Stop the Insanity: Discipline, Retraining, and Rewriting Policies and Procedures to Prevent Incidents
When I conduct TapRooT® Training and ask the attendees why they think we see so many corrective actions focused on discipline, retraining, and rewriting policies and procedures, I usually get two answers:
- They are easy to implement.
- They don’t cost a lot of money.
These answers are true. They are cheap and easy to implement, but I think there is another reason we see things like rewriting policies and procedures so often. I don’t think that answer is as obvious, but I’ve seen it in a lot of investigations and you probably have as well.
Why Do We Choose Discipline, Retraining, and Rewriting Policies and Procedures to Prevent Incidents?
These corrective actions were chosen because there wasn’t enough evidence found during the investigation to conduct a proper root cause analysis. The investigation only went deep enough to identify a mistake(s) that led to a bad outcome.
If an investigation only reveals someone made a mistake that caused a bad outcome, it’s likely the conversation turns to figuring out how that mistake can be prevented in the future. You’re stuck when that conversation begins because you don’t have enough evidence to continue with a proper RCA. You only know what you know.
There aren’t many options that don’t focus on fixing people to be sure they don’t make that mistake again. Discipline, retraining, and rewriting policies and procedures focus on fixing people. Your options are limited to people-oriented corrective actions because you don’t have anything else identified to fix. You have no other evidence to truly analyze the mistake for the underlying root causes or system weaknesses that allowed the mistake to happen in the first place or not catch it before it caused an incident.
Before you say, “Our company doesn’t do that,” consider the corrective actions you see most. Are those corrective actions people-oriented or system-oriented? Do they contain discipline, retraining people you’ve already trained, or creating more red tape and rules?
If so, please don’t think I’m judging or blaming. It simply tells me the investigations aren’t digging up enough evidence to help you understand how the conditions that day affected the work. Usually, in an investigation, you’ll find someone who has done the task correctly many times but made a mistake that particular day. Maybe they took a shortcut or veered away from policy or procedure to get the job done.
If that happens, is it more likely something was different that day and the person tried to adapt, or is it more likely they magically forgot how to do their job? If we believe in magic, we put them through training again or add more rules to drive their actions.
How to Stop the Insanity
A proper investigation will uncover all the conditions and circumstances around the mistakes made. That evidence will help identify the root causes allowing the mistakes to happen or not caught in time to prevent an incident. Identifying root causes and system weaknesses gets organizations away from people-focused corrective actions and onto stronger system-strengthening corrective actions.
Why do organizations sometimes fail to get the evidence needed for a proper RCA? Most likely the investigators are doing the best they can with their own experience and knowledge and miss asking critical human performance or equipment reliability questions that will help uncover the needed evidence. They don’t have anything to help them dig deeper and go beyond their knowledge or biases. That creates anxiety for the investigators because they have to come up with the right questions.
The best thing you can do at that point is to give your team a standardized process and tools for investigating, discovering problems, analyzing those problems to find their root causes, and creating effective corrective actions that will support our people instead of blaming them for ensuring the mistakes found during our investigations stop happening. That reduces risk and continuously improves the organization with every investigation.
Base your Incident Investigations on the Facts
If you want to learn more about collecting better information in your root cause analysis investigations, plan to join us for the PreSummit Course, Effective Interviewing and Evidence Collection, April 29 – 30, 2024 in Horseshoe Bay Texas (near Austin). Then stay for the 2024 Global TapRooT® Summit, May 1 – 3, 2024.
The TapRooT® System will help your team do all that and more. If you would like to see a demonstration of the TapRooT® System to understand what is covered in our training, shoot me a message or email me at email@example.com.