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In brief:
Management of change is not the same as change management. A successful management of change process requires significant front-end planning that makes the implementation go much more smoothly. The multi-disciplinary team assembled to run the change program need to be highly responsive, responsible and diligent.
Have you ever had one of those nights? The only spare parts in stock dont fit because that little midnight upgrade you did last year failed to provide for new spares. Maybe your line has been down for hours as your electrician tries to troubleshoot using a hopelessly out-ofdate drawing. Or did you suffer a near miss because of that uncapped line that was added as an undocumented afterthought and not included in the isolation plan? Have your operators ever damaged a new piece of equipment that they were not trained on? Have you ever had one of those great workarounds that was just the answer in the heat of the night, just to fall flat and create more problems than it solved? And Im sure every one of you knows of some location that has suffered a terrible accident because of an unauthorized substitution or minor change. If any of these have been true for you, you need to learn about what effective management of change is and how it can protect your people, your plant and your bottom line. Although implementation details vary widely, truly effective management of change (MOC) programs start from the same foundation and contain the same basic elements, either singly or in combination. The following 11 steps give you the basic functional guidelines.
big are the risks? Again, being clear and concise are the keys. Increasing temperature by 2 C will increase yield by 0.07% and result in 27,000 lb per year of increased throughput at a variable margin of $0.20/lb resulting in $5,400/year gross revenue. This change in control strategy will decrease nuisance trips by four per year, reducing overtime by 400 hours, valued at $20,000 per year. These fit both criteria quite well.
Each member must represent a different discipline (operations, maintenance or reliability, engineering, HSE or other disciplines as needed). You want a balanced team that can look at the proposed change from many different viewpoints to capture a complete picture of it. Keep in mind that the most serious mistakes come not as a result of people not being competent in their fields, but where the person or team is ignorant of some bit of information outside of their collective area of expertise. That is, they didnt know what they didnt know. The best organizations develop a matrix of the required team makeup based on the nature of the proposed change. The team members must be knowledgeable enough about the proposed change and its implications to be able to make an objective evaluation of possible consequences. They need to know how things really are, not how they are thought to be. Therefore, an experienced operator often is a far superior team member than a manager whos new to the area. Remember that this stage is about knowledge, not approval authority. A team that has only technical people or only shop-floor people rarely is a well-balanced team. Team members must have credibility with their peers and with leadership. They must be willing to speak up about their concerns. Conversely, a team member who dominates the situation and doesnt allow others to express their concerns is equally ill-advised. Evaluating risk is very much a brainstorming exercise and the same rules apply. Identifying the potential risks is the first point where a conditional go or a no go decision can be made. There are simple tools and quite complex tools for performing risk-reward analysis. Choose the one thats right for your business and the circumstances. But, having chosen the tool, never fail to be consistent in its use.
programs and QA. Keep in mind, though, if youre not prepared to complete the mitigation, then you shouldnt be making the change.
A tip for approvers: if you have a dynamic organization with lots of changes and other things going on that require approvals, often the need cant wait for someone to come back from vacation. If you dont have a proxy system for approvals in place, by all means develop one. Your proxy is the person with your specified delegated approval authority in your absence. Everyone in the approval chain should have a designated proxy for timecritical business processes. Effective communication is rare. If a position is designated on an MOC as one to be informed, it means that its important to your business that the person receives this information. Effective electronic communication can be facilitated in our data-overload environment if the information is flagged properly, it arrives in an expected format, the information is succinct and receipt is verified. For most of your to be informed persons, a simple message with a subject line containing MOC xxxx tells everyone who receives it what the change is and that its important to them. The message always should contain at least the position of the person to whom it is directed (people do change jobs and emails do get misdirected), the MOC title, the change effective date and the specific information to be conveyed. It should end with a receipt confirmation request. You might attach a copy of the MOC document as a courtesy, but the key information must be in the email, not buried in the MOC. Flagging the message by clicking Request a Read Receipt is not an effective substitute for ensuring the information has been received. Your procedure should state and your organization must understand that an actual reply is expected. The person who is the single point of accountability (SPA) sending the communication is on the hook until its receipt is acknowledged. And the recipient is expected to act appropriately upon the information received. Most organizations approach to communication with the people on the floor is sketchy at best. This is where it breaks down most often. The way to communicate with operators isnt with a Post-It note on the control console or an all-hands email. For important changes, communication needs to be made by the method that works best for your organization and culture. Communication hasnt happened until every specified person on that to be informed list has signed off to affirm that theyve received and understood the communication. Then, and only then, the SPA for that task might confirm it as completed to the SPA for the change. About now, Ill bet youre thinking Im making a big hoopla over communication. Youre right. Persons would not be on the list of to be informed if it wasnt necessary to manage the change, right? We arent broadcasting here. Were conveying vital information to a select and necessary few. Youre far more likely to have adverse consequences if you fail to inform than by missing an entire approval.
