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Corrective Action Program Best Practice 15 – Condition Report Review Meetings

StrategyDriven Corrective Action Program ArticleEffective corrective action programs promptly and consistently screen newly reported issues for their impact on the organization’s vision, mission, values, and goals. These screenings prioritize and aggregate corrective actions from all business areas with the organization’s strategic initiatives and day-to-day operations; ensuring optimal resource use. Consequently, condition report review meetings are frequently used to review and prioritize newly submitted condition reports.[wcm_restrict plans=”48922, 25542, 25653″]

Condition Report Review Meeting Characteristics

Impactful events and nonconsequential issues often involve numerous functional areas. Furthermore, realignment of organizational resources to address reported conditions is easily forgotten when assigning condition report priorities and follow-on actions. Establishing daily condition report review meetings with the following characteristics helps ensure these challenges are effectively and efficiently mitigated:

  • Daily Meeting – provides for the prompt screening of reported issues. Note that daily implies business weekdays and is not inclusive of weekend days
  • Multidiscipline Meeting Participation – ensures the application of the necessary knowledge, technical expertise, and operating experience to the review, prioritization, and resolution assignment of newly submitted condition reports. Additionally, invites unique alternative perspectives be applied to the resolution of issues (See StrategyDriven Business Performance Assessment Program best practice article, Multidiscipline Teams)
  • Pre-meeting Condition Report List Dissemination – allows meeting participants to investigate the circumstances and resolution status of the condition reports for which their workgroup has primary responsibility. This advanced preparation facilitates meeting efficiency and effectiveness
  • Condition Report Reviews Led by the Associated Functional Group – provides for the assignment of condition reports to those workgroups having the knowledge, technical expertise, and operating experience necessary to effectively investigate and resolve an issue
  • Devil’s Advocate – injects an alternative viewpoint into the prioritization and dispositioning of reviewed condition reports thereby preventing group-think and enhancing the robustness of the decision-making process (See StrategyDriven Strategic Analysis best practice article, advocatus diabolic, The Devil’s Advocate and StrategyDriven Podcast, The Devil’s Advocate)
  • Condition Report Prioritization and Follow-up Action Assignment – consistent prioritization of condition reports ensures follow-on corrective actions are performed in a timeframe consistent with the issues’ impact on the organization’s vision, mission, values, and goals. Specifically assigning follow-up actions to a workgroup provides accountability for their completion
  • Real-time Review Updates – enables real-time updating of condition reports based on review meeting input thereby ensuring all input is captured and speeding the assignment process

Final Thought…

Organizations experiencing a low volume of condition reporting may find daily condition report review meetings to be administratively burdensome. In these cases, less than daily meetings may be held but should not be convened less than once per week. If a less than daily review meeting is adopted, management should periodically evaluate the screening delay to ensure condition reports are processed in a timely manner consistent with their prioritization and organizational needs.[/wcm_restrict][wcm_nonmember plans=”48922, 25542, 25653″]


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About the Author

Nathan Ives, StrategyDriven Principal is a StrategyDriven Principal and Host of the StrategyDriven Podcast. For over twenty years, he has served as trusted advisor to executives and managers at dozens of Fortune 500 and smaller companies in the areas of management effectiveness, organizational development, and process improvement. To read Nathan’s complete biography, click here.

Corrective Action Program Best Practice 14 – Establish Time Limits for Causal Analyses

StrategyDriven Corrective Action Program ArticleDetermining the amount of time required for performing causal analyses is a balancing act. The depth of issue investigation should align with its significance. Consequently, more significant events require additional time to perform the more detailed causal analysis assigned to them. Countering this is the urgency to understand and correct the underlying causes of more significant events as well as to put into place those barriers that will prevent their recurrence. Thus, it is important to establish time limits for causal analysis performance that effectively balance these two opposing needs.[wcm_restrict plans=”48918, 25542, 25653″]

Causal Analysis Time Limits

There does not exist a mathematical formula for universally defining causal analysis timeframes such that depth and timeliness of investigation are appropriately balanced. Instead, appropriate time limits evolve over time based on management experience dealing with an array of events of varying significance.

