Category Archives: Organizational Events
The investigation and recommendations is closed. Opportunities for Improvement are in progress. It is time to make final edits and put the investigation documents in the final format.
- Create an acknowledgement document. Attach evidence that each participant reviewed the investigation report. Include a place to add additional comments or corrections.
- Organize the investigation documents. Put all of the documents and work product in a binder with a table of contents and tabbed dividers.
- Meet with each individual that was interviewed. Thank them for participating. Ask them to review the document and sign off. Inform them that this will be used as education throughout the organization. Encourage them to share the story with others.
- Communicate the investigation results. Prepare a PowerPointÔ presentation summarizing the investigation. Be sensitive to those involved. Do not use the names of those involved. Identify all of the places it will be presented and get on the agenda.
- Report the event to the appropriate organizational and regulatory bodies. Identify the regulatory bodies that require reporting and who will make the report. Be prepared for any potential fallout.
This is the homestretch. Each phase of the investigation has been analyzed. It is time to pull of the work together to create a summary of how processes will be improved and future events prevented.
How do you do this?
- List the changes that have been made. List each of the changes that were made immediately and who implemented the changes.
- List the changes that will be made. Use a tasklist to document each of the changes that need to be made. Be specific. State who will make the change and by when it will be made.
- Monitor process improvement. Identify indicators to measure improvements. List the accountable leader who will follow these indicators and how the improvement will be documented.
How do you prevent similar events from reoccurring?
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?
- 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!
- Ask participants. Hindsight is 20/20. When interviewing the participants, ask them what opportunities for improvement they see.
- 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?