2025 Community of Human and Organizational Learning 31st Annual Conference

What if we told you that human error isn’t the problem – it’s the key to improvement?  Welcome to the world of Human and Organizational Performance (HOP), where failure isn’t a dead end but a doorway to learning.  In this engaging and eye-opening session, we’ll break down the core principles of HOP, exploring how organizations can shift from a culture of blame to one of resilience, adaptability, and continuous improvement.   Through real-world examples, interactive discussion, and practical takeaways, you’ll discover why traditional safety and performance models fall short – and how embracing a HOP mindset can drive better outcomes for individuals, teams, and entire organizations.  Whether you’re new to HOP or looking to reinforce foundational concepts, this session will challenge the way you think about mistakes, accountability, and success.

We are diligently trying to reduce incident occurrence, prevent serious injuries and fatalities, and nurture a safety culture that is vibrant and sustainable.

We chose Safety-2 for many reasons. It makes sense to us on many levels.

Safety-2 comes with various names, a history and its evolution. Emerging form traditional safety (known now as Safety-1), we pass through names and initiatives such as Human Performance Improvement (HPI), Human Performance, Safety Differently, and then on to Safety-2 which is also referred to by many as HOP: Human and Organizational Performance.

I have evolved in calling my initiatives from Safety-2 into HOP.

We have been hearing about it for a few years now.

But now that we know what the HOP / Safety-2 history is and what the principles are, many people search for ways to initiate it and sustain it – to make it work - in the real / tree world.

We talk about it a lot these days, but it seems that we keep talking about its evolution and the same five (5) basic principles again and again.

Most of us want the next level discussions. Most of us want to have the HOP discussion split into at least three (3) levels. HOP 101, 201, and 301, for example. We want practical ways to initiate and sustain our initiatives. We want to share what worked and what didn’t. What are the error traps that trip up both workers and leaders?

This presentation assumes our acceptance of the five (5) HOP principles.Lessons learned on how to initiate and sustain a HOP movement in a practical way by building on wins and effective measures that are already in place. What language and terms need to be changed? What has worked for me personally and what has not? What error traps and pitfalls exist? Wow long does it take to bear good fruit? How does one tell who are allies and who are not? Understanding the journey is hard but worth the effort.

In healthcare, designing safe clinical environments requires more than just theoretical planning—it demands real-world testing and optimization. This session explores how simulation can be strategically leveraged to identify risks, test mitigation plans, and ensure the successful implementation of new services, devices, and clinical spaces. Participants will learn how in-situ simulations and mock-ups can uncover hidden risks, enhance team collaboration, and drive proactive safety improvements before changes reach real patients. Through case studies and practical examples, attendees will gain insights into integrating simulation into the facility design process, reducing costly retrofitting, and improving patient outcomes.

Leader knowledge, language, and behaviors are typically one of the most limiting factors in an effective and sustainable HOP deployment.  In order to not just get leaders onboard (a good first step) but to get them DRIVING the improvement and operational excellence journey you have to be able to permanently shift their paradigms and give them specific leader methods, processes, and tools to get them good at it.  Rob has spent the last 30+ years working directly with leaders to help them understand their roles and providing them with the tools they need for a successful journey.  Learn from over 400 successful deployments how to lead your leaders.