Having worked with numerous organizations, StrategyDriven observed common causal analysis timeframes established among the most effective corrective action programs. Below are three causal analysis types and the common timeframes balancing investigation depth with issue resolution urgency:

  • Root Cause Analysis – formal investigation method used to determine the fundamental underlying cause(s) of an event or adverse trend. Root cause analysis methods logically derive the primary and contributing causes of an event; determining what happened, how it happened, and why it happened.

    Common Time Limit: 1 month

  • Apparent Cause Evaluation – limited investigation method used to identify readily apparent causes and the extent of condition of an event or problem. An apparent cause evaluation identifies corrective actions to minimize the recurrence frequency and impact of the associated event.

    Common Time Limit: 2 weeks

  • Direct Cause Evaluation – Direct cause evaluation (DCE) is a corrective action identification method used to address simple, ‘broke-fix’ issues. A direct cause evaluation identifies the obvious corrective actions to resolve the identified failure.

    Common Time Limit: 1 – 2 days

Monitoring the Timeliness of Causal Analyses

Ensuring the timeliness of causal analysis performance requires management oversight. In addition to day-to-day status updates and engagement with the corrective action program, several performance measures are often used to ensure the timeliness of causal analysis performance and to identify those needing additional management attention:

  • Average Time to Perform RCAs/ACEs/DCEs – Average time to perform the RCAs/ACEs/DCEs completed within the past month calculated monthly.
  • Number of Open RCAs/ACEs/DCEs Greater Than 30 Days Old – Number of RCAs/ACEs/DCEs open on the last day of the month that are greater than 30 days old calculated monthly.
  • Percent of Open RCAs/ACEs/DCEs Less Than 30 Days Old – Percent of RCAs/ACEs/DCEs less than 30 days old as of the last day of the month calculated monthly.

Note that each of the above performance indicators represents three separate metrics, one for each causal analysis type. Additionally, each measure is commonly assigned to a business unit or location and cascaded to all of the subordinate divisions and departments.[/wcm_restrict][wcm_nonmember plans=”48918, 25542, 25653″]


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About the Author

Nathan Ives, StrategyDriven Principal is a StrategyDriven Principal and Host of the StrategyDriven Podcast. For over twenty years, he has served as trusted advisor to executives and managers at dozens of Fortune 500 and smaller companies in the areas of management effectiveness, organizational development, and process improvement. To read Nathan’s complete biography, click here.

Corrective Action Program Best Practice 13 – Formally Defined Reporting Criteria

StrategyDriven Corrective Action Program ArticleEffective corrective action programs support achievement of the organization’s vision, mission, values, and goals. Consequently, adverse conditions and trends as well as performance improvement opportunities entered into the program must be aligned with these stated outcomes lest the program’s resource be diverted to non-value adding issues and its effectiveness be diminished. Formally defining corrective action program reporting criteria helps ensure the desired alignment is achieved and program effectiveness maximized.[wcm_restrict plans=”48912, 25542, 25653″]

Reporting Criteria Characteristics

Condition reporting criteria ensure those issues processed by the corrective action program address only those issues whose resolution is value adding to the organization. In order to achieve this objective, reporting criteria should possess the following characteristics:

  • Aligned with the organization’s vision, mission, values, and goals
  • Supportive of and integrated with leadership’s continuous performance improvement strategy
  • Define the minimum threshold at and above which an issues resolution is materially significant to the organization

Common Condition Reporting Categories

Condition reports document adverse conditions and trends as well as performance improvement opportunities. Each of these represents a work request, the need for action by the organization. Common condition reporting categories group reports by issue and work request type including:

  • Equipment and software failures, deficiencies, and nonconformances including deviations from operating specifications
  • Design specifications, drawing, manual, and operating instruction (procedures, work instructions, and tagging orders) issues
  • Human performance issues including departures from management standards and expectations
  • Administrative issues and work requests
  • Performance improvement recommendations

Note that the impact of reported issues is characterized by its assigned significance level.

