-   Table of Contents

What Constitutes Developing a Corrective Action Plan
[3](#what-constitutes-developing-a-corrective-action-plan)

Establish Statistically Reliable Data that Identifies Where Problem
Areas Exist
[5](#establish-statistically-reliable-data-that-identifies-where-problem-areas-exist)

Identify the Problem Areas [6](#identify-the-problem-areas)

Perform In-Depth Quantitative and/or Qualitative Analyses Revealing the
Root Causes of Problem Areas
[9](#perform-in-depth-quantitative-andor-qualitative-analyses-revealing-the-root-causes-of-problem-areas)

Cause and Effect Diagrams [9](#cause-and-effect-diagrams)

Flow Charts [12](#flow-charts)

Process Chart [17](#process-chart)

Develop Action Steps that Need to be Taken to Correct Any Identified
Problems
[19](#develop-action-steps-that-need-to-be-taken-to-correct-any-identified-problems)

Developing a Plan that Outlines Quantitative Goals for Improvement
[19](#developing-a-plan-that-outlines-quantitative-goals-for-improvement)

Implementing the Plan [21](#implementing-the-plan)

Analyzing and Monitoring Data to Determine how Closely the Data
Corresponds to the Goals Set Forth in the Plan
[22](#analyzing-and-monitoring-data-to-determine-how-closely-the-data-corresponds-to-the-goals-set-forth-in-the-plan)

Documenting the Process so that it Becomes the Standard Procedure for
All Who Use It
[22](#documenting-the-process-so-that-it-becomes-the-standard-procedure-for-all-who-use-it)

Create a Defined Schedule for Proceeding with the Identified Action
Steps
[23](#create-a-defined-schedule-for-proceeding-with-the-identified-action-steps)

What is the Structure of the Corrective Action Process?: A Collaborative
Effort in an Organization
[23](#what-is-the-structure-of-the-corrective-action-process-a-collaborative-effort-in-an-organization)

Where Does the Corrective Action Process Fit and Who Should Conduct It?
[23](#where-does-the-corrective-action-process-fit-and-who-should-conduct-it)

How is the Corrective Action Implemented?
[26](#how-is-the-corrective-action-implemented)

How to Make Corrective Action Part of a Larger Initiative to Increase
Program Performance
[27](#how-to-make-corrective-action-part-of-a-larger-initiative-to-increase-program-performance)

Components of the Corrective Action Plan
[28](#components-of-the-corrective-action-plan)

Conclusion [30](#conclusion)

Bibliography [32](#bibliography)

Figures

Figure 1: Components of Systematic Approach to the Corrective Action
Process [5](#__RefHeading___Toc2582567)

Figure 2: Pareto Chart [8](#__RefHeading___Toc2582568)

Figure 3: Cause and Effect Diagram [11](#__RefHeading___Toc2582569)

Figure 4: Flow Charts---Series of Questions to Ask
[13](#__RefHeading___Toc2582570)

Figure 5: Flow Chart [16](#__RefHeading___Toc2582571)

Figure 6: Process Chart Categories [17](#__RefHeading___Toc2582572)

Figure 7: Process Chart [18](#__RefHeading___Toc2582573)

Figure 8: Five Action Steps for Corrective Action Processes
[19](#__RefHeading___Toc2582574)

Figure 9: Guiding Principles for Determining Who Should be Responsible
for

the Corrective Action Process [24](#__RefHeading___Toc2582575)

Figure 10: Characteristics of a Corrective Action Team
[25](#__RefHeading___Toc2582576)

Figure 11: Approaches for More Successful Corrective Action Teams
[26](#__RefHeading___Toc2582577)

Figure 12: Questions to Guide Corrective Action Implementation
[27](#__RefHeading___Toc2582578)

Figure 13: Components of Corrective Action Plan in Self-Assessment
Report [28](#__RefHeading___Toc2582579)

Figure 14: Deming Quality Wheel (Plan-Do-Check-Act)
[29](#__RefHeading___Toc2582580)

Figure 15: Continuous Improvement Steps [30](#__RefHeading___Toc2582581)

# Self-Assessment Corrective Action Process and Planning

The Personal Responsibility and Work Opportunity Reconciliation Act
(PRWORA) of 1996 revised Federal child support enforcement audit rules
by passing from the Federal government to states the responsibility for
conducting an annual review to determine if Federal requirements are
being met. This annual self-assessment was designed as a management
tool, to help states evaluate their child support enforcement programs
and identify areas that need improving.

As discussed in the self-assessment regulations at 45 CFR 308, a state
must describe how it will change its child support enforcement program
to better achieve the goals of the program and the benchmarks of
self-assessment. The actions described should be clearly aimed at
solving all the problems identified in the self-assessment and to assist
the state in evaluating its own performance against the eight program
criteria specified in the regulations.

