Posts

Corrective Action Program Best Practice 5 – Anonymous Condition Reports

StrategyDriven Corrective Action Program Article | Condition ReportRegardless of the degree to which an organization embraces the values of a learning organization, the reporting of some specific adverse conditions or trends may be perceived to be unwelcomed by one or more potential condition report authors. Whether or not a chilling environment exists, individuals having this perception will likely not report these specific issues and may report few, if any, others because of a fear of reprisal. Consequently, such circumstances rob an organization of the opportunity to improve unless there is a mechanism in place that provides these individuals with a degree of professional safety.[wcm_restrict plans=”48852, 25542, 25653″]

Anonymous condition reports allow individuals to report adverse conditions or trends needing to be address without associating the report with the author. This mechanism creates a programmatic gap – a lack of traceability – providing the condition report author an added degree of separation from the issue so to help alleviate his/her reprisal concerns. In some instances, regulatory requirements governing Employee Concerns Programs require the ability to report issues anonymously.

Enabling Anonymous Condition Reporting

Actions taken to enable anonymous condition reporting depend largely on whether and what type of corrective action program supporting application is employed.

Corrective Action Program Supporting Applications

Special care should be taken when providing for anonymous condition reports within program supporting applications. Corrective action program specific applications often provide for anonymous condition report development; allowing condition reports to be authored without the user first logging into the system or by preventing the storage of user data by default. (Automatic capture of condition report author data is completely disabled and must be triggered by the user.) Applications configured to support the corrective action program (these applications are not specifically designed as corrective action program supporting software) frequently do not support anonymous condition reporting. By design, these applications require all users to login and automatically capture the user identification data upon saving/submitting the condition report. To provide anonymous reporting in this case, system enhancements must be enacted or paper-based anonymous condition reporting employed.

Paper-based Corrective Action Programs

Paper-based corrective action programs easily accommodate anonymous reporting by not requiring the condition report author to identify himself/herself. Because a lack of author identification is contrary to the minimum condition report data requirements (see StrategyDriven Corrective Action Program article, Minimum Condition Report Data Requirements), paper-based programs should provide a unique Anonymous Condition Report Form or anonymous report indicator field (such as a checkbox) on standard condition report forms to convey the author’s desire to remain anonymous. When this form is used or field annotated, investigators should not seek to identify the condition report author.

Providing Initiator Feedback

Providing condition report initiator feedback regarding the status of corrective actions and issue resolution is a key component of an effective corrective action program and critical to an organization’s continuous improvement culture. (See StrategyDriven Corrective Action Program best practice article, Initiator Feedback) Anonymous condition reports complicate the providing of this feedback because the author is unknown. While direct feedback in not possible when an anonymous condition reports are submitted, appropriate feedback can be publicly published such that anonymous initiator have easy access to it:

  • Publish the basic problem statement and status information in one or several centralized, public locations accessible by everyone within the organization.
  • Convey the basic problem statement and status information during all-hands meetings, department meetings, tailgate sessions, prejob briefings, etcetera.
  • Send the basic problem statement and status information to all employees via hardcopy and electronic mail.

Good judgment must be used when conveying the basic problem statement and status information. There should be no inference regarding the identity of the issue originator or originating group. Information shared should be unbiased and factual in nature; taking care not to defame the initiator or diminish the importance of the problem. Furthermore, information of a personal nature, whether related to the initiator or issue, should be kept out of the public domain.[/wcm_restrict][wcm_nonmember plans=”48852, 25542, 25653″]


Hi there! Gain access to this article with a StrategyDriven Insights Library – Total Access subscription or buy access to the article itself.

Subscribe to the StrategyDriven Insights Library

Sign-up now for your StrategyDriven Insights Library – Total Access subscription for as low as $15 / month (paid annually).

Not sure? Click here to learn more.

Buy the Article

Don’t need a subscription? Buy access to Corrective Action Program Best Practice 5 – Anonymous Condition Reports for just $2!