Show It Visually

What is clear to one person may not be so readily understood by another. Therefore, leaders should employ addition mechanisms to bolster corrective action program reporting criteria interpretation consistency among individuals with varying backgrounds, knowledge, skills, and experiences.

An effective mechanism for clarifying reporting criteria is through the use of examples. Such examples clarify leaders’ expectations regarding the identification and reporting of issues within the corrective action program. (See StrategyDriven Standards and Expectations best practice article, Provide Examples)[/wcm_restrict][wcm_nonmember plans=”48912, 25542, 25653″]


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About the Author

Nathan Ives, StrategyDriven Principal is a StrategyDriven Principal and Host of the StrategyDriven Podcast. For over twenty years, he has served as trusted advisor to executives and managers at dozens of Fortune 500 and smaller companies in the areas of management effectiveness, organizational development, and process improvement. To read Nathan’s complete biography, click here.

Corrective Action Program Best Practice 11 – Check for Duplicate Condition Reports

StrategyDriven Corrective Action Program ArticleLeaders valuing continuous performance improvement encourage employee engagement in the corrective action program as a primary input to organizational learning and growth. Combined with a low reporting threshold, these organizations process numerous condition reports every day, some of which will be duplicative when an adverse condition is observed and reported by more than one person.

Each condition report filed requires the expenditure of resources to investigate, prioritize, and resolve. Duplicative condition reports result in the expenditure of resources with no organizational value added. To ensure this does not occur, checks for duplicate condition reports should be performed as early in the process as possible and, when found, duplicate condition reports should be eliminated.[wcm_restrict plans=”48896, 25542, 25653″]

Checking for Duplication Condition Reports

Process Timing

The first check for duplicate condition reports occurs at the time of report development. Prior to documenting an adverse condition, trend, or performance improvement opportunity, the report initiator should seek to determine whether the issue has already been identified. If documented, the new condition report should not be created. Note that if condition reports are closed to the work orders containing their corrective actions then open work orders must also be evaluated for issue duplication. (See StrategyDriven Corrective Action Program best practice articles, Document Reasons for Cancellation or Closure and Initiator Feedback)

The second and third checks for duplicate condition reports occur at the time of review. The initiator’s supervisor should check for duplicate condition reports as a part of his/her validation of the issue and accuracy of its documentation. The daily condition report review meeting participants also check for duplication.

The final duplicate check is performed by the individual tasked with performing the follow-up investigation and creating the work order(s) addressing the identified condition.

Check Method

Condition report duplicate checks focus on the location, system, equipment, component, or procedure associated with open condition reports or work orders. Condition reports and work orders referencing the same location, system, equipment, component, or procedure associated with the identified issue should be reviewed for duplication. While electronic records searches can aid this process, it is incumbent on the individual to review the Description of Condition associated with the open condition reports and work orders to ascertain whether or not the issue has already been documented. (See StrategyDriven Corrective Action Program article, Minimum Condition Report Data Requirements)

Note that the duplicate check performed by daily condition report review meeting participants is typically experience based and not based on a formal review of open documents.[/wcm_restrict][wcm_nonmember plans=”48896, 25542, 25653″]


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About the Author

Nathan Ives, StrategyDriven Principal is a StrategyDriven Principal and Host of the StrategyDriven Podcast. For over twenty years, he has served as trusted advisor to executives and managers at dozens of Fortune 500 and smaller companies in the areas of management effectiveness, organizational development, and process improvement. To read Nathan’s complete biography, click here.