The self-assessment regulations stipulate that a state that is failing
one or more of the self-assessment criteria must complete a corrective
action plan. However, the regulations do not prescribe a criteria or
methodology for creating or developing such a plan. Given this, it is
the goal of this TEMPO to provide states with directions for creating a
corrective action process as well as to provide suggestions for
evaluating program practices and processes for the corrective action
plan.

## What Constitutes Developing a Corrective Action Plan

A corrective action plan may embody several different forms. One state's
corrective action plan may not resemble another state's in its unique
design or creative approach for finding solutions to child support case
management problems. Ultimately, the corrective action plan must be an
ongoing administrative process, utilizing the self-assessment efficiency
scores to develop effective methods of eliminating errors or problems
found during the self-assessment review process. With the enactment of
PRWORA and to ensure broad input, the Office of Child Support
Enforcement (OCSE) designated a self-assessment core workgroup to
consult with a wide variety of program stakeholders to get their
recommendations on: the criteria to be covered in annual reports to the
Secretary; the methodology for reviewing the criteria; and an approach
for reporting the results of these reviews. OCSE considered these
recommendations in developing the proposed rule that preceded the final
regulations on self-assessment. As part of the recommendations, the
self-assessment core workgroup defined their expectations and the
objectives of the corrective action process. These expectations and
objectives are as follows:

> A corrective action process details the causes and effects of
> non-compliant criteria. It also identifies errors and explains the
> direct and indirect cause of the errors with the intent of developing
> an on-going process to correct identified problems.

To meet this definition of a corrective action process requires active
participation and commitment of top management in a state's child
support enforcement agency. Top management commitment is vital because
sometimes the corrective action process can require the allocation of
significant staff and automation resources. Without the allocation of
sufficient resources, the process may fail to provide its intended goal:
improvement in program performance. Top management participation in the
process and their commitment to the details of the corrective action
process will lead to improved performance.

Once top management participation and commitment has been achieved, a
systematic approach should be applied to the corrective action process
and this approach should include the components shown in figure 1, next
page.

[]{#__RefHeading___Toc2582567 .anchor}Figure 1: Components of Systematic
Approach to the Corrective Action Process

### Establish Statistically Reliable Data that Identifies Where Problem Areas Exist

Before you build your corrective action process, you first need to
ensure that your data are both valid and reliable. This is vital
because, naturally, you do not want to make policy and management
decisions based on inaccurate information. To check the validity and
reliability of your self-assessment information, you should evaluate
your self-assessment sample results. To do this, the OCSE Office of
Audit suggests you use the confidence interval method. By doing this,
you can be sure that the sample size accurately reflects your state's
child support caseload.

As we stated in the *Statistical Sampling for Self-Assessment* TEMPO
(OCSE-DCL-02-08, page 16), there is an inverse relationship between the
level of confidence and the precision or width on a confidence interval.
The greater the confidence, the wider the limits and therefore the less
precision the analyst has about a finding. For example, if you use
confidence limits to guess the mean support order amount of
non-custodial parents in your caseload and you use very wide limits,
such as \$50.00 to \$500.00, you will have greater confidence that the
intervals include everyone in the caseload but very little precision.
Management could not base policy and case management decisions on this
kind of information.

Since self-assessment's primary goal is to provide management
information, it should be the goal of the evaluator to have precision
while allowing for a small amount of error. See the *Statistical
Sampling for Self-Assessment* TEMPO for an at-a-glance method of
calculating error and determining sample size at a 95% confidence level.
When evaluating the sample results, the results should be applied to
both statewide samples as well as focused samples.

If your sample has both sufficient precision and confidence, you may
proceed with drafting the corrective action process, assured that you
can make management and policy decisions based on the self-assessment
data.

### Identify the Problem Areas

Once your sample results have been evaluated, you are ready to identify
the problem areas. One of the easiest methods to use is the Pareto
chart. Consider using the Pareto chart if you discover several problems
and need to decide which problem to solve first. A Pareto chart may also
be used to categorize self-assessment efficiency scores into manageable
areas.

The Pareto chart was developed by Vilfredo Pareto, a nineteenth-century
Italian economist whose statistical work focused on inequalities in
data. He proposed that most "activity" is caused by relatively few
factors.[^1] Pareto's concept is called the 80-20 rule, whereby 80
percent of the errors are caused by 20 percent of the factors. Hence, by
concentrating on the 20 percent of the factors, managers can attack 80
percent of the problems.[^2]

A Pareto chart is organized in the following manner (see Figure 2 on
page 8):

1\. Factors are plotted in decreasing order of frequency.

2\. Factors are listed along the horizontal axis.

3\. Each Pareto chart has two vertical axes, the left one showing the
frequency, similar to a histogram, and the right one showing the
cumulative percentage of frequency.

