MES Guide 9

After episodes occur, the many users of data produced by investigators need to determine what response actions they need to take to achieve their objectives. This requires analysts to identify the episodic actions, interactions, linkages and outcomes on which to base their responses. Their responses may take the form of new regulatory action, action recommendations, claims settlements, prosecution, new training material, design changes, policy changes, etc.

A practical way to do this is to create "User Action Needs Statements," to use as the basis for developing users' response actions. A systematic process to identify data BBs and interactions needed for preparing user action need statements is available by using the STEP-MES matrix arrays.

Preparation of User Action Needs Statements is an analytical function rather than an investigation function. This Guide provides an additional reason why STEP-MES matrix arrays should be created. It enables user analysts to

define data

select specific data needed as inputs for user actions development,

prepare User Action Needs Statements for use in developing user responses to episode

Development of User Action Needs Statements (UANS) in response to episodes requires an investigator to thoroughly describe what happened, and comunicate that description promptly, efficiently and effectively to users. The STEP-MES Matrix array provides this description in a format that lends itself well to systematically finding data BBs and links needed to support the UANS development process.[1] The same BBs and I/O pairs or sets used to test the quality of the Matrix array are used to find candidate data to support UANS developmoent.

While they have some commonalty, these UANS development procedures differ in major ways from the investigation procedures used to develop the description of the occurrence. Investigations to determine what happened are retrospective; the investigator must figure out what happened during a historic episode from "historical" data, after the fact.

User actions, on the other hand, are designed to influence future actions and performance, and therefore are predictive in nature. Other differences include data sources, data acquisition methods, need assessment methods, effectiveness prediction and assessment methods, quality control practices and future monitoring and verification tasks. Writing approaches, styles and contents also differ markedly. All are described in this Guide.

OBJECTIVE

The objective of this Guide is to present procedures that can be utilized by investigation report analysts to discover, define and document needs for user action in response to an episode. The analysis outputs are statements of need for user action based on the data in the STEP-MES arrays.

APPLICABILITY

This UANS development process can be used during or after any episode where investigators produce a STEP-MES-based matrix array. The procedure for identifying BBs, BB pair or BB sets to develop UANSs from those arrays can be applied by users of any kind of episode's investigation, whether unintentional, willful or natural,, and by individuals with specific interests within a user entity. The vocabulary used may vary, but the process of finding BB data indicating need for action is common for all. .

DATA REQUIRED

This user action need identification process requires STEP-MES Matrix arrays with linked BBs in order to function efficiently. The process requires analysts'' understanding of their entity's duties, objectives, and procedures, which drive what they will look for in the arrays. They also need to know how to document a UNAS within their user entity.

DATA SOURCES

Analyst's data sources include the STEP-MES-based matrix arrays and at least the following additional sources:

descriptions of the systems where new action will be introduced
internal data sources
experts to consult during analyses
external data sources

USER ACTION NEED STATEMENTS

The main tasks required to develop a UNAS after the episode is understood and documented are to:

find, define and assess the candidate needs suggested by the description of the occurrence.
determine which needs should be addressed by some action.
get concurrence for each action need statement from other appropriate staf or managers.
prepare a decision package for action by the proper manager.

The extent of the documentation should be determined as part of the investigation program plan. The risks and scope of the action need, cost of a response, and sometimes other unique circumstances will dictate the extent and nature of the needs documentation statement.

UANS, by design, tend to arouse less emotion than stating needs for action after episodes as problems, causes, inadequacies, violations, lessons learned, errors, failures or pejorative terms in common usage in investigation communities. <br>

Statement content

As a general rule, the contents of a UANS, which must be persuasive to ensure action, would include the following:

1. Description of what happened.
The interactions(Links) between [BB (1), BB2B) and BB (n)...] -Stte the BB data from the array that demonstrates the need.

2. Description of activities involved.
Explain that the need for action is in the [description of the functional activity, such as operation, design, maintenance, staffing, policy, supervision, etc.
- define the organization function in which the need arose to indicate who "owns" the need and will be responsible for addressing it.
- use "demonstrate," "indicate" or "suggest" a need for sction, depending on the strength of the logic supporting the definition of the system/subsystem/activity
- use additional attributes to define the specific system or subsystem

3. Description the system or obligation within which the need exists or

4. Description the systems whose interactions during the episode create the need.

5. Description of what the need is.
The need for action to [define reason indicated by this BB set.]

-state the need in terms of the MOTEL strategies, or
- state the logic which explains the need

6. Explanation of why it needs to be fixed.
Fixing the need creates a risk with a [use RAC terms here for probability of [?}] which [merits or does not merit] action by user.BR>

- this is where the needs statement must convince the responsible manager that the problem is worth the manager's attention or manager can reasonably live with it in future.

7. Description of what needs to get done.
The relationship among these BBs requires action to (describe output needed by analyst's entity.)

- state what needs to get done
- ensure that wording is compatible with tracking and followup actions

FINDING DATA FOR USER NEEDS STATEMENTS

1. Locate, define and annotate a BB, link, BB pair or BB sets for which user action is required.

In this discussion, the reference to "needs" is intended to encompass all the STEP-MES matrix array contents for which some user action might be indicated. The selection of the contents to mark up depends on user's goals and data needs. Therefore, the markup task should be performed by a user ANALYST, timed to meet the user's functional needs. A safety analyst will look for problem BBs, links, BB pairs or BB sets that are candidates for change to reduce future risks. An insurance analyst will look for BBs, links, BB pairs or BB sets that will support action on claims. A plaintif's analyst will look for actions or omissions that can form a basis for litigation. A trainer will look for options to change training to improve performance. A designer will look for behaviors that indicate a need for redesign. A system operator will look for problems to correct before system restart. Other users will seek data to support their nees.