Background-Timely identification and treatment of sepsis leads to improved outcomes. Despite having a sepsis screening process and sepsis management pathway in place for >10 years, we were not reaching our goals for time-to-antibiotics and time-to-bolus-completion.
Objective-Using a data-driven, team approach, we sought to improve the timely administration of fluids and antibiotics in emergency department patients with suspected sepsis.
method- Quality Nurse Champion and Quality Physician champion reviewed all charts from multiple sources which include Our practice Advisories (OPA) for sepsis occurred for in the ED, a final diagnosis and ED diagnosis for sepsis and two EMR sepsis data pathways when utilized. We identified what worked well that month and what could be done better. We give individual feedback to both physicians and nurses as well as our learners in the ED for those who did not meet the bench mark. Each month we can then review the ED data with our hospital quality group.
result-Timely feedback led to improved rates of completion of bedside sepsis huddles for OPA in the comer ED. To facilitate timely sepsis care, we added a reminder to use the Sepsis Pathway to our OPA. We also implemented antibiotic dose rounding to increase the number of patients who could receive nurse-prepared antibiotics. There were a few months in which we did not meet our goal which has currently led us to pushed toward using IM antibiotics if unable to get an IV. Data regarding compliance with our antibiotic timeliness goal is provided to individual PEM physicians relative to the anonymized group to drive improvement.
conclusion-The data and discussions gathered each week help make changes to the system and improve performance on a daily basis.

~ Why don’t people just follow procedures?
~ Is there a pattern to how experts make real-world decisions?
~ How can we bridge the gap between Work-as-Imagined (WAI) and Work-as-Done (WAD)?
~ How can we help mentor novices to evolve into experts?
~ How can we improve our own decision making right now?

In this fast-paced, interactive, one-hour presentation, you’ll get practical answers to all the questions above.

They're all based on these four core decision making layers used by experts in high-hazard industries across the globe.

1) Explicit procedures (WAI) — How to do a task -- (“Step 1, Turn power off”)

2) General Guidelines / Rules-of-Thumb — What to do, but not how to do it -- (“Switch before fix”)

3) Universal Principles — How a system works, but not how to work it — (“Electricity takes the easiest paths to ground”)

4) Tacit Skill (WAD) — Unwritten knowledge in action -- (“I can solve this problem, but can’t explain how I do it.”)

One Deputy Division Director at a US Department of Energy Research Lab wrote… ”Before this workshop, I thought, ‘Procedures will protect the employee.’ Now I’m realizing that, while still important, not all incidents can be solved by procedures.”

In an era where organizations face ever-growing complexities, investing in learning programs is no longer optional—it’s essential. But securing leadership buy-in often hinges on one critical factor: return on investment (ROI). How do you effectively measure the value of organizational learning, especially when many benefits, like workforce resilience or enhanced safety, are difficult to quantify? This session offers a comprehensive framework for calculating ROI in organizational learning, bridging the gap between qualitative insights and measurable outcomes.

We’ll begin by examining the challenges of traditional ROI calculations, which often fail to capture the multifaceted benefits of learning programs. Attendees will learn how to go beyond monetary metrics by incorporating non-monetary benefits like improved compliance, risk reduction, and cultural transformation. This approach enables organizations to create compelling business cases that resonate with leadership priorities while ensuring a balance between short-term costs and long-term strategic value.

The session highlights practical strategies for integrating ROI into structured problem-solving tools like Root Cause Analysis (RCA) and modern approaches like Human and Organizational Performance (HOP). We’ll explore how these methods contribute to tangible outcomes, such as reducing downtime, preventing costly incidents, and fostering adaptive, resilient teams.

Through real-world examples from industries like aerospace, manufacturing, construction, and utilities, we’ll illustrate how organizations have successfully tied learning programs to ROI. Attendees will learn how to:
• Identify key metrics that align with organizational goals.
• Communicate the value of learning in terms leadership understands.
• Propose solutions that balance cost-effectiveness with long-term improvement.
• Address common barriers, such as skepticism or resource constraints, by demonstrating clear benefits.

This session is designed to be interactive and engaging. Participants will work through ROI scenarios, identify meaningful metrics for their own organizations, and discuss real-life challenges in quantifying learning impact. By the end, attendees will leave with actionable tools to measure, communicate, and maximize the ROI of learning initiatives.

Whether you’re building a business case for a new program or refining an existing strategy, this session equips you to turn organizational learning into measurable, actionable value that drives sustainable improvement.

