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Elements and Performance Criteria

1. Analyse process
   • Identify sources of variability and non-conformance in the process
   • Identify critical control points in process
   • Analyse causes of variability and non-conformance
2. Seek improvements
   • Observe and monitor changes
   • Analyse process again to ensure improvements are sustained
   • Identify sources of variability and non-conformance in the process
3. Identify critical control points in process
4. Analyse causes of variability and non-conformance
5. Develop preventative options
   • Liaise with team members and other people to develop mistake proof options for performing operation
6. Test and validate mistake proofing options
7. Implement permanent fix
   • Liaise with relevant people to have systems and procedures changed to implement solution
8. Liaise with relevant people to implement the solution
9. Liaise with relevant people to ensure self and others in the team or work area have appropriate skills
10. Follow through to ensure implementation occurs
11. Monitor implementation
    • Critically observe the implementation
12. Compare the results of the implementation against the expected outcomes
13. Modify solution to improve outcomes
14. Confirm procedures reflect change
15. Confirm training and assessment reflects change
16. Audit change at agreed period or cycle
17. Address any observed deviation
    • Observe and monitor changes
18. Analyse process again to ensure improvements are sustained