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Human Error Part 2: Policies, Rules and Exceptions

Creating “standard work” is a common goal in manufacturing and other industries. The idea is to find the best way to perform a given task then document and teach that approach to everyone who performs the same task to reduce process variation.  This same concept shows up in many other areas such as human resources. 

Most companies have firm policies in place about the amount of paid time off an employee can take for vacation and sick days. The amount of time a person is allowed is often tied to the number of years the person has been with the company and/or their level on the organizational chart. The purpose of these policies is to help ensure equal and consistent treatment of employees.  If a manager allowed one employee to take an extra week of vacation than everyone else in the department with the same years of service, it would likely cause morale or possibly even legal problems for the company.

 "Two days later someone realized that nearly every police officer in the state was breaking the law because the law did not contain an exception for law enforcement officers."

At the same time, there may be circumstances where it would be appropriate to make exceptions to the rules. The point is that while rules are important, there are times where blind obedience to rules can create their own set of problems, especially if the rules were put into effect without considering the need for exceptions. Two examples of this phenomenon immediately come to mind.

On January 15, 2013 New York Governor, Andrew Cuomo, signed into state law a piece of legislation which made it illegal to possess a firearm magazine capable of holding more than 10 rounds of ammunition and making it a crime to put more than 7 rounds of ammunition into a 10 round magazine. Two days later someone realized that nearly every police officer in the state was breaking the law because the law did not contain an exception for law enforcement officers.

Another example of a “rule” getting in the way of common sense comes from an elementary school in Indiana where a Sheriff’s Deputy was talking with teachers about emergency evacuation procedures for emergencies such as a fire or an active shooter situation.  The Deputy suggested to a group of administrators and elementary school teachers that in the event of an active shooter, the children should be taught to exit through the emergency doors on the North end of the building and proceed to the playground.  One of the teachers immediately objected that the elementary students are not allowed to cross the driveway on the North side of the building. The point is that under normal circumstances it makes sense for elementary students to not cross a driveway on their own but in the event of an active shooter, the risk of crossing the driveway pales in comparison to the risk of standing in the doorway of the emergency exit.

 

Another variation on this theme occurs when the rules themselves are vague or incomplete. For instance, several years ago some adult hospital beds were designed with a “walk away” feature on them so a nurse could press a button once to lower the bed all the way down (similar to the “express down” feature on automobile windows). The purpose of this feature was to save the nurse the time that would be required to press and hold the button for 30 to 45 seconds while the bed lowered all the way down. Unfortunately, this feature contributed to the deaths of 4 children who, after being placed on the bed, climbed under those beds and accidentally activated the down button.

One hospital where this occurred had a written policy that no children were to be placed in adult hospital beds (pediatric hospital beds never had the “walk away” feature). The problem arose when a child was admitted to the hospital and there were no pediatric beds available. The policy clearly stated what NOT to do but it did not give any guidance on what to do if a pediatric bed was not available when a child was being admitted. The policy was violated by a hospital employee who didn’t see any alternative but to put a child on an adult bed because no pediatric beds were available.

I’ve spoken with small business owners who were frustrated by conflicting instructions they had been given by government agencies during audits. In one case the Environmental Protection Agency (EPA) had instructed the company to change their process in a certain way for environmental reasons, then the Occupational Safety and Health Administration (OSHA) had instructed the same business to undo the change because of the risk it posed to worker safety.

"Rules and guidelines are often put in place to enhance one or two of these objectives without taking into account the potential negative impact those rules and guidelines may have on the other objectives."

The point is that most people and most companies are struggling to meet competing objectives such as lower cost, faster service, higher quality, lower inventory, improved safety and less environmental impact. Rules and guidelines are often put in place to enhance one or two of these objectives without taking into account the potential negative impact those rules and guidelines may have on the other objectives. Even the best thought out and best written rules have the potential of being misread or misapplied (such as the teacher not wanting a student to cross the driveway even if someone was shooting at them).

What examples have you seen of policies / rules contributing to human error?