Over the years, I have observed 36 different users of investigation data, and my list is probably not exhaustive.

TABLE 8.1. Potential Users of Episode Investigation Data

The STEP-MES matrix array can serve all users. Except perhaps the public which is looking for "the cause" of the episode.

2. General approach

The general approach is to consider each BB and link in succession, consider if it is needed by the user, and tag each BB, link, BB pairsor BB sets if the analyst decides user action is needed. First, develop candidate statements of need that could be addressed by the user actions. A user action need is something a user must do in response to the episode. A candidate statement of need is the documentation of why user action is necessary. Every BBs, linked BB pair or set and link should be examined to determine if a candidate need statement should be developed from the relationship.

Another way of looking at this task is the view it as a action needs discovery and definition task. This procedure describes the UANS task.

3. The procedure

a. Examine BB and links. Start at the right end (outcome) of the array and begin by selecting linked BBs and links to analyze, one at a time, from right to left on the matrix array.
User Action Needs Statements,

NOTE:

On a completed STEP-MES Matrix array, all linked pairs will have a input-output relationship. If the links are continuous from the first to the last BB, all the BBs had to occur for the episode to progress from its beginning to its conclusion or outcome(s).

b. Define needs. For each BB pair, ask two questions about the BBs and their link:

Did the BB pair occur as it was expected to occur ? If the answer is "NO", the difference may indicate a need to change what occurred to match expectations. If what is supposed to happen is ambiguous, it may be necessary to change expectations to match what occurred. For example, that can be used to develop a needs statement. If the answer is "Yes" go to the next step
Does something about the BB pair need to be changed to modify the relationship? If the answer is "YES" that points to a need: the system did not function as needed.

The general STEP-MES needs definition strategy is to try to identify possible changes to the elements of each BB set which would change the process interactions. To achieve the change, action to "de-link" the BBs is needed, so the relationships described will not occur in the future. Thus, the need is defined by the actions which would change future interactions.

De-linking can mean changing either BB in the pair or their linkage. BBs may need to be changed in any of several ways. For example, a BB's timing might need to be earlier, later, or not occur at all. Its duration might need to be longer, shorter or otherwise different. Its intensity might need to be stronger, weaker or different. Its location might need to be different, or its magnitude might need to be reduced if its influence on the next BB has to be changed. These are a few examples of how needs might be defined.

c. Add "diamonds" If it is determined that a need related to one of the BBs or the link does exist, mark the BB or link with a "diamond" containing a sequence number beginning with 1, and number ther need statement with that number. This notation scheme provides a stable reference to the BB which indicated the defined needs. It also helps avoid duplication, and provides a quality control check point. It also helps investigators show reviewers that they considered a need even though it might have been dropped from later consideration

NOTE:

The user's rule to remember is to define a need in terms of what is to get done, rather than in the form of a problem that simply states what is wrong. It is also a good practice to state the need in terms of "The investigation disclosed a need to ....." and keep out any extraneous discussion of all the past problems analysts have seen. Stick to the BBs and links.

The numbered "needs diamond" attached to a BB or link is the record of the analyst's consideration of that BB and link during this procedure. If the same need is found at another BB, use a different number but define the need with the same words. Alternatively use the same number with a suffix such as 1a, 1b, so analysts can identify common needs by sorting on numbers, and yet know exactly where they were identified. However, individual numbers are preferred. Where the recommended action development tasks are assigned to a single individual or group, it may be preferable to serially number every candidate need without restarting each diamond series in a new investigation with a 1. Wheen the user response action development tasks are assigned to a single individual or group, it may be preferable to serially number every candidate need without restarting each diamond series in a new investigation with a "1." The choice depends on the manner in which the information is to be stored and retrieved, which varies from organization to organization.

d. Work through BB pairs. After all needs statements have been completed for the first BB pair, continue through the STEP-MES Matrix array to identify the needs indicated by each BB pair or link. The reason for looking at all the BB pairs is to ensure that no candidate needs will be overlooked - to minimize errors of omission. Remember to note each need with its own number in the diamond attached to the BB or link which demonstrates the need.

NOTE:

To manually record the analyst's work, it is a good idea to use a separate sheet of paper (or word processor page) for each needs statement. As the process continues, the analyst will be adding information about each need and will quickly run out of room for those notes if enough space is not available.

Figure 8-1 shows the general layout of the BBs, links and Diamonds on an MES Matrix array. The configuration is the same in software matrix arrays, but the appearance may be different.

Figure 8-1 Appearance of Matrix Array with Needs Diamonds

e. Review analyses. When the analyst reaches the last BB pair on the left of the Matrix, it is a good idea to review the marked-up array with another qualified person to verify that all the user action needs have been identified. Alternatively, a second person could repeat the work analysts have done to verify the completeness of the user action needs identification task, and the results compared and harmonized. The main quality control procedure is to review the UANSs to ensure that they state each user action need in terms of the actions needed, and not in terms of a problem.

PREPARE THE UANS DOCUMENTS

Upon completion of the quality assurance steps, the last task is to prepare the User Action Needs Statements for each selected need. When the statements are completed, check the content of each to ensure it contains the:

2. Description of activities involved.

3. Description the system or obligation within which the need exists or

4. Description the systems whose interactions during the episode create the need.

5. Description of what the need is.

6. Explanation of why it needs to be fixed.

7. Description of what needs to get done.

When all the candidate UANS have been completed, and the Matrix array contains all the numbered diamonds corresponding to the UANS, analysts should be ready to proceed to the selection of needs to address by proposed user actions.

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Guide 9 IDENTIFYING USER ACTION NEEDS WITH STEP-MES MATRIX ARRAYS

Table of Contents

Guide 9
IDENTIFYING USER ACTION NEEDS
WITH STEP-MES MATRIX ARRAYS