Editor’s note: Our Safety Leadership column is written by experts Michael Greene, Blair Bigham and Daniel Patterson. Following is part 10 of a 12-part series.
Alice: I was just wondering if you could help me find my way.
Cheshire Cat: Well, that depends on where you want to get to.
Alice: Oh, it really doesn’t matter, as long as ...
Cheshire Cat: Then it really doesn’t matter which way you go.
Safety Leader: If only for a simple map and compass …
When it comes to designing a safety management system (SMS), it matters where you are going and where you want to get to. One way to help you figure that out is to use gap analysis, which is a tool that helps organizations compare actual performance with potential performance. At its core are two questions: Where are we (current state)? and Where do we want to be (future state)?
Over the past several months, my co-authors and I have described the concept and elements of an SMS. We have laid the groundwork, presented compelling arguments, told stories and given personal examples—all to inspire you toward the ultimate goal of having a safe high reliability organization (HRO). Now, through gap analysis, you’ll discover the starting point—the current state of your organization—en route to building your SMS.
Using a map and compass analogy, we are going to use the four pillars, the roof, the foundation and the 11 elements to “triangulate” your organization’s current state. The gap analysis will fall under six general headings: leadership, culture, policy, risk management, assurance and promotion. The standards under each category are essentially the 11 elements in greater detail, as we’ve discussed in previous issues.
Of course, we’ll need a tool for measurement and a scale to measure the distance—and progress—toward the goal. Our recommended scale draws on the “Five P” model that we’ve talked about earlier and is based on a percentage scale of 0 to 100. Using this scale, you and your project team will grade your organization on each SMS element. Let’s say you have an emergency response plan (element 3 under the Policy pillar) but you lack key paperwork of the plan in practice—so you might score your organization at 81 percent compliance with that element. Or maybe you feel your competencies and training on SMS (element 10 under Promotion) are top-notch—so you score yourself 100 percent.
Next we take these components and build a spreadsheet where we’ll document the gap analysis. I prefer an electronic document, but pencil and paper will suffice. The figure on page 9 illustrates the layout of the working document: five columns, starting with the standard or element. Next is a rating of where the organization stands against the standard (using the percentage scale). The third column is designed for comments and notations about existing policies and procedures, or items needed to meet the standard (to be built into an action plan). The fourth column should list the manager/leader who is responsible and accountable for this element (the “go to” for documentation). Finally, the fifth column is where the due date or timeline for needed items is noted.
I don’t want to go on a rant here, but the last two columns are vital to the success of your SMS development and implementation. Individuals must be responsible and accountable for the standard, even if it’s 100 percent complete. Accountability ensures that the mind, eyes, hands and heart are on the policy, procedure or process … because, after all, it’s all about ownership and commitment. But let’s not forget about the importance of deadlines. We all need them, as they provide motivation and boundaries and ensure progress toward a goal.
The next step is the actual analysis. A team approach to this step will promote buy-in to your fledgling SMS, create an organizational commitment and reduce potential fear of the process, so name a project team. Remind the team that gap analysis does not mean looking for individuals at fault or creating blame. Rather, it is a means of strengthening the organization by examining systemic factors in its current state and building a better, safer future. I also emphasize that this analysis is more than likely to discover and highlight best practices within the organization, as well as gaps.
Here are some additional guidelines related to your gap analysis team:
- Select champions and skeptics alike to participate on the team. Both bring value to the process, balance to the analysis and different perspectives on the current state.
- Use the rating scale and definitions to objectify and de-personalize the scoring.
- Some gaps may be identified as underlying structural issues that need to be addressed. Root cause analysis may be employed to determine key factors for improvement.
- Gaps call for action plans, but remind the team not to get bogged down in problem-solving or implementing solutions during this phase. Implementation of an SMS is admittedly a fluid process, but it is critical to have a clear snapshot of the current state of the organization to plot a path to the goal.
- Keep the gap analysis timeline tight to maintain team enthusiasm and motivation.
With a clear picture of the organization’s present location, now is the time to chart a route to the future and begin to close those gaps. Equipped with a map, starting point (current state), ending point (future state) and compass (HRO), the project team should be reassembled to develop the SMS action plan. Using the document produced for the gap analysis, any standard or element falling below 100 percent is introduced to the project team for deliberation, development and agreement on actionable steps. All tasks are assigned, timelines established, and marching orders issued!
Now for a reality check. You may be asking yourself, Who’s going to pay for all this? Honestly, cost always comes up because there is inevitably some thing, equipment or software that the project team views as the silver bullet. The easy answer is that the organization may need to provide capital funds for needed improvements; the not-so-easy answer is that it truly is a cost-benefit question for you and your organization. But before I preach about safety at any cost, let me propose that no single issue should deter you from the goal. There are countless ways to “skin the (Cheshire) cat.” A fully integrated, satellite-based, automated, live incident reporting system may be nice, but a simple paper process may suffice. Don’t let simplicity deter you from a fully functional, albeit low-tech, solution if it meets the goal.
One final note: Celebrate your success. Nothing keeps motivation, enthusiasm and inspiration higher than a good celebration. Throw a Mad Hatter party, play “pin the tail on the cat” or read a chapter from a children’s book.
Want More Info?
Details on gap analysis tools used in other industries can be found at the following websites:
atcvantage.com/resources-tools.html
fema.gov/pdf/plan/prevent/floodplain/fema_cap_ssse_program_gap_methodology.pdf
gapanalysis.usgs.gov
Michael Greene, R.N., MBA, MSHA, is a senior associate at Fitch & Associates. He has served in numerous front-line and leadership positions throughout his career, working in volunteer and paid search and rescue and as a paramedic, county EMS director and air medical/critical care transport director. He is the author of numerous articles and chapters on EMS and air medical transport topics. He can be reached via e-mail at mgreene@fitchassoc.com or by phone at 816-431-2600.
