The fourth quadrant of the PDCA cycle includes the sub-parts of reviewing performance and learning lessons.
Carrying out reviews will confirm whether health and safety arrangements still make sense. For example:
- check the validity of the health and safety policy;
- ensure the system in place for managing health and safety is effective.
An organisation will be able to see how the health and safety environment in the business has changed. This will enable it to stop doing things that are no longer necessary while allowing it to respond to new risks.
Reviewing also provides the opportunity to celebrate and promote health and safety successes. Increasingly, third parties are requiring partner organisations to report health and safety performance publicly.
The most important aspect of reviewing is that it closes the loop. The outcomes of review become what is planned next with health and safety.
Learning lessons involves acting on:
- findings of accident investigations and near-miss reports;
- organisational vulnerabilities identified during monitoring, audit and review processes.
Even in well-designed and well-developed management arrangements, there is still the challenge of ensuring that all requirements are complied with consistently.
After an accident or case of ill health, many organisations find they already had systems, rules, procedures or instructions that would have prevented the event but were not complied with.
The underlying causes often lie in arrangements which are designed without taking proper account of human factors, or where inappropriate actions are condoned implicitly or explicitly by management action or neglect.
Analysis of major incidents in high-hazard industries, with different technical causes and work contexts, has identified several common factors involved when things go wrong. These factors are related to:
- attitudes and behaviours;
- risk management and oversight.
When these aspects of an organisation become dysfunctional, important risks can become ‘normalised’ within it, leading to serious consequences.
Organisational learning is a key aspect of health and safety management. If reporting and follow-up systems are not fit for purpose, for example, if a blame culture acts as a disincentive to reporting near misses, then valuable knowledge will be lost.
If the root causes of precursor events are not identified and communicated throughout the organisation, this makes a recurrence more likely.
In many cases, barriers within an organisation – where different departments operate in ‘silos’ – inhibit organisational learning.
Leaders and managers need to be aware of the people-related, cultural and organisational issues that may prevent lessons from being learned effectively in their organisations.