4\. A cumulative frequency curve identifies the few vital factors that
warrant managerial or corrective action process attention.

When using a Pareto chart, keep in mind that the cumulative frequency
curve identifies how much a particular factor contributes to the larger
problem. For example, the sample Pareto chart in Figure 2 reveals a
"snapshot" of the paternity and order establishment criterion. The
"snapshot" lists all the components (sometimes known as subsets of the
criterion) on the horizontal axis. Next, it details the number of errors
associated with each component. As we see from the cumulative frequency
curve, the complete service component clearly contains the most errors.
The cumulative frequency curve shows that complete service accounts for
nearly 80 percent of the problem in this criterion, in keeping with
Pareto's 80-20 rule.

The Pareto chart is only the second step in crafting a successful
corrective action process. The chart identifies that a problem does
exist and that the problem needs to be explored further and in greater
detail. This exploratory course of action is essential to creating an
effective corrective action process because it provides the initial
insight that allows us to proceed to the next step in the systematic
approach, which is to uncover the root causes of problems.

[]{#__RefHeading___Toc2582568 .anchor}Figure 2: Pareto Chart

### Perform In-Depth Quantitative and/or Qualitative Analyses Revealing the Root Causes of Problem Areas

One of the most critical components in the corrective action process is
identifying the root causes of problems. Without identifying root
causes---or by misidentifying roots causes---resources can be needlessly
wasted and the program may develop strategic difficulties that can put
it on the wrong path and render it incapable of improving performance.
The process of constructing the cause and effect diagram brings both
management and analyst attention to the primary factors affecting
performance for each category of the self-assessment.

Many tools can help you determine the root causes of problems. The
challenge you face in utilizing these tools is using them properly,
without skipping steps or cutting corners, and knowing which tool to
apply in what situation. If you skip steps or cut corners you will have
incomplete information---and thereby unreliable data---on which to base
management decisions.

In this section we will discuss the following three root cause analysis
tools:

1.  Cause and effect diagrams

```{=html}
<!-- -->
```
1.  Flow charts

2.  Process chart

#### Cause and Effect Diagrams

The cause and effect diagram is most often used to identify design
problems. It relates key problems to their potential causes. The diagram
helps to trace errors directly to the operations involved. Cause and
effect diagrams are sometimes called "fishbone" diagrams because of
their resemblance to the skeletal system of a fish.

A cause and effect diagram allows you to organize the information that
surrounds the problem or error. Further, it allows for total
brainstorming and ensures that you have accounted for all causes of
problems. As shown in the example on the following page, the main error
or problem is labeled as the fish's "head," the major categories of the
potential causes are the structural "bones," and the more specific
causes are the "ribs."

[]{#__RefHeading___Toc2582569 .anchor}Figure 3: Cause and Effect Diagram

Using the paternity and order establishment example from the Pareto
chart, the fish's "head"---that is, the main error or problem---would be
"complete service." The structural "bones"---that is, the major
categories of potential causes---might include the court system, process
servers, and order establishment personnel.

Finally, the "ribs"---that is, the specific causes, which can be listed
in order of importance with data supporting the ordered list---might
include, under the court system category, a lack of training on child
support policy and procedures. Documentation supporting this lack of
training on child support policy and procedures would also be included
on the "rib." This documentation can be obtained by qualitative
interviews with staff and/or by a review of documentation contained on
the automated system (if the documentation pointed to a clear lack of
training). The documentation would reflect the number of staff who
indicated that they did not have training on child support policy and
procedures. Other specific causes which might be included on the "ribs"
in this example are absenteeism and poor communication between the court
system and the child support program. Everything on the "ribs," then,
illustrates specific causes for the major categories of problems/errors
associated with complete service.

#### Flow Charts

Flow charts systematically map the details of a specific program aspect
or process to allow for better understanding of it. This tool should be
applied to operations having one or more of the following
characteristics:

-   The process is slow in responding to customers. A customer can be
    defined as any outside entity that interacts with the program, such
    as a custodial parent, non-custodial parent, court, governors
    office, etc.

-   The process results in too many problems or errors.

-   There is a suspected bottleneck in the process with work piling up
    waiting to go through it.

-   There is little value added in the process. For example, the process
    does not add to a specific outcome such as establishing orders.

The process of flow charting involves breaking a process into detailed
components. To do this a series of questions should first be asked, as
shown in the figure below.

[]{#__RefHeading___Toc2582570 .anchor}Figure 4: Flow Charts---Series of
Questions to Ask[^3]

Answers to questions such as those shown above in Figure 4 can often
lead to creative answers that can result in a breakthrough in the design
of the process. Given this potential, you should brainstorm with other
staff on as many aspects of the process as possible and list as many
solutions as possible. By doing this, you may be able to eliminate many
unnecessary functions or processes, thereby saving time and money and
improving outcomes.

