Procedure gap review for approval

Use this review when the written procedure no longer quite matches the work people do. You will produce a gap register that separates evidence from proposed changes, so the process owner can approve, reject or revise each amendment.

This is for operations managers who hold the procedure, recent exception records, staff notes and policy changes, but need one reviewable decision document rather than four disconnected sources.

1. Set a review boundary

Choose one procedure and one defined review period. Do not combine adjacent processes because they share a team or system. For example, review Supplier invoice approval from the current procedure against exception logs and notes from the last calendar month.

Create a review folder with these files:

• The current approved procedure, including its document owner, version date and approval date.
• Exception logs for the selected period.
• Staff notes, meeting actions or handover notes that describe workarounds.
• Policy changes that affect the procedure.
• A blank Procedure gap register spreadsheet or table.

Record the procedure name, procedure owner, review period and source document dates at the top of the register. This stops an old exception from being used to justify a current change.

If your source files contain personal, supplier or commercially sensitive information, remove details that are not needed to assess the process. Follow your organisation's handling rules before pasting anything into an AI tool.

2. Extract the procedure into testable steps

Read the procedure once without changing it. Then list each action as one testable row. A useful step has an actor, an action, an input or trigger, and an outcome.

For example, replace Invoices are checked before payment with:

• Accounts assistant checks the purchase order, receipt and invoice match.
• Finance approver records approval in the finance system before payment release.

For each step, capture these fields:

Field	What to record
Step ID	A stable reference, such as AP-04
Procedure step	The action as currently written
Named owner	Role responsible for doing or approving it
Trigger or input	What starts the step or what is required
Control or evidence	The check, record or approval that proves it happened

Ask the model to turn the procedure into this table, but tell it not to infer missing owners or controls. Use a prompt such as:

Extract the procedure into testable steps. Keep the wording close to the source. For each step, identify only owners, triggers and controls explicitly stated. Mark anything absent as Not stated.

Compare the resulting table to the source document before moving on. The model is useful for structuring text, but it can join two sentences into a step that the procedure never actually requires.

3. Classify the operational evidence

Read the exception logs, staff notes and policy changes against the extracted steps. Give each item one primary classification:

• Missing step: work needed to complete the process is absent from the procedure.
• Unclear owner: the procedure uses a team name, passive wording or conflicting roles, so nobody has clear responsibility.
• Broken control: a required check, approval, record or separation of duties did not happen or cannot be evidenced.
• Policy conflict: the procedure contradicts, omits or has not caught up with an approved policy change.
• Training or compliance issue: the procedure is clear, but the evidence shows it was not followed. This is not automatically a procedure amendment.

Keep the original evidence reference. Use the exception ID, note date or policy reference, not a summary with no trail back to the source.

4. Build the gap register

Create one row per distinct gap. Use this structure:

Field	What belongs in it
Gap ID	A reference such as PGR-07
Procedure step	Step ID and current wording, or No current step
Evidence	Source reference and a short factual summary
Gap type	Missing step, unclear owner, broken control, policy conflict or training issue
Operational risk	What can go wrong if it remains unresolved
Proposed amendment	Exact addition, deletion or replacement wording
Proposed owner	Role accountable for the amended step
Control evidence	Record, system status or approval that should exist
Decision	Approve, reject, revise or defer, completed by the process owner

Give the model the extracted procedure table and evidence list, then ask it to draft the register. State that it must quote the relevant source reference and must not invent incidents, policy requirements or roles.

Use specific amendment wording. Clarify ownership is not an amendment. Replace “Finance reviews exceptions” with “Finance operations manager reviews exceptions each business day and records the decision in the exception log” is reviewable.

5. Check where the output is wrong

Do a source check on every high-impact row, and a sample of the remainder. The output is wrong or incomplete if you see any of these signs:

If you see this	Check or correct this
A confident claim with no source reference	Add the exception ID, note date or policy reference. Remove the claim if none exists.
A named role not used in the procedure or evidence	Mark the owner as unresolved. Ask the process owner to assign it.
Several gaps built from one exception	Decide whether they are separate failures or one root issue with several consequences.
A proposed control with no evidence method	Specify where the check is recorded and who reviews it.
A policy change treated as approved procedure text	Keep it as a proposed amendment until the required owner approves it.

Also look for a common false conclusion: repeated exceptions do not always mean the procedure is missing a step. They may show poor training, system failure, insufficient capacity or a control that exists but is not being performed. Keep those findings visible, but do not rewrite the procedure to conceal the underlying problem.

6. Run the approval review

Send the register with the current procedure and a short decision request. Ask the process owner to record one decision per row: Approve, Reject, Revise or Defer. For deferred items, require an owner and review date.

After approval, update the controlled procedure, its change record and any linked training material. Retain the gap register as the reason for the change. Check the current capabilities and document handling guidance in the xAI documentation overview, as these can be version-dependent.

Make this a repeatable habit: run the review after material policy changes, recurring exceptions, or a scheduled operational review. Use the same fields each time so you can compare unresolved gaps across periods.

When the review does not work

If the model produces vague recommendations, reduce the input to one procedure section and a small set of evidence items. Require source references for every finding. If the register has too many rows, group duplicate exceptions first and identify the shared failed step. If staff notes contradict the procedure, record the conflict rather than choosing a side. Take that row to the process owner with both sources and ask for a decision on the intended method.