[/wcm_nonmember]


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 4 – Initiator Feedback

StrategyDriven Corrective Action Program Article | Condition Report | FeedbackActive employee engagement is critical to corrective action program effectiveness. Not only are engaged employees more dedicated to reporting the occurrence of adverse conditions and trends, they are more also more committed to identifying and implementing corrective actions. Subsequently, leaders should proactively involve employees throughout the corrective action process.[wcm_restrict plans=”48844, 25542, 25653″]

Ongoing condition report initiator feedback is one method of maintaining employee engagement with the corrective action program. Such feedback acknowledges the employee’s contribution during each step of the corrective action process including:

  • Condition Report Initiation: Acknowledgement of the issue by the initiator’s supervisor. When necessary, the supervisor requests additional elaborating/clarifying information from the initiator to be included with the condition report prior to its screening.
  • Condition Report Screening – Cancellation: Notification that the preliminary investigation revealed the problem to be a non-issue or below the issue reporting threshold. This feedback is often provided by the corrective action program supporting application.
  • Condition Report Screening – Closure: Notification that the preliminary investigation revealed the problem to be a duplicate of a previously submitted condition report or that no further actions were required and the report has been tagged and closed to trending. This feedback is often provided by the corrective action program supporting application.
  • Condition Report Screening – Resolution Assignment: Notification that the preliminary investigation revealed the need for additional corrective actions. Information identifying the work order(s) associated with these corrective actions is frequently included. This feedback is often provided by the corrective action program supporting application.
  • Corrective Action Completion: Notification that a corrective action related to the condition report has been completed. This feedback is often provided by the corrective action program supporting application.
  • Condition Report Closure – Condition Resolution: Notification that the condition report has been closed because all of the associated corrective action work orders have been completed. This feedback is often provided by the corrective action program supporting application.

Final Thoughts…

It is common for condition report feedback to be provided by the corrective action program supporting application. While efficient, this type of feedback is typically not the most effective or engaging. For more significant issues, managers should consider providing personal issue and resolution status feedback to the condition report initiator. Furthermore, these interfacing opportunities should be used to further engage the employee in developing and implementing the corrective actions.

On an ongoing basis, managers should encourage condition report initiators to follow-up with status and resolution questions or concerns and to engage with those working to resolve their reported issues. While such engagement should occur at any time, moments when feedback is provided should serve as a prompting for additional initiator interaction.[/wcm_restrict][wcm_nonmember plans=”48844, 25542, 25653″]


Hi there! Gain access to this article with a StrategyDriven Insights Library – Total Access subscription or buy access to the article itself.

Subscribe to the StrategyDriven Insights Library

Sign-up now for your StrategyDriven Insights Library – Total Access subscription for as low as $15 / month (paid annually).

Not sure? Click here to learn more.

Buy the Article

Don’t need a subscription? Buy access to Corrective Action Program Best Practice 4 – Initiator Feedback for just $2!

[/wcm_nonmember]


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 3 – Employ Multiple Condition Report Types

StrategyDriven Corrective Action Program Article | Condition Report TypesEffective condition report forms balance the need for data with the ease of problem reporting. Enough data must be collected to enable problem investigation, prioritization, and resolution. Concurrently, the administrative burden of completing a condition report must be minimized to facilitate issue reporting.

Information needs vary based on the type of issue being reported and the associated regulatory requirements. In order to ensure the appropriate information is gathered while also minimizing the administrative burden, situation specific condition reports should be used.[wcm_restrict plans=”48836, 25542, 25653″]

Basic Condition Report Type

Most organizations employ a basic condition report type that requires only the minimum data common to all condition reports. (See StrategyDriven Corrective Action Program article, Minimum Condition Report Data Requirements) This data includes:

  • Condition Report Author
  • Location, System, Equipment, Component, Procedure
  • Description of the Condition
  • Date/Time of Condition Occurrence, Discovery, or Condition Report Creation

These basic forms may also include a few optional fields to facilitate condition report review, processing, search, and analysis including:

Functional Report Types

While most performance deficiencies can be effectively captured using the basic condition report type, a few specialty reports are best supported by a unique condition report type. Examples of these reports and their associated issues include:

  • Basic Condition Report Type – Adverse equipment (maintenance work requests), analysis (engineering work request), document (procedure, manual, drawing, etcetera change requests), behavior (human performance errors), event (adverse operational incident), and trend (aggregate performance trend analysis) reports
  • Software/Technology Report Type – Information technology trouble report or change request
  • Customer Trouble Report Type – Customer service work request or trouble report

Regulatory Report Types

Some business units, divisions, or locations are subject to specific regulatory regimes associated with their industry, operations or location. To the extent that these regulatory requirements demand additional information, reviews, and/or analysis, regulation-specific condition report types should be developed.

Note that these condition report types are typically associated with only one or a few business units, divisions, or locations and their availability should be limited to those entities so to minimize the administrative burden of the other organization groups. For those organizations using corrective action program supporting software, this can be achieved by limiting access to condition report types based on login location. For paper-based systems, only applicable condition report type forms should be made available at each organization location.