Many individuals have a preferred format to use when constructing a flow
chart. Technically, however, a flow chart may be drafted minimally with
boxes, lines, and arrows (see Figure 5 on page 16 for a sample flow
chart). For the corrective action process, you should use the format
that works best for your program.

When constructing a flow chart that describes a process, it may be
useful to construct more than one, taking into consideration how the
process may be seen from the perspective of different customers (e.g.,
the custodial parent, the non-custodial parent and the child support
enforcement (CSE) agency itself). For example, a flow chart of an
enforcement tool such as income withholding would look very different
from these three different perspectives. The custodial parent would
(ideally) only see money going into her account, the non-custodial
parent would receive a notice that his wages were going to be garnished
by income withholding to pay his child support responsibility, and the
CSE agency would flow chart the process of locating the non-custodial
parent, sending the income withholding order/notice to the employer,
receiving the funds and transferring them to the correct accounts. Then
you might realize you also needed to flow chart the employer's interface
with the income withholding process as well.

Further, process measurements are also helpful to include beside each
box of the flow chart. Such measurements include:

-   Total elapsed time

-   Error frequency

Many organizations, such as state audit divisions, already have detailed
flow charts of the program's case work processes. Often, these processes
were charted when the program began creating its new automated system.
It is helpful to look at these official flow charts and use them as
reference material. However, these official flow charts should
[not]{.underline} be used to conduct root cause analysis for two
specific reasons:

1\. Frontline workers may have changed a practice that was originally
included in the official flow chart. Whether or not the new practice
helps or hinders the process, it should be re-charted and documented to
determine how it works with the larger case-processing scheme.

2\. Frontline workers may be using outdated materials, or they may have
created their own new, and they think better, materials. Again, whether
or not the outdated materials or the newly created materials are better,
worse, or redundant, re-chart the practice to determine exactly its
impact on the larger case-processing system.

In addition, official organizational flow charts are useful for
cross-referencing purposes and they provide a map with a clear case
processing strategy. However, child support case work, as with most
organizational processes, is interactive and involves many entities.
These entities may experience a change in management, organization, or a
change in legislation, law, or regulation. Given this, if a program
wants to determine the root cause of a problem, it is always smart to
create a new flow chart. This will allow the program to capture the most
current processes and thereby hope to identify the root cause of any
problem.

[]{#__RefHeading___Toc2582571 .anchor}Figure 5: Flow Chart

**Process: Paternity and Order Establishment**

**Subject Charted: Complete Service**

**Beginning: Case submitted for service of process**

**Ending: Order established**

#### Process Chart

A very useful and simple technique for determining the root cause of any
problem is process charting. A process chart is an organized way of
recording all the activities performed by an employee or customer.
Usually a process chart is grouped into at least five categories:

[]{#__RefHeading___Toc2582572 .anchor}Figure 6: Process Chart Categories

+--------------------+-------------------------------------------------+
| ######## Proces    |                                                 |
| s Chart Categories |                                                 |
+--------------------+-------------------------------------------------+
| #                  | Records a change, creates or adds something.    |
| ##### 1. Operation |                                                 |
+--------------------+-------------------------------------------------+
| **2.               | Moves the study's subject from one place to     |
| Transportation**   | another. The subject can be a person, a case    |
|                    | file, a custodial parent or a non-custodial     |
|                    | parent, etc.                                    |
+--------------------+-------------------------------------------------+
| **3. Inspection**  | Checks or verifies something but does not       |
|                    | change it.                                      |
+--------------------+-------------------------------------------------+
| **4. Delay**       | Occurs when the subject is held up waiting for  |
|                    | further action. For example, waiting for a copy |
|                    | of a court order from the district court's      |
|                    | office.                                         |
+--------------------+-------------------------------------------------+
| **5. Storage**     | Occurs when something is put away until a later |
|                    | time. For example, filing a case file into a    |
|                    | file cabinet.                                   |
+--------------------+-------------------------------------------------+

These five categories are most commonly used; however, you may use other
categories depending upon the situation**.**

**Figure 7** on the next page represents an example of what a process
chart could look like. However, you may modify or create your own
process chart that may better represent the categories and subjects more
common to your program. If you decide to create your own process chart,
it is important to include:

