Kicking over rocks
Happy Wednesday, and welcome to this week’s root cause analysis tips.
Today I would like to address an interesting question; what do I do with information about problems I encounter during my investigation that turn out to not have anything to do with the incident I am investigating?
When we are in the beginning stages of an investigation, we are gathering as much information as possible and compiling the information on our SnapCharT®. We then define causal factors, perform root cause analysis, and apply corrective actions. In the process of gathering information, we may “kick over some rocks” and you know what happens next……things start to pop out.
For example, you might be doing an investigation and during the document review, you find that training records are out of compliance. As you continue through the investigation, you might determine that training was not an issue for this incident. But should you ignore the non-compliance? You can’t.
That example is a compliance problem, so it is a no brainer, it has to be addressed. But what about process improvements? You might find some real problems with one of your processes but they may have nothing to do with the incident you are investigating. In my previous life this was one of my strengths, but it was also a curse at times, because it would create a lot of extra work! I would quickly solve the actual problems that caused the incident but end up with a two-year project over something that popped out from under the rocks. As professionals, you know what is important and you know what your resources are, so prioritize and solve some problems; I think you will find it is worth it.
So as you uncover things like this, make a list of them and address them after you have finished your investigation. Be careful not to get side-tracked, make sure you take care of the matters at hand first. After you have issued your investigation report you can work on the other things.
One best practice that one of our clients shared with me is that rather than making a list like I suggested, when they start pruning their SnapCharT®, they move the other issues they want to address to a separate page of the chart so they have it all in one place. I like that.
If you have been to one of our courses, you know that when we talk about proactive use of TapRooT®, we teach the concept of “significant issues,” the proactive equivalent of casual factors (in a reactive application). You can do root cause analysis of these significant issues you discover during an investigation just as you would those you find during an audit. If you want to look at an entire process, just map the process out and spot potential failure points, and perform root cause analysis on them.
Problem solving is a lot more fun than investigating incidents. And you never know, the problem you solve today might be the investigation you don’t have to do tommorrow!