Full 191-entry dataset, July 2024 – May 2026. The prior version of this analysis was limited to the first ~33 rows by a tool read limit. This version is based on a complete parse of the workbook. The five root-cause themes from the partial read are confirmed at scale — and three structural findings invisible in the sample are now visible.
35% of the register is open with no visible escalation mechanism — the register itself does not flag this as a risk.
PP&C produces 41% of CI submissions — more than Operations, Customer & Practice, and Corporate Services combined. Operations manages frontline shift delivery and participant risk, yet generates fewer than half PP&C's volume. Either frontline staff are not using the register, or operational improvement is happening through channels that bypass it.
Three explanations are possible and not mutually exclusive: (a) PP&C has stronger CI discipline than other functions; (b) workforce management has the most outstanding documentation gaps as Achieve scales; (c) some PP&C submissions relate to documents that sit in PP&C's quality management system but are used operationally across all departments.
79 of 135 categorised entries are changes to things that exist — the register is correcting more than it is building. A reactive-documentation pattern.
One executive holds formal accountability for 34% of all CI items — and is also the highest-volume individual raiser in the register. A single person both generating and owning the most items is a meaningful single point of dependency.
Activity accelerated significantly from mid-2025. Three separate months hit 15 submissions each (May 2025, Sep 2025, Nov 2025, Mar 2026). What drove the surge is not recorded in the register — whether regulatory change, internal quality audit, a new CI champion, or event-driven burst remains an open question.
These patterns were first identified in the 33-entry sample. The full dataset confirms they aren't sample artefacts — the conditions that produce them persist across the full 23-month register.
One CEO Notifiable Incident Report policy change triggers a cluster of separate CI requests to manually update every downstream document — four different category labels, one source process.
Governance documentation citing old role titles, an outdated "EGMS" structure, and a missing formal definition of "Senior Staff" — three separate entries, three different raisers (including the CEO), one condition: governance docs not updated when the org changes.
Four documents failing their intended audience on format grounds — a vision-impaired staff member, the CI form itself, a garbled PDF, a printing defect — each discovered only when someone hit the barrier directly.
EIRT attendance, WHS/incident cross-notification, SIL transition responsibilities, CCTV access — four different processes, the same shape: a cross-functional process with no single documented owner.
The CEO personally raised IMP000342 — Risk documents referencing an outdated org structure — through the same standard CI form used by frontline staff. The "governance hasn't caught up with restructuring" problem isn't a frontline-only complaint.
IMP000334 shows the organisation had no documented definition of "Senior Staff" until the Chief People Officer proposed one via a CI request — a basic governance term undefined at $130M revenue scale.
Five entries in the sample ran 6–11+ months past their formal due date with no comment, flag, or explanation — all still marked Completed with the same templated closure text as on-time items. The full register's 35% In Progress rate suggests this is the norm, not the exception.
| CI ID | Due date | Actual completion | Months late |
|---|---|---|---|
| IMP000316 | 13/10/2024 | 28/07/2025 | ~9.5 |
| IMP000318 | 19/09/2024 | 02/04/2025 | ~6.5 |
| IMP000328 | 24/10/2024 | 16/06/2025 | ~8 |
| IMP000329 | 27/11/2024 | 13/08/2025 | ~8.5 |
| IMP000339 | 22/11/2024 | 23/10/2025 | ~11 |
IMP000337 (Not Approved) was closed immediately with no owner. IMP000338 (also Not Approved) still has an owner assigned and a status of "In Progress" months later — work is continuing on an item the approval field marks as rejected. The field does not reliably predict what happens next.
Every root cause is labelled EVIDENCED (multiple entries directly show this) or INFERRED (a plausible reading the register data doesn't confirm). All five themes from the 33-entry sample are confirmed in the full dataset.
185 of 191 submissions were approved (97%). Six were not. If the approval step is meaningfully evaluating submissions, six rejections across 191 is a plausible rate. If it isn't, the register is spending governance overhead on a step that adds little. The "Not Approved" + "In Progress" combination — an item both rejected and still being worked on — is the most direct evidence of the latter.