-   The number of steps

-   Amount of time it took to do each task

-   Distance traveled to complete the task

[]{#__RefHeading___Toc2582573 .anchor}Figure 7: Process Chart

<table>
<colgroup>
<col style="width: 10%" />
<col style="width: 8%" />
<col style="width: 12%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 9%" />
<col style="width: 13%" />
<col style="width: 0%" />
<col style="width: 11%" />
<col style="width: 11%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="6" rowspan="7"><p><strong>Process</strong>: Serve process
for paternity and order establishment cases</p>
<p><strong>Subject Mapped</strong>: Preparing case for hearing.</p>
<p><strong>Beginning</strong>: Process has been served</p>
<p><strong>Ending</strong>: Case is ready for court.</p></td>
<td colspan="8"><h6 id="summary">Summary</h6></td>
</tr>
<tr class="even">
<td colspan="4"><strong>Activity</strong></td>
<td><strong>Number of Steps</strong></td>
<td colspan="2"><p><strong>Time</strong></p>
<p><strong>(Min)</strong></p></td>
<td><p><strong>Distance</strong></p>
<p><strong>(ft)</strong></p></td>
</tr>
<tr class="odd">
<td colspan="4"><strong>Operation </strong></td>
<td colspan="2"><strong>1</strong></td>
<td><strong>3</strong></td>
<td><strong>1</strong></td>
</tr>
<tr class="even">
<td colspan="4"><strong>Transport </strong></td>
<td colspan="2"><strong>2</strong></td>
<td><strong>11</strong></td>
<td><strong>16</strong></td>
</tr>
<tr class="odd">
<td colspan="4"><strong>Inspect </strong></td>
<td colspan="2"><strong>1</strong></td>
<td><strong>1</strong></td>
<td><strong>6</strong></td>
</tr>
<tr class="even">
<td colspan="4"><strong>Delay </strong></td>
<td colspan="2"><strong>1</strong></td>
<td><strong>15</strong></td>
<td><strong>10</strong></td>
</tr>
<tr class="odd">
<td colspan="4"><strong>Store </strong></td>
<td colspan="2"><strong>1</strong></td>
<td><strong>3</strong></td>
<td><strong>1</strong></td>
</tr>
<tr class="even">
<td><strong>Step no.</strong></td>
<td><p><strong>Time</strong></p>
<p><strong>(Min)</strong></p></td>
<td><p><strong>Distance</strong></p>
<p><strong>(ft)</strong></p></td>
<td><strong></strong></td>
<td><strong></strong></td>
<td colspan="2"><strong></strong></td>
<td><strong></strong></td>
<td><strong></strong></td>
<td colspan="5"><h6 id="step-description">Step Description</h6></td>
</tr>
<tr class="odd">
<td>1</td>
<td>8</td>
<td>15 ft</td>
<td></td>
<td><p id="x" class="heading">X</p></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td colspan="5">Case worker receives case.</td>
</tr>
<tr class="even">
<td>2</td>
<td>3</td>
<td>1</td>
<td><strong>X</strong></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td colspan="5">Print necessary documentation.</td>
</tr>
<tr class="odd">
<td>3</td>
<td>3</td>
<td>1</td>
<td></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td><strong>X</strong></td>
<td colspan="5">Place supporting documentation in file until
needed.</td>
</tr>
<tr class="even">
<td>4</td>
<td>3</td>
<td>1</td>
<td></td>
<td><strong>X</strong></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td colspan="5">Send required documentation to court.</td>
</tr>
<tr class="odd">
<td>5</td>
<td>1</td>
<td>6</td>
<td></td>
<td></td>
<td colspan="2"><strong>X</strong></td>
<td></td>
<td></td>
<td colspan="5">Inspect case file.</td>
</tr>
<tr class="even">
<td>6</td>
<td>15</td>
<td>10</td>
<td></td>
<td></td>
<td colspan="2"></td>
<td><strong>X</strong></td>
<td></td>
<td colspan="5">Documentation missing in case file.</td>
</tr>
</tbody>
</table>

Once this information has been recorded, it can be analyzed to determine
whether the process by which the function is organized should be
modified to improve efficiency.

The three root cause analysis tools discussed in this section---cause
and effect diagrams, flow charts, and process chart---all provide sound
techniques to assist in identifying the root causes of operational
problems.

### Develop Action Steps that Need to be Taken to Correct Any Identified Problems

Now that you have determined that your data are accurate and you have
figured out the root causes of your problems, you need to determine the
action steps to correct the problems. There are five action steps that
should be a part of any corrective action process:

[]{#__RefHeading___Toc2582574 .anchor}Figure 8: Five Action Steps for
Corrective Action Processes

#### 

#### Developing a Plan that Outlines Quantitative Goals for Improvement

An essential step in developing the corrective action process is to
develop a plan that outlines how the program will attempt to correct the
problem or errors identified. The plan should include:

-   An assessment of costs and benefits for fixing the problem

-   Alternative solutions

-   An implementation strategy

-   Quantifiable measures for improvement

Some plans may include more or less detail concerning each of the
bulleted points. However, all plans at a minimum should include
information pertaining to these bulleted points.