Why do so many transformation initiatives fail to achieve their intended results?
It’s not because we lack capable, dedicated people.
It’s not because we lack the skills, tools, or processes needed to execute.
The real challenge? Culture.
Change is disruptive and creates natural tensions. Culture shapes how change is received, and in turn, change reshapes culture. Without cultural awareness and the ability to manage this tension, even the best strategies struggle to gain traction.
So how can we engage leaders and peers more effectively to build a culture-aware, resilient organization?
In this interactive workshop, participants gain insights to:
- Shift from a check-the-box approach for change to a human-centered, culture-aware one.
- Identify cultural factors that enable or inhibit resilience.
- Manage tensions between cultural norms and change to reduce resistance and improve outcomes.
- Use role modeling to reinforce trust, safety, and engagement.
Join us to rethink transformation through the lens of culture and turn cultural awareness into a strategic advantage.

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Session Objectives:
1. Understand why transformation efforts often fail due to cultural blind spots.
Learn simple, research-backed models to assess and influence cultural tensions.
2. Apply cultural awareness to real-world change scenarios.
3. Explore the role of leadership behaviors in fostering resilience.
4. Develop actionable strategies to integrate cultural awareness into transformation efforts.

Session Flow & Activities:
1. Welcome & Framing (~10 min)
Connection activity to engage participants.
Share insights related to change, culture, and safety.
2. Culture & Change: Why It Matters (~25 min)
Concepts: Competing Values Framework, Schein’s Levels of Culture, SCARF model.
Activity: Identify cultural traits in participants’ organizations.
3. Role Modeling for Resilience (~25 min)
Activity: “Silent Signals” Exercise – How leadership behaviors shape culture.
Concepts: Self-Awareness, Accountability, Psychological Safety, Change Behaviors.
Activity: Self-reflection on individual change tendencies and influence.
4. Applying Culture & Self-Awareness for Resilience (~25 min)
Group Exercise: Assess cultural factors in a past or current change initiative.
Discussion: Table-talk on aligning change efforts with cultural norms.
5. Action Planning & Closing (~15 min)
Action Plan: Develop a next-step strategy to integrate insights into leadership or transformation efforts.
Sharing & Q&A: Open floor for key takeaways and reflections.

Background: The Children's Hospitals' Solutions for Patient Safety (SPS) network is comprised of 150 Children's Hospitals across the United States and Canada, unified in the mission to work together to eliminate serious harm across all children's hospitals. Given significant ongoing opportunity to improve pediatric safety outcomes, coupled with the limitations of traditional approaches to safety improvement, Network leaders and subject matter experts committed to embracing a modern, proactive approach to safety.

Aim/Objectives: SPS Network leadership and subject matter experts aimed to support all Network hospitals in adopting proactive safety concepts and tools within local hospital improvement efforts, with the goal of accelerating safety outcome improvements.

Methods: Efforts began with the development of an interdisciplinary guiding team from across the Network, who contributed to the development of a proactive safety toolkit. The proactive safety toolkit included resources on various proactive approaches to safety including the use of learning teams, Walk-Through-Talk Throughs (WT3), proactive safety huddles, proactive safety simulation and ways to evolve our language with the frontline. Initial Network-wide will-building was followed closely by a multi-phased approach to support knowledge acquisition and practical application of tools at a local hospital level. This session will highlight the strategies utilized to support Network-wide adoption of proactive safety concepts and tools and share case examples of the practical application at the Network and hospital level.

Results: The process measures and initial outcomes will be discussed at the presentation.

In the ever-evolving field of EHS, effective leadership and data-driven decision-making are crucial to creating safer, more resilient organizations. This session will focus on three actionable process changes that enable EHS leaders to elevate their programs through thoughtful use of data, strategic leadership involvement, and a focus on Human and Organizational Performance (HOP).

1. Organizing Data into Risk Categories for Consistent Application: To better manage safety risks, data should be categorized into standardized risk types. These categories can then be consistently applied across both leading indicators (such as risk assessments and inspections) and lagging indicators (like hazard reports and incident data). This ensures that both preventive and reactive measures are aligned and more effective in managing safety performance, while providing clearer insights into the health of your program.