Final Thought…

A large number of condition report types also represents a high administrative burden. In our experience, use of more than a few condition report types confuses employees who are then less likely to report deficiencies, events, and performance improvement opportunities. For this reason, care must be taken when introducing specialty condition report types.[/wcm_restrict][wcm_nonmember plans=”48836, 25542, 25653″]


Hi there! Gain access to this article with a StrategyDriven Insights Library – Total Access subscription or buy access to the article itself.

Subscribe to the StrategyDriven Insights Library

Sign-up now for your StrategyDriven Insights Library – Total Access subscription for as low as $15 / month (paid annually).

Not sure? Click here to learn more.

Buy the Article

Don’t need a subscription? Buy access to Corrective Action Program Best Practice 3 – Employ Multiple Condition Report Types for just $2!

[/wcm_nonmember]


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 2 – Causal Analyses

StrategyDriven Corrective Action Program | Causal AnalysisOrganizations experience incidents of every sort, some with almost imperceptible impacts and others inflicting catastrophic consequences. While impractical to mitigate all adverse events, it is imperative to prevent recurrence of the most significant incidents, important to limit the frequency and impact of moderate happenings, and necessary to only correct low impact deficiencies. Such a grade approach to corrective action implementation optimally applies the organization’s resources based on the value of event recurrence mitigation.[wcm_restrict plans=”48830, 25542, 25653″]

Condition reports documenting adverse events are prioritized across a continuum relative to the incident’s impact. (See StrategyDriven Corrective Action Program article, Condition Report Prioritization) These priorities provide the basis for a graded approach to the performance of causal analysis identifying the corrective actions necessary to prevent or mitigate event recurrence.

Types of Causal Analyses

Three common causal analyses provide a spectrum of investigation methods and depths. Each analysis type is described below:

Root Cause Analysis

Root cause analysis (RCA) is a 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. These analyses identify the extent of the adverse condition and corrective actions to prevent event recurrence (CAPRs).

A root cause analysis is typically performed by a multidiscipline team and may take up to a month to complete.

Apparent Cause Evaluation

Apparent cause evaluation (ACE) is a 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.

An apparent cause evaluation is typically performed by a knowledgeable individual or small team and may take up to a few weeks to complete.

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. In worst case scenarios, troubleshooting is required to identify the necessary corrective actions.

A direct cause evaluation is typically performed by the responsible department’s Corrective Action Program Coordinator or a knowledgeable staff member and is often completed at the time of condition report processing.

Relationship between Causal Analyses and Condition Report Significance Level

Each causal analysis type requires a different amount of resources related to the depth of investigation performed. Consequently, a condition report’s significance should dictate the type of analysis performed so that the organization realizes an appropriate return on this investment.

Significance Level 1 Condition Reports

Significance Level 1 condition reports represent an issue or event resulting in a significant impact. A root cause analysis is almost always performed for Significance Level 1 issues.

Significance Level 2 Condition Reports

Significance Level 2 condition reports represent an issue or event resulting in a moderate impact. A root cause analysis is performed for more serious Significance Level 2 issues or collection of related Significance Level 2 issues. An apparent cause evaluation is performed for most Significance Level 2 issues.

Significance Level 3 Condition Reports

Significance Level 3 condition reports represent an issue or event resulting in a minor impact. An apparent cause evaluation is performed for more serious Significance Level 3 issues or collection of related Significance Level 3 issues. A direct cause evaluation is performed for most Significance Level 3 issues.

Significance Level 4 and 5 Condition Reports

Significance Level 4 condition reports represent a low-level problem, typically closed to immediate actions taken or other readily identifiable follow-up corrective actions that requires trending. Significance level 5 condition reports represent an enhancement, opportunity for improvement, or commendable behavior that does not require trending. A direct cause evaluation is performed for Significance Level 4 issues not resolved by the performance of immediate actions. No causal analysis is performed for Significance Level 5 items.

Note that collections or trends of Significance Level 4 issues are commonly captured within a rollup Significance Level 3 condition report and the appropriate causal analysis performed.[/wcm_restrict][wcm_nonmember plans=”48830, 25542, 25653″]


Hi there! Gain access to this article with a StrategyDriven Insights Library – Total Access subscription or buy access to the article itself.

Subscribe to the StrategyDriven Insights Library

Sign-up now for your StrategyDriven Insights Library – Total Access subscription for as low as $15 / month (paid annually).

Not sure? Click here to learn more.

Buy the Article

Don’t need a subscription? Buy access to Corrective Action Program Best Practice 2 – Causal Analyses for just $2!

[/wcm_nonmember]


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.