##### Assessment of Costs and Benefits

Each plan should contain an assessment of the costs and the benefits for
fixing the problems or errors. Some examples of what the assessment
could include are:

-   Costs for any modification to the automated system

-   Costs of not fixing the problem (e.g., redundant casework,
    caseworkers spending more hours on the phone with customers trying
    to manually fix cases)

-   Approximate hours of labor

-   Hours for training on the new procedure/process

-   Benefits of fixing the problem (e.g., caseworkers spending less time
    on the phone and more time working the cases, higher productivity
    due to increased resources)

##### Alternative Solutions

Compiling a list of alternative solutions can be very beneficial,
especially if later monitoring reveals that the implemented solution did
not work as planned. Should this happen, you can look to your list of
alternative solutions to determine a better solution to implement.

##### Implementation Strategy

The implementation strategy should cover the anticipated process for
putting the plan in place. You should take time to ponder the "what
if's." For example, try to construct a list of what could possibly go
wrong during implementation and how you would fix it. This can reduce
the chance of being caught off guard should something go wrong during
implementation.

##### Quantifiable Measures for Improvement

The most important step is to develop quantifiable measures of success.
Quantifiable measures will allow you to know if you have fixed the
problem. The measures should contain both process measures as well as
outcome measures. We suggest having both because process measures help
in determining exactly where something went wrong and outcome measures
demonstrate the significance of the identified problem area. A frequency
distribution of error causes is a good example of a process measure and
a self-assessment criterion efficiency rate is a good example of an
outcome measure.

#### Implementing the Plan

For effective implementation, you must collect data continuously to
measure improvements in the process. You should document any changes or
departures from the original plan. Should the original plan change, you
should revise it to reflect the changes. By doing this, you create an
up-to-date record of what it has and has not accomplished with respect
to the plan.

Some points you should think about when implementing the plan are:

-   How often should the program collect and analyze its data?

-   What are the costs associated with collecting the data?

-   What are the costs associated with not collecting the data? Can the
    program afford not to analyze this problem?

-   How should the data be collected and analyzed? Will it take a team
    of analysts to collect the data manually, or can it be done through
    an ad hoc report?

-   Is the system put in place to collect the information so cumbersome
    that it will defeat the purpose of collecting the data?

#### Analyzing and Monitoring Data to Determine how Closely the Data Corresponds to the Goals Set Forth in the Plan

Once you have implemented a new process to fix problems or errors,
monitoring the effectiveness of the new process can save dollars,
resources, and re-work later on. For example, sometimes fixing a process
can cause a problem in another area or procedure. Without monitoring,
you will not discover this problem until it is too late and the damage
has been done.

To effectively monitor, you should collect and analyze data to determine
how closely the data corresponds to the quantifiable measures set forth
in the plan outlined above. If major shortcomings are apparent, you
should reevaluate the plan. When you reevaluate your plan, pose these
questions to gain greater insight into the shortcomings:

-   What is an [acceptable]{.underline} level of departure from the
    quantifiable measures set forth in the plan?

-   What is an [unacceptable]{.underline} level of departure from the
    quantifiable measures set forth in the plan?

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-   What are the costs of going forward should there be major
    shortcomings?

Should the monitoring reveal little or no shortcomings, the corrective
action process should proceed to the next action step.

#### Documenting the Process so that it Becomes the Standard Procedure for All Who Use It

If the results of the implementation are successful, you should
officially document the revised process so that it becomes the standard
procedure for all who may use it. Documenting the procedure usually
consists of including it in the program's policy and procedures manual
as well as sending notification of the new process to all employees.

### Create a Defined Schedule for Proceeding with the Identified Action Steps

Now that we have clear and precise action steps for the corrective
action process, the next task is to develop a schedule for proceeding
with the action steps. To accomplish this, you must carefully analyze
what needs to be done. Give thought to determining how long it will take
to draft a clear, concise, and succinct plan and its associated
quantitative goals. Once you have drafted the plan and the goals and it
has been agreed upon by all the necessary parties, you need to give
consideration to implementing the plan. Unfortunately, many
organizations let too much time pass between the planning steps and the
implementation steps. When this occurs, the plan usually becomes watered
down because the organization's enthusiasm for the plan has waned and it
therefore lacks the momentum to improve.

Monitoring should be an on-going process. However, as we pointed out in
the above steps, consideration should be given to how often the program
should collect and analyze the data. Further, thought should also be
given to the availability of the organization's resources. To make this
task manageable given these considerations, you should create a
controllable schedule and adhere to it. This makes the task of
monitoring and analyzing the data much easier to accomplish.

