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Quick Glance Case Study: Major Incident Capture

“The Lean review has helped to significantly improve the identification, follow-up and closure of incidents, along with ensuring the team have an accurate understanding of the associated financial impacts and risks to the business”

 After completing a ChangeWise Lean Practitioner training course, one candidate submitted the following work-place project to gain their qualification to LCS Level 1c.

The Business Challenge

A new process for reporting and recording Major Incidents for a specific front-line area of our business was introduced in early 2016. The reporting tool covered incidents that were deemed business impacting at various levels. The process was also designed to include the reason for incidents and any required follow-up actions. However, this process ceased to function within a few months of being instigated. In addition, there was no analysis of the effectiveness of the process in preventing recurring incidents or reducing overall volumes of incidents over time. As a result, it was not reaching its aims to improve service by helping to identify and address underlying problems and prevent incidents from reoccurring.

A Lean review was required to ensure the process was value-add and capable of supporting the business in helping to drive both service and cost improvements.

Photo by Brett Jordan on Unsplash

Key people involved from client site

Specialists including The Incident Reporting Team and members of the Senior Leadership Team were involved in the Lean review.

Lean Methodology Employed

DMAIC (Define, Measure, Analyse, Improve, Control)

Various Lean methodologies were used including Current State Mapping, Value & Failure Demand Analysis, Fishbone/Cause & Effect Diagrams and Root-Cause Analysis.

Lean Activities and Findings

In order to identify the key issues in the current state, we analysed the existing incident data and completed current state mapping:

  • Accurate records were only kept for 6-9 months from the start of the new process
  • While many incidents were logged using the correct process, few resulted in clearly defined Actions
  • Where actions were raised, very few were completed – with many never receiving a deadline for completion of follow up activities
  • The categorisation of incidents was vague, but recurring incidents could be identified from the current log

Following our analysis, we completed interviews with department managers.

Focusing on areas where low-ratios of completed actions occurred, we used Cause and Effect techniques to drill down into the root causes of issues:

  • The process stopped functioning when the team members who created and actively managed the process, moved on to other roles within the organisation. This was due to the absence of a handover process for new colleagues
  • Duty Managers and Incident Managers who raised incidents and completed reporting did not take ownership of the process in the absence of a defined individual owner
  • The current state reporting form:
    • Was completed retrospectively
    • Had a vague timeline section offering no guidance for completion and follow-up
    • Relied on the user to follow-up and complete actions
    • Focused on events and symptoms (not resolutions).
  • Completion of incident reporting, along with subsequent review meetings for each incident, were not perceived as value-add
  • All relevant management teams were required for a regular review of the report and this was often time consuming and unrealistic
  • The perceived lack of value was a result of poorly defined benefit measures that did not produce tangible outputs
  • No review or chasing of actions resulted in no visibility of the issues once the reporting form was completed

Future State & Benefits

The Future State was centred around eliminating key issues identified during the current state analysis, having an effective governance structure, a follow-up process, owner accountability, management visibility and an effective measure of business value and impact:

  • The incident process owner is now responsible for measurement of the action, creation and completion of incidents
  • Visual tracking tools will be used to measure progress, this will include:
    • Actions completed within 5 working days of incident identification
    • Number of actions completed within 30, 90 and 180 days
    • Number of actions assigned per manager/team member
    • Improved benefit measures with a process that ensured the relevant teams were involved in costing exercises

These changes were communicated to all management teams who fed back to their teams. Processes are in place to regularly refine the process and ensure incident volumes are reduced.

Photo by Brett Jordan on Unsplash

In Summary

The Lean review has helped our organisation to significantly improve the identification, follow-up and closure of incidents, along with understanding the associated financial impact and risks to the business. This was achieved through building an effective governance structure, a follow-up process, owner accountability, management visibility and an effective measure of business value and impact.

Interested in looking at how Lean can help improve your visibility and follow-up process for incident reporting? Contact us at and let’s talk about how we can help.

ChangeWise believes employee engagement is the foundation for successful Change. Training and coaching your people to use simple continuous improvement techniques will enable your organisation to continuously adapt and stay ahead in a constantly changing and challenging environment.


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