According to a famous quote often attributed to management pioneer W. Edwards Deming: “Every system is perfectly designed to get the results it gets.” This is especially true for your incident management system. For the sake of this discussion, the term “system” means not only the process itself but also the execution thereof.
You may have the best incident management process in the world, but it will fall short if you don’t execute it well.
One way to evaluate your process execution is to perform a bulk review of historical execution metrics. This requires that your process is intentionally designed to allow for specific metrics to be captured and evaluated. Sphera’s annual benchmarking study is such an activity. Our experts evaluate more than 80 process metrics and compare them to other study participants as well as across the participants’ organizations. This not only highlights how they are performing among their peers but also among themselves as well.
A more proactive step that can be built into the incident management system to review effectiveness of the process execution is a Quality Audit. This audit is used to measure the adherence to the process used during the management of the incident. These audits should be performed on a statistically significant number of incidents regardless of actual severity or potential risk rating. These audits would be performed by a subject-matter expert in your incident management process who ideally is not involved in the resolution of the incident being audited.
Typical Quality Audit contents include:
- 1) Completeness of information provided
- 2) Number of times the record was recycled in the process (rejected, then resubmitted)
- 3) Appropriateness and completeness of the investigation
- 4) Number of root causes identified
- 5) Relevance of root causes
- 6) Number of action items tied to root causes
- 7) Appropriateness of action items to address root causes
- 8) Efficacy review of action items performed
- 9) If action items were not considered effective, were there other action items that were effective?
- 10) Number administrative overrides used
Data from the audits should be reviewed frequently (e.g., quarterly), and corrective action plans should be put in place. These corrective actions should address deficiencies in not only process execution but also the process itself. Overall safety performance should be monitored for improvement as process execution improves. Once your process execution performance has reached an acceptable level, if your safety performance is not at an acceptable level, then it is likely time for changes to be made to your incident management system.
Sphera has worked with its clients to design and implement incident management execution quality audits. Please contact us for more information.