INVESTIGATION PROCESS

Sponsor to decide on the investigation level (may depend on consequences/ potential consequences).

Identify a team (min 2 but keep as small as possible). Experts need not be full members but can participate as needed.

Define the problem and set up a Terms of Reference for the Investigation Team.

Investigation Team generates a Timeline. This will be modified as the investigation unfolds.

Team gathers data and conducts interviews.

A Cause and Effect diagram is drawn up. Note that items 4, 5 & 6 are constantly reviewed during the investigation phase.

Test conclusions with relevant stakeholders.

Develop solutions that address the underlying causes identified.

Generate a report and capture actions.

Share learnings with all stakeholders