Operations manages the bulk of shift delivery, rostering, and participant risk across sites — yet generates 31 submissions (16%), fewer than half PP&C's volume. Either frontline operational staff are not using the register, or operational improvement is happening through channels that bypass it (incident reports, direct manager escalation, site meetings). This is a participation gap worth investigating, not assuming away.
| # | Question | Why it matters |
|---|---|---|
| 1 | Of the 66 In Progress items — what proportion are genuinely in flight vs stalled vs forgotten? | The register cannot answer this. If even half are stalled, that's ~33 improvement commitments with no active owner. |
| 2 | What happened to the 6 Not Approved items after rejection? | Were they abandoned, escalated, or addressed via another channel? The inconsistency between IMP000337 and IMP000338 suggests the answer varies unpredictably. |
| 3 | Why is Operations submitting at roughly 40% of PP&C's rate? | If frontline staff are using other channels, those channels are invisible to QA reporting. If they're simply not raising improvements, that's a participation problem. |
| 4 | Does the lead executive actively manage 65 CI items, or is "Executive Responsible" a form default? | If it's a default, accountability for a third of the register is nominal. If it's genuine, that executive is carrying a disproportionate improvement load. |
| 5 | What drove the submission peaks in May 2025, Sep 2025, Nov 2025, and Mar 2026 (15 each)? | Understanding the driver matters for forecasting future volume and for identifying whether CI engagement is event-driven or cultural. |
Source: CI register (191 entries) cross-referenced against the KPI set in the Strategy Implementation Report (CSO, June 2026). The question: does CI register activity connect to what Achieve tracks as organisational performance?
| KPI area | KPI / current status | Related CI register activity | Correlation verdict |
|---|---|---|---|
| Employee engagement | Score 3.94, no change year on year | PP&C generates 41% of all CI items — some likely relate to HR process improvements. No CI entries are tagged to engagement or culture outcomes. | Indirect at best — no structured link between CI activity and engagement score |
| Corporate communications | EDM open rate ~50%, Town Hall attendance on track | No CI improvement category for communications. Not visible in the register. | No correlation |
| Workforce includes people with disability | 34 employees (declining, behind target) | No CI register category for workforce composition. Not visible. | No correlation |
| Employee retention — early-tenure exits | 35.5% leave within 12 months, worsening | PP&C CI items may include onboarding/induction procedure improvements. None are tagged to the early-tenure exit rate or analysed for that linkage. | Possible but unstructured — worsening KPI, no CI investigation visible |
| Financial performance | Net income $1.2M below budget — most critical KPI in the set | Corporate Services generates 18 CI items (9%). Revenue and billing process improvements (SOS format, reconciliation, claim error management) are not visible as CI entries despite being documented as major operational gaps across five separate analyses. | Very weak — most critical KPI, least visible CI coverage of underlying causes |
| Workplace injuries (LTIFR) | 19.3% — above 12% target and above the 15.5% starting point | WHS-related process improvements appear in the register (Theme 4 — cross-functional processes lacking a single owner includes WHS/incident cross-notification). But LTIFR is worsening: the CI items are not translating to injury rate reduction. | Activity without effect — CI items exist but KPI is moving in the wrong direction |
| Client satisfaction (occupancy, exits) | Occupancy 91.6%; voluntary exits 1; involuntary exits rising (4 in May) | Customer and Practice generates 44 CI items (23%) — client-facing procedure and form improvements. But occupancy and exit KPIs are commercial/operational metrics, not quality metrics. The CI activity and the KPIs are measuring different dimensions of the client relationship. | Partial overlap — some CI activity, no traceable link to KPI movement |
| Client voice | KPIs not yet defined — "to be decided" | Cannot be measured — no KPI exists to correlate against. DSP Committee charter names Customer Voice as its first domain; CI register has no client experience improvement category. | Not measurable — KPI undefined, CI category absent |
Financial performance (net income $1.2M below budget) and LTIFR (19.3%, above both target and starting point) are the two KPIs in most urgent need of improvement. Neither has visible CI register activity directed at the root causes identified in this analysis.
For financial performance: the revenue gaps documented across five separate diagnostic exercises — SOS format, reconciliation process, claim error management — appear nowhere in the CI register. If those gaps had been captured in the register when they were first identified (2024), they would carry a two-year history and escalation record by now.
For LTIFR: WHS-related CI items exist but the injury rate has worsened from 15.5% to 19.3% across the same period as the CI register has been active. Either the CI items are not addressing the right root causes, or the process improvements are not being implemented consistently at site level.
Operations generates 31 CI items (16%) — fewer than PP&C's 79, despite managing the bulk of shift delivery, rostering, and participant risk. Workplace injuries and participant safety events occur in Operations. If Operations is not raising CI items against its own safety processes, the WHS improvement work is happening somewhere other than where the injuries are occurring.
This connects to the LTIFR finding: a 19.3% injury rate worsening while Operations submits minimal CI activity against WHS processes suggests the improvement mechanism and the problem are in different parts of the organisation.