Root out recurring problems in your business.

We don’t like making mistakes twice. Here’s the tool we use to understand our mistakes and design them out of our operations.

Investigate

“It is a familiar and significant saying that a problem well put is half-solved.” –John Dewey

Is urgent action necessary to “stop the bleeding” before undertaking the IDEA process?
What happened?
Who was involved?
Who should be interviewed?
Who are relevant problem solvers?
What were the short- and long-term costs (human, financial, etc.) of the failure?
Was this the first time it happened? What do we know about prior failures?
Will it happen again, and how often?
What is our best understanding of the fundamental cause of the problem?
Was it a system problem or a personnel problem?

Ø If system problem, where did it break down?

Ø If personnel problem, what happened?

§ Was it just a one-off human error, or repeat issue?

§ Where was the deficit—training, focus, intelligence, supervision?

Determine Solution

"Give me six hours to chop down a tree, and I will spend the first four sharpening the axe." –American proverb

What if we did nothing?
Brainstorm all the possibilities.
Will the preferred solution work well enough to justify the costs of implementing and sustaining it?
Are there any likely unintended consequences to consider?
Is now the right time to implement, or should we wait for a better moment (e.g. January 1, or with a new release)?
Are we capable of implementing the change?

Execute

“Your future is being created through the actions you take today.” –Clyde Lee Dennis

What is the proposed change?
Is there consensus on this course of action? If not, did we seriously consider the alternative points of view?
What will success look like and how likely are we to succeed?
Who will implement it?
By when?
Who will communicate the change to all affected people, preferably in advance of implementation date?

After-action Follow up

“People do what you inspect, not what you expect.” –Louis Gerstner

Set a tickler to follow up at a few intervals (e.g. 30, 60, 90 days) to make sure adjustments aren’t needed.
Did we learn anything that should be shared with relevant people?