MONITORING CHANGES

Investigation Catalyst supports the orderly development of an objective operational monitoring plan and the continuing monitoring of changes implemented as a result of an incident investigation

A combination of the Investigation Catalyst Matrix and Diamonds data supports development of the monitoring plan after recommendations are selected. The plan should provide for monitoring the implemented input/output behavior sets, to ensure what is advertised gets done, and monitoring the changes over a longer time to ensure that the anticipated benefits are realized.

If the Matrix was updated to show the intended interactions after changes are implemented, the people and objects affected by a change are easily identified and trained, and can be designated as monitoring points during installation of the change. This should include downstream actors who will be affected by the change. If it was not updated, do the best you can with what you have on the Matrix, using the same approach.

Use the Matrix as the expected basis for the operation, and compare observed actions with actions and sequences described on the matrix. Use the attributes from the Diamond panels to monitor the continuing applicability of those assigned initially.

Investigation Catalyst Matrix and Diamond features help analysts decide what to monitor, and how often to do it.

The first monitoring should be planned during the changeover, if interactions between people or people and objects will occur.

The default evaluation and ranking data which indicate the significance of a problem, provide an indication of how detailed and how often monitors should observe the operation. The greater the risk level, the more frequent and more detailed the monitoring should be planned.

When observations indicate deviations from the EBs on the Matrix, action can be initiated to either revert to the expected behavior, or change the expectations to minimize inadvertent deviations. Designate actions the observer should take if deviations are observed.

Show flexibility about terminating any monitoring of changes if this activity can be coupled with routine quality assurance or safety surveys, for example. The Matrix is sufficiently detailed to support use for monitoring by other than investigators.

The primary monitoring support offered by Investigation Catalyst is the Matrix and Diamonds panels. Up-to-date printed copies of this data can accompany the observer during the monitoring steps, enabling the ready recording of new observations.

Any deviations, reports of surprises during operations or other potential indicators of unexpected changes in new operations can be displayed as Comments on the Matrix. Then use the Matrix to show the context of the deviations to everyone at a glance. Of course, update the Matrix or Diamond panel contents whenever needed.