2. Data Use Plan: A key foundation for impactful EHS leadership is understanding who should be engaging with specific data and at what level. By developing a Data Use Plan, organizations can align leadership with data that requires action, ensuring that decisions are based on real-time insights and that leaders are empowered to address safety challenges at the right moments. This step promotes greater accountability and efficiency in managing EHS data.

3. Infusing HOP into Event Reviews: A shift in mindset is required for truly transformative safety management. Instead of focusing solely on human error, event reviews should embrace a systems-based approach, integrating HOP principles. By analyzing incidents through this lens, organizations can uncover deeper, systemic causes and move toward a culture of learning, where corrective actions focus on improving processes rather than assigning blame.

Join us for a collaborative session where we’ll explore how these process changes—anchored in data-driven leadership and HOP—can elevate your EHS program and create a safer, more proactive workplace. Attendees will leave with tangible strategies to implement within their organizations, fostering a community-oriented, safety-focused culture.

Enhancing Human and Organizational Performance in High-Risk Activities
In our upcoming presentation, we will explore the operationalization of Human and Organizational Performance (HOP) principles within high-risk work activities. HOP is a risk-based operating philosophy rooted in six core principles: humans are fallible, blame stops improvement, context drives behavior, learning and improving is vital, leader response matters, and safeguards save lives.
Our presentation will detail the integration of HOP components into activities such as in-line inspections (ILI) and well workover and logging. Key improvements include:
1. Peer Review Process: Implementation of formal Peer Review Training to ensure procedural integrity, resulting in reduced errors and increased error detection.
2. What-If Analysis: A Process Hazard Analysis tool that identifies potential deviations and safeguards, streamlining the review process and enhancing risk management.
3. Error Reduction Tools: Training and practical application of 12 error reduction tools to minimize the probability of consequential errors.
4. Procedure Tabletop Review: Pre-activity reviews with stakeholders to ensure familiarity with procedures and critical steps.
5. Field Walkdown and Dry Run: On-site walkthroughs and mock executions to build team confidence and preparedness.
6. Field Coaching: Continuous on-site coaching to reinforce the use of error reduction tools and build habit strength.
7. Cultural Change: We have experienced a marked cultural change that has built strong trust, psychological safety, and shared accountability. Employees are now asking for more support, proactively identifying risks, and actively participating in operational learning.
Since implementing these improvements, we have observed significant reductions in errors and incidents, improved team dynamics, and enhanced procedural rigor. Our approach emphasizes creating system resilience and conditions for success, ultimately supporting safer and more efficient high-risk operations.

Checklist-style pre-job briefs are everywhere in high-risk industries, yet they are often seen as just another bureaucratic task—forms to complete rather than tools that enhance safety. Too often, these processes are reduced to "pencil-whipping" and thought of as a routine step to get through before real work can begin rather than a meaningful conversation about risk. When filled out by a single person, pre-job briefs limit engagement and stifle the critical thinking needed to manage dynamic and emerging risks.

This session presents a case study from the mining industry that reimagines task risk management—shifting from a compliance-driven approach to one that empowers workers. By expanding the focus to uncertainty, emerging risks, and real-time decision-making, we explore ways to restore dignity and respect to workers, enabling them to take an active role in shaping safer, more adaptive work environments.

Leader knowledge, language, and behaviors are typically one of the most limiting factors in an effective and sustainable HOP deployment.  In order to not just get leaders onboard (a good first step) but to get them DRIVING the improvement and operational excellence journey you have to be able to permanently shift their paradigms and give them specific leader methods, processes, and tools to get them good at it.  Rob has spent the last 30+ years working directly with leaders to help them understand their roles and providing them with the tools they need for a successful journey.  Learn from over 400 successful deployments how to lead your leaders.

Background: Decrease Unplanned Extubation (UE) rate and better understand work as done compared to work as imagined in Intensive Care Units (ICU).

