What is a unplanned change? While change is always occurring it happens whether it is planned or not planned. What we mean in this context is change in response to an accident or incident. This type of change usually is associated with a critique or team learning session and a cause map to facilitate a rapid response and return to the action that was interrupted by the issue or accident. This type of precipitous responses usually come without the checks and balances of a planned change and thus serves as little more than a bandage on a severe wound. Also, with an unplanned change there is usually little thought given to validating the change: quality points for verification, via follow on inspections or predetermined assessment points. This is not to say that all changes need to be planned; if the process for an effective root cause analysis is employed and follow up corrective actions are thoroughly reviewed and understood, this response can be as effective as a planned change. However, experience has shown that in most of these type cases, even when the changes are thoughtfully developed, little is implemented to ensure the changes last.
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