Corrective Action Program Best Practice 10 – Everyone Can Submit a Condition Report

StrategyDriven Corrective Action Program ArticleAdverse conditions and opportunities for improvement present themselves at unpredictable times and in unexpected places; possibly observed by only a few or one. Furthermore, an organization benefits most when its workforce contributes the full measure of its intellect and creativity. Thus, it is critically important that everyone, including contractors, be able to submit a condition report.[wcm_restrict plans=”48889, 25542, 25653″]

Leaders focused on engaging workers involve them in the performance improvement process including the submission of condition reports. They recognize that by doing so, their organizations benefit by:

  • Obtaining timely information on operational events and equipment deficiencies by those specially educated and trained on the design, monitoring, operation, and maintenance of the facility
  • Receiving feedback on the accuracy of procedures, work instructions, and tagging orders
  • Gaining first-hand insights into floor-level operational performance from the perspective of the ‘doer’
  • Providing insight on how management decisions and communications affect the workforce and how they are being interpreted relative to the organization’s stated goals and values

While there exists many benefits to allowing everyone to submit condition reports, some guidelines should be in place to ensure the program is used for its intended purpose:

  • Adverse conditions and trends should be reported in a timely manner as soon as possible following discovery
  • Documented information should be fact-based
  • Condition reports should not include confidential personnel information
  • Condition reports written by any one individual (managers included) should not ‘target’ a specific person or group
  • Management reprisals for factual condition reports are not tolerated up to and including dismissal of offending managers
  • Condition reports written by non-management personnel should be addressed in the same manner and with the same priority as those written by the management team
  • Non-management personnel should be recognized and rewarded, as appropriate, for their contributions to the corrective action program

Enabling All Employees to Submit a Condition Report

Allowing all employees to submit condition reports alone is not enough to realize all of the desired benefits. Employees must also be trained on the methods and mechanisms for filing condition reports and the system for doing so needs to be easy to use.

Corrective Action Program Training

In order for employees to effectively participate in the identification and documentation of condition reports, they must have a thorough understanding of the problem reporting process. This training should include the standards and thresholds for problem reporting, actions to be taken at the time of issue discovery, condition report types and minimum data requirements, and how to document and submit a condition report. As all employees, including contractors, can submit condition reports, this training is often delivered as a part of employee onboarding or site access training.

Condition Report Filing Mechanisms

Employee participation in the condition reporting process is further facilitated by an easy to use, highly accessible reporting system. Such systems commonly possess the following characteristics:

  • Condition reporting applications and forms are intuitive to complete (See StrategyDriven Corrective Action Program article, Minimum Condition Report Data Requirements, and best practice article, Employ Multiple Condition Report Types)
  • All employees have easy access to the condition reporting system or forms
  • Paper-based forms are available in the absence of electronic systems (See StrategyDriven Corrective Action Program best practice article, Availability of Paper Forms)
  • Kiosk-like electronic reporting systems or paper-based forms are provided for contractor use thereby removing their need to directly access company information technology systems

Final Thoughts…

Employees contributing condition reports often feel a greater sense of ownership for the organization’s success because of their direct involvement in affecting performance improvement. Thus, allowing everyone to submit condition reports can help heighten overall employee engagement which in-turn increases productivity and other contributions. (See StrategyDriven articles, The StrategyDriven Organization and StrategyDriven Employee Engagement Center of Excellence)

Confident, capable managers do not fear condition reporting by subordinates but instead welcome this input as an opportunity for issue resolution, risk mitigation, and organizational improvement. Managers overly resistant to involving subordinates in the identification and submission of issues may themselves warrant additional performance scrutiny.[/wcm_restrict][wcm_nonmember plans=”48889, 25542, 25653″]


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About the Author

Nathan Ives, StrategyDriven Principal is a StrategyDriven Principal and Host of the StrategyDriven Podcast. For over twenty years, he has served as trusted advisor to executives and managers at dozens of Fortune 500 and smaller companies in the areas of management effectiveness, organizational development, and process improvement. To read Nathan’s complete biography, click here.