People are not perfect.  Processes are not perfect.  Mix the two together and sooner or later there will be a mistake or breakdown.  One way to ensure future breakdowns and mistakes is to identify what can be done differently. 

 How is this done?

1. List process flaws.  Compare the policies and processes that were not followed to the processes that should have been followed. The result: a gap analysis!
2. Ask participants.  Hindsight is 20/20. When interviewing the participants, ask them what opportunities for improvement they see. 
3. Study evidence-based practices.  Learn more about evidence-based practices here.

 How do you uncover OFIs?

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?

Document review is part of investigating events.  Invest time in this.  It is the foundation for the final phase of the investigation.  The goal is to collect all of the documents that apply to the event.

1.  Identify policies and procedures.  List all that apply, those that the participants thought applied and those that were not followed. 

2.  Research evidence-based and best practices.  Hit the library and conduct your own research.  Include new information.

3.  Incident reports.  Learn more about incident reports by clicking here.

4.  Other documents.  Gather documents referenced during their perception interview and review them.  These documents may or may not be significant to the investigation.

 What documents do you review when conducting an investigation?

Interviewing each participant is part of the response to an organizational event.  Each person involved has a perception of what happened, how the event transpired and why it occurred.   You are now an investigative journalist.  Get your Clark Kent on and get busy!

 1.  Document the interview.  Inform the interviewee that you will document their perception of what occurred and that they will have the opportunity to review and sign-off on it.

2.  Ask open-ended questions.

3.  Use short, simple and complete sentences.

4.  Write the way you talk.

5.  Use terms your reader can picture.

6.  Write to explain, not to impress.

 How do you conduct an interview?

A solid foundation must be laid before interviews begin.  As the investigator, your job is to find the answers to the who, what, when, where, why and how. 

 How is this done?

 1.  Document the issue.  Describe the event or incident in two to three sentences.  State the facts as reported.  When reporting an event, especially when time is relevant, state the time, the date and the place that the event occurred. Use words liked said, stated or noted instead of words like felt, believed or any other verb that is emotive and leaves room for speculation. 

2.  Identify who was involved.  List each person who was involved in or had significant knowledge of the event.

 3.  Establish the timeline of events.  Stick to the facts!  List the key milestones of the event making sure to document the date, time, and location with a description of what occurred. 

 How do you begin an investigation?

Before getting down to business, conduct a little prep work with those involved.  Meet with each person individually at a mutually agreeable time.  Make sure they understand the reason for the meeting and how long you expect the meeting to take. 

 1.  Create a professional environment.  Conduct the meeting in a private, quiet area.  Hallway noise, telephones and people wandering in and out of the room are distracting.  Privacy is a must.  The person you are interviewing may become emotional.  Make tissues and water available. 

 2.  Clarify your role.  Explain that your goal is to gather the facts of the event, not to judge or place blame.

 3.  Share the process.  Staff want to know what to expect.  Explain what will happen.  Include the expected timeframe and who to call if they have questions.

 4.  Reassure those involved. Remind them that we have a culture that is focused on process improvement.  We believe that employees come to work with intentions to do their best work.  If individual accountability is an issue, the proper processes will be followed.

 5.  Clarify questions.

 How do you prepare to investigate a serious event?

When a serious or significant organizational event occurs emotions run high.  Most leaders are not able to contain their feelings.  Leaders throw “I think” and “I believe” around as the gospel and the truth is distorted.  Leaders should remain calm and begin an investigation.  Read more about managing feelings by clicking here. 

How is this done?

 1.   Remind yourself of your role.  As the leader your job is to conduct the investigation.  Get your emotions and opinions in check.  You are the Chief Calming Officer.  Remaining unbiased and neutral is the name of the game.

 2.   Develop an investigation process.  The process must be thorough.  List the questions that need answered.  Begin with the issue and end with everyone involved reviewing, agreeing and signing off on the investigation report.

3.   Develop a documentation template.  The template keeps you focused on facts.  It lends consistency and results in a final report of the event.

 How do you respond to significant events?

Holding leaders and staff accountable is crucial to improving processes and determining if the process is bad or if the tasks are just not being performed.  Regular meetings allow the leaders to review key measures, refine action plans, and discuss what is and isn’t working.  

How is this accomplished?

1.  Document the results.    Select the indicators that matter, identify short and long-term goals and use a balanced scorecard to track perfomance monthly.  Click here to read Organizational Results:  Set Demanding Goals.

2.  Communicate the problem, the plan and the progress.  Keep your key stakeholders informed.  Tell them what the problem is, how you plan to fix it, and when they can expect to begin seeing improved results.

3.  Design, document and deploy new processes.  Click here to read Organizational Results: Demand Process Improvement and click here to read Organizational Results:  Adopt Evidence-Based Processes.

4.  Improve the problem solving process.  Take a few days to enjoy success, then reflect on what went well and what could have gone better and implement the improvements with the next problem that needs solved.

 How do you check the effectiveness of process change?

Detailed planning is necessary to ensure the process changes are successfully implemented.  Even the best leaders will do what they want and what they enjoy rather than the tasks that must be completed.  Creating detailed task lists is one technique to ensure the process improvements are implemented and that leaders stay-focused the work that needs to be performed.

1.  Decide on the next steps.  Take time as a team to prepare a thoughtful and organized task list. Start each task with a verb.  Identify which leader is responsible and when the task will be completed.

2.  Write an action plan.  Click here to read Organizational Results:  Insist on Innovative Action Plans.

3.  Agree on a timeline. Task lists keep leaders focused on the work that needs to get done in order to produce results and minimizes their ability to do what they want to do.

4.  Execute the plan. 

5.  Select indicators to measure progress.  Identify the key measures that indicate performance.  Click here to read Organizational Result:  Measure Things That Matter.

 How do you implement process improvements?

 Leaders rarely, if ever, have to make a decision in a vacuum.  In fact, most of the best decisions are made by teams.  When leaders with passion, focus and determination get together sparks fly and improved results follow.  How do leaders do this?

1. Identify failure to follow process.  Document the steps of the process as it should flow, verify it and then require that everyone follow it.  Click here to read Organizational Results:  Adopt Evidence-Based Processes.

2. Identify the available options.  Begin your list with doing nothing.  End it with the ridiculous.  Then consider every other reasonable option in between. 

3. Consider the pros and cons for each option.  This process quickly eliminates any unreasonable option yet demonstrates that everything was considered.

4. Select the best option.

 How do you begin to solve problems?