Methods: Leadership rounding was implemented in late July after a leadership call-to-action meeting to discuss current state and foster engagement. Leadership rounding consisted of a nurse manager, respiratory manager and quality representative. A rounding tool was developed to maintain consistency and identify trends and gaps in care. Initial rounds focused on reviewing x-rays, accuracy of airway cards at bedside, integrity of the endotracheal tube tape (ETT) and gauging associate concerns about UE being addressed. Subsequent rounds incorporated a new order via Epic called “Endotracheal Tube Position” which provided one source of truth when determining proper ETT placement.

Results: Prior to implementation, January-July 2024, UE events occurred every 26 days. Since implementation of the leadership rounds in late July 2024, NCH-FL’s average between UE events has increased to 105 days. Additionally, our ICUs maintained 130 days without a UE event (Figure 1). At the end of 2024, our overall UE rate was 0.34 per 100 ventilator days allowing us to outperform our annual goal.

Conclusion: Leadership rounds that started in July 2024 proved to be effective through the end of the year and so far into 2025. Frontline engagement has increased, and associates feel more comfortable with voicing their concerns about ETT safety. The successes of UE leadership rounds are being adapted to focus on prevention of Unplanned Decannulation (UD) events, with UD leadership rounds beginning in 2025.

Background
Resilient teams are the foundation of high-performing, patient-centered care in the Emergency Department (ED). In the high-acuity environment of the Comer Pediatric ED, increasing patient volume and complexity have highlighted the need for stronger teamwork, communication, and psychological safety. To address these challenges, the ED implemented cold debriefs—structured post-event discussions designed to support team learning, emotional resilience, and process improvement. These debriefs provide frontline staff with a safe space to reflect, learn from both successes and failures, and drive meaningful system changes.
Methods
A structured cold debriefing process was introduced to strengthen human and organizational resilience:
• Psychological Safety & Team Support: Creating a non-punitive space for staff to process high-stress events, share experiences, and voice concerns.
• Multidisciplinary Collaboration: Bringing together nurses, providers, and ED leaders to discuss challenges, decisions, and system-level improvements.
• Structured Learning Approach: Using event categorization (trauma, resuscitation/ROSC/death, critical sepsis, and other high-risk cases) to identify common themes and improvement opportunities.
• Data-Driven Reflection & Action: Tracking insights in RedCap to analyze trends, address recurring challenges, and guide system-wide safety enhancements.
• Targeted Training & Practice Changes: Translating debrief outcomes into education initiatives, workflow refinements, and resilience-building strategies.



Results
80 Cold Debriefs Conducted (2023–2024):
• 40 trauma cases
• 30 resuscitation/ROSC/death cases
• 6 critical sepsis cases
• 5 other critical cases
Key Outcomes & Team Resilience Enhancements:
• Increased Psychological Safety: Staff reported greater confidence in managing critical events and an improved sense of team support.
• Empowered Frontline Voices: Cold debriefs reinforced a culture where staff feel valued, heard, and engaged in decision-making.
• Targeted Clinical Improvements:
o Standardized Pediatric Difficult Airway Process to improve emergency response.
o Strengthened hypoglycemia prevention protocols for high-risk pediatric patients.
o Expanded NICU/OB/Trauma simulations to enhance multidisciplinary preparedness.
o Developed standardized bedside handoff tools to improve patient transitions.
o Optimized Epic workflows for streamlined documentation and triage efficiency.
• Sustained Team Learning & Adaptability: By fostering ongoing reflection and knowledge-sharing, cold debriefs have become a core component of continuous professional growth and adaptive teamwork.
• Scalability Across Units: Cold debriefing is now being integrated into all pediatric units, reinforcing a hospital-wide commitment to resilience and patient safety.
Conclusion
Cold debriefs serve as a powerful mechanism for building resilient, high-functioning teams in the emergency department. By promoting psychological safety, structured learning, and frontline engagement, they have strengthened collaboration, decision-making, and patient safety culture at Comer Children’s Hospital.