Today’s blog will wrap up this series on successfully resolving issues the first time around, thereby avoiding reliving bad days like Bill Murray’s character Phil Connors in the comedy Groundhog Day. We’ve covered the first four principles below…so on to #5!
- 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
Organizations tend to have short attention spans. Once we’ve stopped the bleeding from one crisis we’ll move on to the next, often forgetting to keep the tourniquet tightened. And now our old crisis reemerges as a new, sometimes larger one. I saw this happen at a manufacturing company for which I was performing a cause analysis on a costly product quality issue. Procedure changes the company implemented in response to a prior occurrence had been removed during a subsequent revision by an individual who was unaware of their origin and intent. While the quality issue was caught internally the first time around, defective products had escaped to a customer this time and created a much bigger problem for everyone!
So how can we avoid situations like this one? Well, the first thing we need to do is ensure that whatever barriers we erect to reduce the risk of incident recurrence are incorporated into technical procedures, design drawings, or other formal documents. While doing so, visually flag (using dashed lines or other means) the provision or design feature that provides the barrier in a manner that clearly denotes its connection to the resolution of an incident. Include verbiage that identifies the relevant incident and requires obtaining concurrence of the appropriate management position or committee before modifying or deleting the provision.
To make this happen, establish requirements within the procedure governing your organization’s Corrective Action Program to visually flag all document provisions intended to provide barriers against the recurrence of your more significant incidents. In addition, include a protocol by which individuals can solicit concurrence of the appropriate authority to modify or delete those provisions, as well as a means for documenting that concurrence was obtained. Ensure the process includes consideration of the risk of incident recurrence when approving any requests to modify or delete these provisions.
Organizations should maintain a list of all active risk reduction measures implemented in response to significant incidents and periodically verify that those measures are still in place. Better to proactively identify that a barrier has been compromised, rather than find out reactively like the manufacturing company mentioned above!
As the owner of Compass Performance Improvement LLC, 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.