THE GPTHE CONTRACTOR & THE EMPLOYER

Marion Foster March 2011

GP Partner as a Contractor and Employer

UNDERSTAND:

The duties, rights and responsibilities

The RISKs

OBJECTIVESOBJECTIVES

ABRIDGED PRESENTATION — FOR ILLUSTRATIVE PURPOSES ONLY

© 2009, Clifford & Garde

Major MalfunctionMajor Malfunction

Package

“”

CAN GENERAL PRACTICE LEARN FROM CAN GENERAL PRACTICE LEARN FROM THE CHALLENGER DISASTER?THE CHALLENGER DISASTER?

THETHE LEGACYLEGACY OFOF CHALLENGERCHALLENGER

The Rogers Commission, which investigated the incident, determined:

The SRB joint failed when jet flames burned through both o-both o-rings rings in the joint

NASA had long known about recurrent damage to o-recurrent damage to o-ringsrings

Increasing levels of o-ring damage had been tolerated tolerated over time

Based upon the rationale that “nothing bad has “nothing bad has happened yet” - happened yet” - Complacency

1. Maintain Sense Of Vulnerability

2. Combat “Normalization Of Deviance”

3. Establish an Imperative for Safety

4. Perform Valid/Timely Hazard/Risk Assessments

5. Ensure Open and Frank Communications

6. Learn and Advance the Culture

KEY ORGANIZATIONAL CULTURE FINDINGS

– What NASA Did Not Do

MAINTAINING A SENSE OF VULNERABILITYMAINTAINING A SENSE OF VULNERABILITY

NASA’s successes (Apollo program, et al) had created a “can do” “can do” attitude that minimized the consideration of failure

Near-missesNear-misses were regarded as successessuccesses of a robust system rather than near-failures near-failures

A weak sense weak sense of vulnerability can lead to taking future successsuccess for granted granted… and to taking greater risksgreater risks

NASA’s “can do” can do” attitude often made it hard for individuals (even groups) to step forward and say “this can’t be done.” say “this can’t be done.” The imperative of “we must succeed” “we must succeed” had overwhelmed the consideration of “we could fail.”“we could fail.”

1. Maintain Sense Of Vulnerability

2. Combat “Normalization Of Deviance”

3. Establish an Imperative for Safety

4. Perform Valid/Timely Hazard/Risk Assessments

5. Ensure Open and Frank Communications

6. Learn and Advance the Culture

Key Organizational Culture Findings– What NASA Did Not Do

COMBATING NORMALIZATION OF DEVIANCECOMBATING NORMALIZATION OF DEVIANCE

“This history portrays an incremental descent into poor judgment.”

Diane Vaughan,The Challenger Launch

Decision

Each successful mission reinforced reinforced the perception that foam shedding was unavoidableunavoidable…either unlikely to jeopardize safety or an acceptable risk.acceptable risk.

Foam shedding, which violated the shuttle design basis, had been normalizednormalized

Challenger parallel… tolerance of damage tolerance of damage to the primary o-ring… led to tolerance of failure tolerance of failure of the primary o-ring… which led to the tolerance of damage tolerance of damage to the secondary o-ring… which led to DISASTERDISASTER

1. Maintain Sense Of Vulnerability

2. Combat “Normalization Of Deviance”

3. Establish an Imperative for Safety

4. Perform Valid/Timely Hazard/Risk Assessments

5. Ensure Open and Frank Communications

6. Learn and Advance the Culture

Key Organizational Culture Findings– What NASA Did Not Do

ESTABLISH AN IMPERATIVE FOR SAFETYESTABLISH AN IMPERATIVE FOR SAFETY

“When I ask for the budget to be cut, I’m told it’s going to impact SAFETY onthe Space Shuttle … I think that’s a bunch of crap.” Daniel S. Goldin, NASA Administrator, 1994

Burden of proof The technical staff for both Challenger and Columbia were put in the position of having to prove prove that management’s intentions were unsafewere unsafe.

The traditional approach - to assume ssume that a problem existedexisted, then seek the sound technical evidence and analysis necessary to prove to prove (if possible) that the problem did not existdid not exist.

This reversedreversed their normal role of having to prove mission safety.

ESTABLISH AN IMPERATIVE FOR SAFETYESTABLISH AN IMPERATIVE FOR SAFETY

International Space Station deadline 19 Feb 04

Desktop screensaver at NASA

As with Challenger, future NASA funding required meeting an ambitious launch schedule

Conditions/checks, once “critical,” were now waived

A significant foam strike on a recent mission was not resolved prior to Columbia’s launch

Priorities conflicted… and production won over safety

1. Maintain Sense Of Vulnerability

2. Combat “Normalization Of Deviance”

3. Establish an Imperative for Safety

4. Perform Valid/Timely Hazard/Risk Assessments

5. Ensure Open and Frank Communications

6. Learn and Advance the Culture

Key Organizational Culture Findings– What NASA Did Not Do

PERFORM VALID/TIMELY PERFORM VALID/TIMELY HAZARD/RISK ASSESSMENTSHAZARD/RISK ASSESSMENTS

“Any more activity today on the tile damage or are people just relegated to crossing their fingers and hoping for the best?”