## What is the Structure of the Corrective Action Process?: A Collaborative Effort in an Organization

### Where Does the Corrective Action Process Fit and Who Should Conduct It?

Many programs question where exactly the corrective action process fits
in a child support organization. This question is not easily answered
because there is not [one]{.underline} right place, but several,
depending on the structure of your organization. To determine the right
spot within your organization for the corrective action process, you
must first look at the set-up of your organization and base your
decision on its internal structure. For example, if your organization is
a state/centrally-administered program, you would put the corrective
action process in a different part of the organization then you would if
it was a county-administered program.

No matter where you locate the corrective action process, it should be
based upon the premise that it is a collaborative team effort involving
several individuals throughout the entire organization. Who should shape
the corrective action process really depends on the program's internal
structure. When determining who should shape the corrective action
process, there are some guiding principles, as shown in Figure 9.

[]{#__RefHeading___Toc2582575 .anchor}Figure 9: Guiding Principles for
Determining Who Should be Responsible for the Corrective Action Process

Given these principles, you should determine who should do the
corrective action.

Many child support programs struggle with finding resources to commit to
the corrective action process. Given budget constraints and overwhelming
caseloads, program directors often find that they cannot hire new staff
to tackle such a process. As a result, some programs have created
corrective action teams using experienced existing personnel.

Such corrective action teams are designed to tackle all the corrective
action needs of an organization. The corrective action team should
involve a small group of employees from all levels to create solutions
to problems and should:

1\. Have a common purpose

2\. Set their own performance goals and approach

3\. Hold themselves accountable for success

The philosophy behind the approach is that the people who are directly
responsible for providing the services will best be able to consider
ways to solve problems regarding the service.

A corrective action team differs from a more typical working group, as
outlined in the figure below.

[]{#__RefHeading___Toc2582576 .anchor}Figure 10: Characteristics of a
Corrective Action Team

Many states have encountered problems with teams they had worked with in
the past. These problems ranged from members not being committed to the
process to the team being a part of a larger negative environment.
Research concerning teams has concluded that the management of the team
plays a vital role in its success.[^4] According to this research, the
approaches shown below in Figure 11 lead to more successful teams.

[]{#__RefHeading___Toc2582577 .anchor}Figure 11: Approaches for More
Successful Corrective Action Teams

### How is the Corrective Action Implemented?

Implementing the corrective action is one of the most challenging
aspects of the corrective action process. How to implement it depends
upon the approach you took to create the corrective action process. And,
again, there is not one way of implementing the process. However, there
are some questions the organization should put forward and consider to
aid in implementation. These questions are shown in figure 12 on page
27.

[]{#__RefHeading___Toc2582578 .anchor}Figure 12: Questions to Guide
Corrective Action Implementation

While these questions do not provide a road map to successful
implementation, they do create a structure for organizing it. Further,
they ensure that the program considers all the challenges before
embarking on the task.

### How to Make Corrective Action Part of a Larger Initiative to Increase Program Performance

When the first self-assessment core workgroup met in the summer of 1997,
its goal in formulating the self-assessment process was to create an
efficient management tool that would help focus on core program
functions. The workgroup also hoped that CSE programs would make the
self-assessment corrective action process part of a larger initiative to
improve overall program performance. To accomplish this, the workgroup
believed a program would need to start to use the self-assessment report
to develop and interpret the relationship between performance and
compliance. To do this, the self-assessment report needed to be analyzed
to determine whether there is a direct or indirect relationship between
compliance and performance. Presently, there are many opinions about
whether the data from the OCSE-157 Report can be compared with
self-assessment compliance data. Until a statistically valid and
reliable method is presented to the states, the best way to analyze both
performance and compliance data is through the process of benchmarking
and comparing internally the difference between the self-assessment
scores and the state's results from the OCSE-157 Report. The tools
outlined in this TEMPO may be adapted to conduct analyses related to the
program performance measures/indicators. This will allow you to complete
a more robust evaluation of your program.

### Components of the Corrective Action Plan

Many states have asked us to provide an example of a solid corrective
action process and plan. Further, states wanted to know how to set up
this process within their self-assessment reports. With the help of the
self-assessment core workgroup, we developed a list of the components of
a corrective action plan. These components are designed to allow a
program to have creativity in their own specific design yet ensure all
necessary parts are included.

The corrective action plan within the self-assessment report should
include the components shown in the figure below.

