Let’s continue our series on the following principles for resolving issues the first time around, thereby avoiding the unpleasant experience of weatherman Phil Connors in the best comedy ever made (in 1993, anyway), Groundhog Day:
- Find the REAL source of the problem
- Don’t assume the problem is isolated
- Identify solid long-term fixes, rather than band-aids
- Implement fixes promptly and correctly
- Ensure fixes remain in place until no longer needed
Today’s blog elaborates on Principle #4: Implement fixes promptly and correctly.
One of the more unpleasant situations an organization can experience is having an incident recur. It’s particularly disheartening when the incident recurs AFTER we’ve identified Corrective Actions for the previous occurrence but BEFORE we’ve implemented them. It’s like we’ve left our front door cracked open for a moment and something undesirable wandered in!
It’s a given that Corrective Actions robust enough to permanently reduce the risk of incident recurrence can rarely be implemented overnight. For example, an equipment modification can take months to design, approve, install, and test. Even a seemingly minor procedure revision can take days to roll out if numerous individuals on multiple shifts will need to be trained on the changes. Since we can’t just wave a magic wand and instantly make things happen, we’ll need to pick Corrective Action due dates that make sense based upon three key factors: 1) the level of effort required to develop and implement the action; 2) the risk posed to the organization if the incident recurs; and, 3) the existence of equivalent or greater risks that are competing for our organization’s limited resources. Careful consideration of these three factors necessitates the active involvement of management and impacted stakeholders when developing the Corrective Action plan, rather than simply relying on the team who completed the incident’s cause analysis to come up with solutions.
After we’ve identified optimal due dates for our Corrective Actions, we’ll need to determine how best to manage the risk while awaiting their implementation. That’s where Interim Actions come in, which are temporary risk reduction measures that will be stopped as soon as the Corrective Actions are in place. Let’s say we had a bulk chemical enter a storm drain while drawing a sample for analysis. While we’re awaiting completion of a modification to reroute the sample valve and piping away from the storm drain, we should enact Interim Actions such as sharing lessons learned with applicable personnel, placing a removable cover over the storm drain whenever drawing samples, and perhaps also having a supervisor perform a pre-task briefing prior to every sampling activity.
Once we’ve established Corrective Action due dates that make sense AND have Interim Actions in place, management will need to keep their fingers on the pulse to ensure that the due dates are achieved. In cases where an action owner desires to extend a due date, concurrence of the same management role(s) that approved the original due date should be obtained. The extension process should include verification that the proposed delay in action completion won’t result in an unacceptable degree of residual risk.
Now that we’ve covered promptly implementing Corrective Actions, let’s talk briefly about implementing them correctly. The best barrier for assuring this occurs is the verbiage of the Corrective Action itself. I’ve seen many cases over the years where a poorly worded Corrective Action resulted in some pretty crazy things being implemented that weren’t even in the same hemisphere as the action’s original intent. The action verbiage must provide very specific direction to the action owner…so specific in fact that we are confident that a different person could get it right if they later inherit ownership of that action. I know this sounds a bit like predicting the future, but there’s a practical way to go about it. Specifically, provide the proposed verbiage of the Corrective Actions separately to several individuals and ask them to interpret what each action is directing them to do. If their answers aren’t consistent and accurate, reword the offending action(s) and try again!
One last thing, and we’ll be ready for the last blog in this series. It’s always a good idea to have someone who understands the origin and intent of the Corrective Actions validate they were implemented as intended by the action owner, especially for those actions we’re counting on to resolve our organization’s more risk-significant incidents. Validation should take place as each Corrective Action is completed, rather than waiting until the last pup in the litter is born.
I’ve partnered for several years with Fisher Improvement Technologies (FIT) to develop Cause Analysis approaches that integrate solid methodologies with the practical application of HOP principles. We’d love to help if your organization wants to avoid reliving the same problems. Please visit www.improvewithfit.com to learn more about the products and services FIT offers, including how to enroll in our upcoming Cause Analysis Workshops. You can also contact me directly via LinkedIn or by sending an email to firstname.lastname@example.org.