Investingating is like constructing a building. Both require a solid foundation.  Each phase of the investigation continues to build on the previous work.  Compare the participants’ perceptions of what happened to the documents that you reviewed.  Look for inconsistencies and begin documenting.

1.  Identify the suspected process flaws.  List each suspected process flaw or failure in the order they may have occurred. 

2.  Determine why each of these flaws occur.  “Why, why, why?” Ask this until the root cause of each flaw has been identified. 

3.  List policies and procedures that may not have been followed.  Learn more about reviewing documents here. 

4.  Identify the opportunities for improvement (OFIs).  List the possible OFIs separately in the order they appear in the process.

 What information do you document when conducting an investigation?