The post-implementation tasks, such as permanent procedure updates and updating the operator training manual, are just as critical, even if they dont have to be completed before start in most industries. Without exception, these tasks must be completed before the MOC can be closed out. The process owner and change SPA are on the hook until every action is completed. Every omission here is an opportunity for a failure or an incident to occur for the life of the change that was made. Omissions at this stage are the equivalent of planting land mines in your facility for the next generation to step on. Later doesnt mean its unimportant or can be ignored. It simply means later. Although the SPA for executing the change might be responsible for performing many of the tasks, in an effective MOC process its the owner of the system being changed who is accountable for ensuring that theyve been done. Accountable in this context means the buck stops here. That individuals organization is, after all, the one that will have to live with the change, for good or for bad. It might not be the pilot who fuels the airliner, but you can be sure he confirms the fuel level before taking off and for the same reasons.
8. Confirm effectiveness
At first look, this strikes most people as silly. Of course it did what we planned it to do. This is an often overlooked but important step in MOC. Its simply verifying that the change worked as intended. Not all changes give the intended results. And many, despite the best planning, result in unintended and often undesirable consequences. The organization expended resources and possibly incurred some increased risk to gain some benefit. They expect to get it. The method of determining effectiveness is best developed and documented before approving the MOC. Then, if the change isnt going as planned, the options are simple: restore the system to the original configuration, which includes all of the necessary follow-up actions and communications the change necessitated. Or execute a new MOC to address another option. What you must not do is keep on tinkering and changing the change until its outside of its original approved scope, hoping to get it right without a repeat of the previous steps. This defeats the purpose of the original MOC. The MOC isnt an open-ended license to experiment, although most experiments need to have an MOC performed.
This is the part that everyone hates. Every last mitigation item, from document update to setting up spare parts and training the users, that was identified as a condition for approving the MOC must be completed and completed on time. There are several real reasons for doing this. First of all, its how you ensure that youve not left behind any of those potential land mines to step on. Its where you prevent introducing or worsening future emergencies. Have you ever tried to troubleshoot an electrical system problem with out-of-date prints? Or done the same with software that has undocumented changes? How about when that new, improved bearing that was supposed to last five years Figure 1. The most critical MOC question to ask reaches five years in service? is: Should I make this change at all? Avoid When it fails because you didnt unintended consequences. set up the required lubrication PM and the correct spare isnt in stock because you didnt change the BOM or add the stock number, and the old bearing wont fit the modified shaft, what do you do? To those without good MOC processes in place, it becomes another emergency and another opportunity for an undocumented midnight modification. Secondly, this is how you ensure the change sticks and some or all of the new conditions dont morph back into the conditions before the change. Sustainability is a critical element of a successful change. In this step you build the foundation for sustainability. How important is sustainability? The best example of this is a minor control system set-point range change. It absolutely fixed a problem that was costing more than $500,000 in losses each year. As a loss-elimination exercise it was fantastic: teamwork, structured problemsolving, an enormous ROI measured in orders of magnitude. And one month after the problem was cured, the problem returned. The relatively minor mitigation item update SOP and re-train control room operators almost got done. And no one continued to confirm effectiveness. Entropy is at work out there. When left to themselves, systems always degrade to the lowest state. Finally, there are sound legal and ethical reasons. Lets say you were in the habit of making changes without an MOC process and, as a non-hazardous industry, your business didnt require a formal MOC. If theres an accident as a result of a not-too-well-thought-out change, you might be found to be guilty of ordinary negligence. If, on the other hand, you make a well-thought-out change, clearly identify a risk and the mitigation tasks to control it, but dont complete the task, then your degree of negligence ratchets up to a new level. You just might be found guilty of culpable or criminal negligence. And regardless of the legal outcome, if someone is injured, your conscience leaves you nowhere to go if you failed to do what you knew needed to be done. Until all the stated risk control action items have been completed, we dont proceed. A best practice is to publish a list of outstanding action items that are within one month of being due for completion. Another is to report action items immediately to site management the
minute that theyre overdue or at risk of becoming so. Legal reasons aside, the potential risk to your business generated by overdue action items can be considerable. The best practice is a zero-tolerance policy for overdue action items. If your organization doesnt have the resources to execute all the tasks necessary to control reasonable risk associated with changes, then youre making more changes than you can control. And most likely, an appreciable number of the reactive situations tying up your valuable human resources are the results of past uncontrolled changes.
Management of change is a proactive business process focused on preventing losses. It might be applied to almost any industry that has assets and systems that it wants to protect regardless of the perceived safety of the process. MOC is an ideal complementary process for a business with an active loss elimination or continuous improvement process. In most businesses an appropriate MOC implementation can reduce reactivity and just plain makes financial sense. When implementing MOC, focus on preventing the generation of future risk first and only then follow up with correcting past mistakes and omissions if a business case exists. The most serious problems facing a business implementing MOC are changing the organizations behavior initially and then sustaining that change over time. Principles of change management must be applied to the human element of the management of change implementation. Sam McNair, P.E., CMRP is senior consultant at Life Cycle Engineering, headquartered in Charleston, South Carolina. Contact him at smcnair@lce.com.