[]{#__RefHeading___Toc2582579 .anchor}Figure 13: Components of
Corrective Action Plan in Self-Assessment Report

+-----------------------------------------------------------------------+
| > **Corrective Action Components**                                    |
+=======================================================================+
| 1.  Details concerning the cause of any errors or problems during the |
|     self-assessment review.                                           |
+-----------------------------------------------------------------------+
| -   Explain and cite the root cause analyses performed. You could     |
|     include your own process chart, flow chart, Pareto chart, or      |
|     fishbone diagram.                                                 |
+-----------------------------------------------------------------------+
| -   Include a list of factors that are influencing performance and    |
|     preventing the state from meeting the compliance benchmark.       |
+-----------------------------------------------------------------------+
| 2.  Describe the action used or implemented to stop the errors.       |
+-----------------------------------------------------------------------+
| -   Describe possible alternatives to the implemented action (should  |
|     the chosen action not succeed).                                   |
+-----------------------------------------------------------------------+
| -   Describe the pros and cons of the action and each alternative     |
|     action.                                                           |
+-----------------------------------------------------------------------+
| 3.  State general timeframes for fixing the problem/errors.           |
+-----------------------------------------------------------------------+
| -   Explain short-term vs. long-term fixes.                           |
+-----------------------------------------------------------------------+
| -   Determine benchmarks.                                             |
+-----------------------------------------------------------------------+
| 4.  Implement a monitoring process and plan (as describe earlier in   |
|     this TEMPO) to determine whether the proposed solution to the     |
|     problem worked or created another problem.                        |
+-----------------------------------------------------------------------+
| -   The monitoring plan should explain whether the program has        |
|     progressed to its self described goal.                            |
+-----------------------------------------------------------------------+
| -   The monitoring plan should also reveal whether there is enough    |
|     data to continue with the proposed corrective action.             |
+-----------------------------------------------------------------------+
| 5.  For each self-assessment report, the state should look back to    |
|     the previous year's corrective action and report any changes in   |
|     the plan should the monitoring reveal that the plan did not       |
|     produce the desired results.                                      |
+-----------------------------------------------------------------------+

The above table details all the components needed to produce an
effective corrective action plan within the self-assessment report. The
cycle is represented using the Deming Quality Wheel, as shown in the
figure below.

[]{#__RefHeading___Toc2582580 .anchor}Figure 14: Deming Quality Wheel
(Plan-Do-Check-Act)

![](media/image2.wmf){width="4.205511811023622in"
height="2.8346456692913384in"}

The cycle represents the steps in a method of problem solving resulting
in continuous improvement. These steps are detailed in the figure below.

[]{#__RefHeading___Toc2582581 .anchor}Figure 15: Continuous Improvement
Steps[^5]

+-----------------------------------------------------------------------+
| > **Steps in the Process to Continuous Improvement**                  |
+=======================================================================+
| 1\. Plan                                                              |
|                                                                       |
| -   Determine the procedure that needs to be improved.                |
|                                                                       |
| -   Document the procedure by analyzing the data.                     |
|                                                                       |
| -   Set quantitative goals for improvement (include various ways to   |
|     achieve goals, assess benefits, costs, and alternatives).         |
|                                                                       |
| -   Develop the plan.                                                 |
+-----------------------------------------------------------------------+
| 2\. Do                                                                |
|                                                                       |
| -   Implement the plan and monitor its progress.                      |
|                                                                       |
| -   Collect data continuously to measure improvements.                |
|                                                                       |
| -   Document any changes in the original plan.                        |
+-----------------------------------------------------------------------+
| 3\. Check                                                             |
|                                                                       |
| -   Analyze the data collected during the Do step.                    |
|                                                                       |
| -   The data should be analyzed to determine how closely the data     |
|     corresponds to the goals set forth in the Plan step. If major     |
|     shortcomings exist, reevaluate the plan or stop the project.      |
+-----------------------------------------------------------------------+
| 4\. Act                                                               |
|                                                                       |
| -   If the results are successful, document the revised process so    |
|     that it becomes the standard procedure for all who may use it.    |
|     [^6]                                                              |
+-----------------------------------------------------------------------+

## Conclusion

A successful corrective action process contains the many essential
elements outlined in this TEMPO. A corrective action plan should be:

-   Management-oriented with a commitment to success in improving
    performance.

-   Collaborative, engaging all who may be impacted in the organization.

-   Based on a fully integrated progression of analysis, planning,
    implementation, and evaluation.

Ensuring the corrective action process incorporates these
characteristics will lead to a more carefully crafted process that will
have a greater impact in eliminating programmatic problems. However,
each corrective action process should be tailored to the discrete needs
of your state program. Further, as with any research and analyses tools,
the corrective action process has its limitations. But even with these
limitations, the corrective action process, applied as one of your
management tools, increases the performance of your child support
program.

# Bibliography

Krajewski, Lee J. and Ritzman, Larry P. *Operations Management Strategy
and Analysis*. Massachusetts: Addison-Wesley Publishing, 1996.

[^1]: Krajewski and Ritzman, *Operations Management Strategy and
    Analysis* (Massachusetts: Addison-Wesley Publishing, 1996), p. 163.

[^2]: Ibid.

[^3]: Ibid., p. 116.

[^4]: Ibid., p. 147.

[^5]: Ibid., p. 152.

[^6]: Ibid., p. 182.