Process Improvement and Accountability

In my previous life as a Commander at a sheriff’s department, we had to implement many processes and procedures. We were often asked to find a solution for a particular problem, or implement a solution that someone had developed. One of the most important steps within the problem solving process and implementation process is the evaluation step. Regardless of which model you use, there are typically four or five steps; identify or define the problem and the resources you have available, determine the plan(s) to address the problem, implement a chosen course of action, observe the results of your implementation, and transition to a new or adjusted plan based on the need to improve your outcome.

In my situation at the sheriff’s office, I discovered that we were skipping the evaluation step more often than we were conducting the evaluation. In my inquiry as to why we didn’t complete the evaluation step, this was the response I received; because evaluations take too much time and effort. The assumption was, if we didn’t get any complaints, we were doing it correctly. So the only review process was how many complaints we got? I hope you see the problem with this methodology. Especially in the realm of emergency preparedness, we should be evaluating most everything we do, and have formalized procedures to ensure valid recommendations are listened to, followed up on, and completed. I use the “valid” recommendations here, because we all know someone who is going to recommend an improvement that has no direct impact on what it is that you are evaluating. When I say that we should be evaluating almost everything we do, I mean everything and we should be asking the following questions:

1. What went wrong? Or as some like to say, what are our opportunities for improvement?
   
   
2. What went well? Here we are trying to measure our successes and advances. But be careful here, because you should know why you were successful. Meaning, you should also ask yourself; were you successful because your process was the correct process, or did you just get lucky? If there was anything that caused you to say, we got lucky on that one, then you need to remove the luck factor out of that process. (I’ll give you an example of this in the next paragraph)
   
   
3. If there were opportunities for improvement, what were they and who is responsible for correcting or improving them.
   
   
4. What category does the improvement fall under?
   1. Was it a training issue?
   2. Was it an individual issue?
   3. Was it a policy issue?
   4. Was it a facilities issue?
      
      
5. Documentation: who is responsible for documenting the suggested improvements (good and bad). There may be a need to explain why certain recommendations were not acted upon.
   
   
6. Who is responsible for ensuring all determined action steps are taken and completed?
   
   
7. Finally, once an action has been recommended, who is responsible for the implementation of a new direction to ensure everyone who needs to know, does.

Why it is so important to evaluate our successes and understand why they were successful. Here is a Kelly Story for you: In the middle stages of my law enforcement career, I was assigned to the Special Operations Division. As part of that assignment, we were often tasked with high-risk prisoner transports. On this one occasion, one of my partners and I were assigned to escort a high-risk prisoner, who was an escape risk, from our jail to the state prison. When we arrived to pick up the prisoner, we were told the jail staff would transport the prisoner and that we were no longer needed. After some protesting (my mild way of putting it), my partner and I were canceled by my command. The jail staff successfully transported the prisoner to prison. The jail viewed this a success and told us as much. The issue for us was that we had specific training for this type of operation and they did not. They knew of the risks and disregarded those risks. The only reason this operation was successful and was not met with tragedy, was they got lucky the threats made by the inmate to ambush the transporting officers were not acted upon.

Some final thoughts: almost no one expects everyone to perform perfectly every time under emergency circumstances. However, almost everyone expects us to learn from past events, drills, exercises and others. Many different people call process improvement by different names: The military and most law enforcement agencies call them After-Action Reviews; the fire service is likely to call them Hot-washes; many other organizations call them debriefs. No matter what term you use to refer to them, the fundamental objective of these tools is to enhance your procedures, resulting in increased safety, greater efficiency, and reduced exposure to potential hazards and legal liabilities for both you and your organization.