Incident Investigation: The How and Why of the What and Where

Completion of the incident report or report of an occurrence or incident is just the tip of the iceberg. It will give you the what happened statement and where it happened location usually, but the how it happened and the whys behind it will require a thorough investigation and root cause analysis.

Goals of Workplace Investigations

Once a thorough and non-biased review of all the evidence has been completed and a root cause analysis has been defined, it is easy to determine weaknesses in business practices and verify if policies and procedures are being followed.
Protecting those directly involved, the company’s reputation, staying aware, and adhering to local and federal regulations should be primary goals for investigating community level incidents. There are, however, important personal management reasons.

Why Investigate?

• You have a duty. Investigations are a key component of an effective risk management program and meeting regulatory requirements.
• There are benefits; the real how and why may eliminate the next incident and may preempt later claims.
• They serve as a chronicle of when facts became known to management and decision makers.
• Investigations can solidify compliance with the organization’s goals and improve operational procedures.

There are five main procedural steps to all investigations, and they should be the basis of all actions and education.

1. Maintain confidentiality throughout the process and no common details shared with anyone participating in the interviews.
2. Make no assumptions, keep a skeptical mindset until all the details surrounding the event are secure, keep it fact based.
3. Keep an open mind, do not let preceding details or personality of anyone involved become a part of the process.
4. Keep it prompt, there will be varying levels of interaction timeframes, but timeliness is of key importance.
5. Safeguard the documents and findings, any unwanted disclosures could cause legal and reputational problems for the community.

To gather good evidence, you need a plan which can go into practice with knowledge of the occurrence.

The Plan

• Designate a company spokesperson, appearance and demeanor will drive opinions.
• Initiate the plan with awareness of happening, the best information is firsthand.
• Keep it fact based. If it is not or cannot be verified, it is not evidence.
• Remain impartial, opinions are of little value with investigations.
• Capture all efforts and define the weak areas and connect the actions.

Designate someone that can represent your company in the investigation and can conduct and research without any favoritism. They should also be able to act independently, have patience to see the entire process through, and have a strong knowledge of the process.

Start the incident investigation as soon as someone learns of the incident, and immediate corrective action, if needed, should be initiated as soon as the incident is made known. This is why the investigation process should be taught to most staff. Delaying an investigation could result in specifics of the incident being lost or valuable information becoming distorted.

Train incident reporters to stay away from subjective statements and opinions. Ensure all reporting and investigation gathering is based on facts.

Encourage all involved in the investigation process to remain fair-minded and objective. Investigations should be handled with integrity. Preserve the names and details of the investigation throughout the process. Complainants or whistleblowers will expect to be anonymous and should be protected from retribution.

Protect the documents, witness statements, photos, and any other evidence obtained during the investigation. Instruct witnesses and anyone with knowledge of the investigation to refrain from commenting about incident notes or reports in the medical record if resident related.

The Process

• Determine who may be impacted by the incident. A typical incident will likely have more than one person involved and many who can contribute information. It is also important to determine what type of incident you are investigating. A resident fall, an employee allegation of abuse, or a resident/family complaint may warrant a different investigator.
• Form a plan to complete the investigation. There should be a clear strategy from the start and the purpose should always remain the same – to gather evidence needed for clear discovery. Careful planning might involve an outline of the process.
• Evidence collection is the next step. If the gathered information cannot be verified in some way, it may not be 100% valid. Evidence speaks for itself and may include verbal or written statements provided through interviews, photos, or drawings of the incident and location.

Evidence should be gathered from all three categories, if possible: physical, people, and paper, photos, or videos.

• Physical evidence might include timesheets, medical records, or documentation of the environment where the incident took place. A review of the corresponding company policies and records should take place to determine if a breakdown in the procedures occurred.
• The second category of evidence is people. This includes verbal or written witness statements and documentation of body language during the interview process. Establish a good rapport with the witness and ask as many open-ended questions as possible.
• Paper, photo, or video evidence should be maintained securely and all policies in place should establish how long contributing items are to be kept.

The final step of how is why

Analyzing all the findings and determining a root cause is the most important step in reducing the opportunity of recurrence. After collecting all information that could possibly be related to the event, the whys can be initiated.

Final Steps

• Develop a problem statement
• Ask why
• Identify a corrective action
• Monitor the efforts

Begin the exercise by identifying the specific problem. Next, ask why the problem transpired and record that answer under the initial specific problem. Continue to ask “why” a minimum of five times, but do not stop until you get to the very root of the incident. A thorough root cause analysis will often determine a process or lack of process that may cause a succession of problems.

This is typically where most companies and people miss a step. Taking the time to complete all initial steps will lead to little if the result does not include reviewing and addressing any corrective action needed. All action taken should be documented. If resident specific, remember to review the resident’s care plan or service plan for any needed modifications. The importance of follow up action items brings closure and gives reassurance to those involved that this process was handled and handled correctly.

Follow Up Actions

• Monitor any temporary or immediate corrective action to address the incident. Some corrective action may occur right away, while other action might happen once the investigation is completed.
• Share any change in procedures. This sometimes occurs based on the findings of the root cause analysis, but some information sharing will take longer if policy revision is required.
• Capture the process as documentation of any education provided or procedural changes made that were a result of the investigation.
• Offer updates on process, and to maintain a positive company reputation schedule appropriate follow up with those involved both within and outside of the community, if warranted.

Finally, there should be company procedures to assess the effectiveness of corrective action and preventive steps taken.

Investigation practices should be used as an opportunity to improve systems, policies, and education. A thorough investigation and a root cause analysis ensures that today’s incident does not become another incident tomorrow.