Email Exchange at NASA

“… hazard analysis processes are applied inconsistently across systems, subsystems, assemblies, and components.”

CAIB Report, Vol. 1, p. 188

NASA lacked lacked consistent, structured approaches for identifyingidentifying hazards and assessing risks

Many analyses were subjective, subjective, and many action items from studies were not addressed not addressed

In lieu of proper risk assessmentsrisk assessments, many identified concerns were simply labeled as “acceptableacceptable”

Invalid computer modeling of the foam strike was conducted by “green” analysts“green” analysts

1. Maintain Sense Of Vulnerability

2. Combat “Normalization Of Deviance”

3. Establish an Imperative for Safety

4. Perform Valid/Timely Hazard/Risk Assessments

5. Ensure Open and Frank Communications

6. Learn and Advance the Culture

Key Organizational Culture Findings– What NASA Did Not Do

ENSURE OPEN AND FRANK COMMUNICATIONSENSURE OPEN AND FRANK COMMUNICATIONS

I must emphasize (again) that severe enough damage… could present potentially grave hazards… Remember the NASA safety posters everywhere around stating, “If it’s not safe, say so”? Yes, it’s that serious.

Memo that was composed but never sent

Management adopted a uniform mindset that foam strikes were not a concern not a concern and was not open not open to contrary opinions.

The organizational cultureDid not encourage “bad news”“bad news”Encouraged 100% 100% consensusEmphasized only “chain of command” “chain of command” communicationsAllowed rank and status to trumptrump expertise

1. Maintain Sense Of Vulnerability

2. Combat “Normalization Of Deviance”

3. Establish an Imperative for Safety

4. Perform Valid/Timely Hazard/Risk Assessments

5. Ensure Open and Frank Communications

6. Learn and Advance the Culture

Key Organizational Culture Findings– What NASA Did Not Do

LEARN AND ADVANCE THE CULTURELEARN AND ADVANCE THE CULTURE

The organizational dysfunctions that had been identified in the Challenger incident, and which persisted persisted through the Columbia incident, strongly suggest that NASA had not learned from its mistakes…

NASA had not learned not learned from the lessons of Challenger

Communications problems still existed still existed

Experts with divergent opinions still had difficulty getting heardgetting heard

Normalization of deviance Normalization of deviance was still occurring

Schedules Schedules often still dominated dominated over safety concerns

Hazard/risk assessments were still shallowshallow

Abnormal events Abnormal events were not studied in sufficient detail, or trended to maximize learnings

What is Safety Culture and What is Safety Culture and Why is it Important?Why is it Important?

Safety Culture

is the critical barrier

that protects workers, the public, and the

environment

from the inherent risks or dangers

in the organisations’ work.

What is Safety Culture and What is Safety Culture and Why is it Important?Why is it Important?

WHAT IS RISK?WHAT IS RISK?

Chinese word for Risk

Wei Ji

Danger Opportunity

REMEMBER RISK HAS AN UPSIDE!REMEMBER RISK HAS AN UPSIDE!

WHAT ARE OUR HIGH RISK AREAS?WHAT ARE OUR HIGH RISK AREAS?

System Failures negligence claimsSystem Failures negligence claims

Over ¼ of 200 cases settled

Repeat prescribing –11.5%

Dealing with results –7%

General office systems –3.5%

Cervical cytology –1.5%

Recall / protocols / referrals 5%

MDDUS Statistics

EXAMPLES OF LEGISLATIONEXAMPLES OF LEGISLATION Freedom of Information Act. 2002 The Medicines Act, 1968 The Misuse of Drugs Act 1971 The Children’s (Scotland) Act 1995 Health and Safety at Work Act 1974 Data Protection Act 1998 Access to Health Records 1990 The Misuse of Drugs Act 1971 The Children’s (Scotland) Act 1995

Business Continuity Planning

• Low likelihood

• Very High impact

BUSINESS CONTINUITY MANAGEMENTBUSINESS CONTINUITY MANAGEMENT

CIVIL CONTINGENCY ACT 2004• Loss of premises - Fire / Flood

• Loss of staff - Key People / Mass sickness / Flu

• Loss of IT / Patient Records / QoF Data / Key documents

• Loss of power

• Restricted access to building

• Partnership split

• Loss of telephones

Corporate Governance

Business Continuity

Management

Site Recovery planning

Business Continuity planning

Work Area Recovery planning

Human Resource planning

Technology Recovery planning

Crisis Management

planning

Managing the crisis

Essential staffStaff relocation

Business as usual

Site salvage / restoration

ContextContext

SenariosSenarios