by

official work practices

Government

Regulators,

Associations

Company

Management

Staff

Work

Hazardous process

Laws

Regulations

Company

Policy

Plans

Action

Public opinionChanging political climate

and public awareness

Changing market

conditions and financial

pressure

Changing competency

levels and education

Fast pace of

technological change

Barriers• No knowledge of accident

causation models (22/38).• Reasons’ Swiss cheese (12/38)• Use of inconsistent

methods/models.

Facilitators• Integrated into all organisation

documents (1 organisation).




Data collection

Analysis

Recommendations

Decision-making



Incident management

policy

Data collection

tools

Training on reporting/ investigatio

n


Taxonomy of


WMSDs



Incident management

policy

Data collection

tools

Training on reporting/

investigation

Database for storing

learning

Taxonomy of


WMSDs

Taxonomy of contributing factors

Best Practice:

• Domain specific taxonomy

Facilitator:

• Integrated into all aspects of reporting and investigation

Barriers:

• Unclear/overlapping categories

• Physical risks only

Taxonomy

Risks associated with

the task

Factors that influence whether

risk controlmeasures work

Risks associated with the task

Equipment Physical environment Job design

Factors that influence whether risk control measures work


Worker support

Work systems Work scheduling

Resources Management systems Leadership

Factors that influence whether risk control measures work


Worker support

Work systems Work scheduling

Resources Management systems Leadership

Government

Regulators Unions and employer associations

Suppliers Customers

Data collection toolsBest Practice Facilitator(s) Barrier(s)

Incident forms collect information required to support decision making around investigation

Forms collect info from multiple people

Free text boxes for detailed description of events/conditions, cont factors, recommendations

Forms encourage selection of single contributory factor

Forms time consuming

Lack of space for incident description and contributory factors

Confusing categories

Range of standardised investigation tools available that target data around levels of Rasmussen’s framework

Interview questions

Previous risk assessments

Same tools used in all WMSD investigations

Informal chats

Reliance on single tool

Tool use based on personal preferences




Data collection

Analysis

Recommendations

Decision-making



Incident management

policy

Data collection

tools


investigation


Taxonomy of


WMSDs

The process – the learning cycle

Data collection

Analysis

Recommendations

Decision-making


Data collection – reportingProcess Best Practice Facilitator(s) Barrier(s)

What to report Definition states the minimal requirements for reporting WMSDs

What to report is reinforced in all organisational documents, and regularly discussed within the workplace.

Lack of clarity around “reportable” and “notifiable” incidents.

Lack of clarity regarding the differences between workers compensation claims and incident reports.

Pain, discomfort or any injury associated with a task or working conditions, regardless of whether

treatment is required.

Conditions of work that may result in pain, discomfort or injury (i.e.

hazards)

Data collection – investigationsProcess Best Practice Facilitator(s) Barrier(s)

Investigation goals Goal is learning with a focus on reviewing risk controls and identification of targets for prevention

Rebadging of investigations e.g. ‘Review of risk controls’, ‘Review of practice’

Competing goals e.g. compliance, punishment, litigation

Lack of clarity on difference between internal and external investigations

Investigation scope Investigations focus on factors influencing behaviour rather than immediate context of injury

Investigation goes ‘up and out’ rather than ‘down and in’. Focus also on why risk controls didn’t work

Focus is on injured person, ‘root cause’, what ‘should have been done’

Design of recommendations

Best Practice Facilitator(s) Barrier(s)

Formal consultation process incorporates:

- Multiple participants- Multiple recommendations- Consideration of

interactions with existing control measures

- Barriers to implementation

- Produce number of recommendations with risk matrix and strengths and weaknesses

- OHS team have frequent verbal contact with senior manager

- Lack of workload allocation to participate

- OHS team are perceived to be responsible for developing recommendations

Selecting recommendations

Best Practice Facilitator(s) Barrier(s)

Decision made based on whether recommendations:- Target factors influencing

behaviour- Target organisational redesign- Apply across the organisation- Include plans for long term

maintenance

- OHS team has frequent interactions with senior management

- Recommendations address personal factors

- OHS team communicate with senior management through business cases or monthly reports




Data collection

Analysis

Recommendations

Decision-making



Incident management

policy

Data collection

tools


investigation


Taxonomy of


WMSDs

Evaluate your own system

• https://www.worksafe.vic.gov.au/resources/improving-manual-handling-risk-controls-after-musculoskeletal-disorders

• Self-assessment questionnaire

• Information on best practice

https://www.worksafe.vic.gov.au/resources/improving-manual-handling-risk-controls-after-musculoskeletal-disorders

Interested in using systems thinking methods to investigate MSDs?

Thank you!

Dr Natassia Goode

Centre for Human Factors and Sociotechnical Systems

[email protected]

mailto:[email protected]

optimising learning from reports of msds

Documents