As I was listening to Todd Conklin’s recent podcast on “transparency,” I started thinking about some of the “HOWS” for making risk more transparent.
Part of risk transparency is ensuring that, through our written guidance, we set the performers up for success, and make the risk and the avoidance or mitigation of the risk obvious to the user.
Effective written guidance doesn’t necessarily mean that every option is covered, but that the user is provided opportunities to recognize and effectively manage the predictable risks in a task.
Very often organizations have either no written guidance for a task, or written guidance that exists, but isn’t very good.
There are several ways the written guidance can fail the user that could lead to error and incidents.
The first is when the guidance is technically inaccurate. In other words, the guidance, even if performed as written, would not accomplish the task or could produce an incident.
The second and much more prevalent is when the written guidance isn’t “usable” for effectively performing the task.
Many times, a user will approach a subject matter expert who either wrote the guidance or owns the system telling them that the guidance “doesn’t work.”
What the subject matter expert reacts to is that it is technically inaccurate – they typically say – yes it works, you just need to follow it. But what the user was trying to get across is that the guidance may not be USABLE. And these are very different things.
My Robservation is that, in the over 250 companies that we have worked with globally, MOST of the people who are responsible for writing and reviewing guidance and procedures do not know there are about 25 “procedure error traps” or ways that written guidance or procedures can actually DRIVE errors or incidents, just by the way they are written.
They haven’t been taught how to avoid the traps and write more effective guidance?
In the early 1990s, a company called PII produced some data that defines the top process error traps and how to avoid them. We have expanded this information to the Top-5 traps in written guidance that increase the probability of an error or incident.
- Field Decisions – when the user has to decide between options that are not clearly identified (if applicable, when applicable, if needed, when needed, if desired, or if required). Steps that contain these phrases have a documented error rate 11 times higher than a step that tells someone what to do or the conditions under which to do it.
- Difficulty – when we make the task or steps more difficult than the user perceives the need to be, it drives the potential for unintentional shortcuts. The difficulty may be mental; or hard to remember things they need to do that may not be written in the step. Sometimes it can be physical; or more difficult to perform the task as written than how the user knows it could be done.
- Vague or misleading information – there is a difference between flexibility and ambiguity. Flexibility (clear information) – here is your box – stay in it! Ambiguity – there is a box out there, find it and get in it. Sometimes the ambiguity can leave the door open to producing a risk that wasn’t anticipated by the user, and sometimes it is misleading as to the risk.
- Conflicting information – this is information that either doesn’t make sense to the user or directly conflicts with what the user expects to see or do. This can be as simple as a change in font, the placement of a note, caution, or warning. Or as complex as not notifying the user of something different or unexpected about the system.
- Multiple or embedded actions – putting three or more discreet actions in a step or “hiding” an action in a note, caution warning, precaution, or limitation.
You may already see that some of your written guidance contains some of these attributes. When these traps or any of the other 20 traps are present, we reduce the transparency of risk and increase the probability that an individual or group will be surprised by the risk or bad outcome.
As you discover examples of the top five process error traps, please share them in the comments.
If you want to learn how to effectively write more error-free guidance, procedures, or processes, sign up for our Effective Process and Procedure Writing Workshop in the Charlotte area in January 2020.
For more info on this workshop and others related to integrating Human and Organizational Performance concepts, visit our website by clicking the link in the description.
And remember, Intentional Leadership starts with you.