Root Cause Analysis GRBUS 611, Quality Management Duquesne University Instructor: Hank Sobah

Root Cause AnalysisGRBUS 611, Quality Management

Duquesne UniversityInstructor: Hank Sobah

Root Cause Analysis

What is it?

Understanding problem sources?

How does RCA work • methods, process, and tools

Example of Uses of RCA?

Root Cause is…

The most fundamental reason a problem has occurred when performance does not meet

expectations

Defining Root Cause Analysis

Root Cause Analysis (RCA) is…

The determination of the most basic cause of an event which, if corrected, will prevent recurrence.


Root Cause Analysis Goals:

To find out: What happened? Why did it happen? What do you do to prevent it from

happening again?


Root Cause Analysis is:

A tool in the systems approach to prevention not punishment of adverse events

A tool in the effort to build a “culture of excellence”

A process for identifying basic or contributing causes

A process for identifying what we do about it to prevent recurrence


The Role of RCA Champions

Select the RCA team members Select an appropriate RCA

methodology Provide training to the RCA team on

RCA techniques and tools Establish a schedule Keep the team on schedule


Characteristics

Inter-disciplinary Involves those most familiar with the

process Digs deeper by asking, why, why, why??? Identifies changes that could be made to

systems and processes to eliminate error Impartial as possible


The Whole Point:

Is to help us avoid or eliminate problems now and in the future

By developing action plans to make things better

And moving “beyond blame”


To Be Thorough, RCA must include:

A determination of human & other factors; & related processes & systems

Analysis of underlying systems through a series of “why” questions

Identification of risks & their potential contributions

Determination of potential improvement in processes or systems


To Be Credible, RCA must:

Include participation by the leadership of the organization & those most closely involved in the processes & systems

Be internally consistent Include consideration of relevant

information and related literature


Systems and Processes

85% of problems are the result of the system or process

A process is the sequence of activities which transform inputs into value-added outputs

A system is formed by the grouping of interrelated processes

Understanding the Source of Problems

Procedures and Performance

Procedures are written instructions for performing work

Performance is the measure of whether the intent of the written procedures has been met


Attitudes and Behavior

Attitudes represent thoughts and emotions which motivate action

Behavior is the visible manifestation of attitudes


Risk Tree Analysis

Uses a system-based schematic to identify safety-program oversights, errors, and omissions; and optimize allocation of resources to mitigate hazards

Also called MORT, or Management Oversight and Risk Tree Analysis

Overview of RCA Methods

Events & Causal Factors Analysis

Uses sequence diagrams and charts as a method to determine events and causal factors contributing to the occurrence of a problem


Fault Tree Analysis

Uses reliability and logic sequence techniques to identify potential reliability failures for complex and dynamic systems


Barrier Analysis

Examines the existence of controls to determine if an event was caused by their failure to prevent unwanted action


Change Analysis

Compares successfully performed activities to those that were unsuccessful to determine differences as a source for problems


RCA and Decision Making

Change systems/processes Revise/Develop new procedures Identify the need for training Identify the need for employee

counseling Insitute a preventive action

Managing the RCA Process

The results of root cause analysis is used to:

Corrective vs. Preventive Action

Corrective action is taken to mitigate the immediate effects of a deficient condition in order to eliminate a problem or hazard

Preventive action is taken to modify a system or process in order to eliminate or reduce the recurrence of a deficient condition


Monitoring System Effectiveness

Identified root causes, when corrected, prevent recurrence

Proper techniques and tools are utilized

The results of analysis are properly documented


RCA systems must be monitored to ensure:

RCA Tools

brainstorming flowcharting cause & effect

diagrams pareto charts barrier analysis change analysis checklists

failure mode, effect & criticality analysis

tree analysis interrelationship

digraph planning matrix questioning attitude

RCA Tools

Basic Brainstorming

Invented by Alex Osborn in the 1950s Used to generate ideas and stimulate

discussion Can be structured or unstructured

RCA Tools

Basic Brainstorming

Exercise

You’re on a desert island and all you have is a belt.How do you use it?

RCA Tools

Flow Charting

Provides a pictorial representation of a work process

Shows the sequential relationship between tasks or activities

Is used by a team to identify process related causes of problems

Is done using standard symbols to ensure understanding

Is also referred to as process mapping

RCA Tools

Flow Charting

RCA Tools

Start/Stop

Document

Decision

NewPage

InspectionOperationYes

No

Flow Charting

RCA Tools

A

Alarm Goes Off

Have Extra Time?

Hit SnoozeButton

Get Up

Look in Mirror

OK?

Shower Brush Teeth andComb Hair

Select Clothes

Get Dressed

Yes

Yes

No

No

Flow Charting

RCA Tools

A

Hungry?Have Time?

Fix Breakfast

Cereal Eggs & Bacon

Leftover Pizza

Eat Breakfast

Go to Work

Yes

Yes

No No

Barrier Analysis

Provides a way for evaluating an idea for advantages and disadvantages

Is used in problem solving to identify issues impacting a proposed solution

Provides a starting point for implementation planning

Is also called Force Field Analysis

RCA Tools

Barrier Analysis

RCA Tools

Exercise

Analyze the ‘value’ of attending an MBA course and obstacles to attaining that value

Cause & Effect Diagrams Invented by Kaoru Ishakawa in 1943 Used to represent the relationship

between a given “effect” and the possible “causes” influencing it

Used by a team to identify, explore, and display the causes for a specific problem or condition

Use standard headings for sorting the various causes

Are also called fishbone diagrams

RCA Tools

Cause & Effect Diagram

RCA Tools

RoomNot

Available

Forgot to confirm Language

Other guestextended

Minimal training

Overbooked

Rooms under repair

Computer Down

Equipment Material

MethodsPeopleNo Confirmation

Furnace Broken

Tree Diagrams Used to display the relationships between

elements of a process or system Help a team understand how activities in a

system or process affect each other Assist in data collection and organization

by providing a way to organize ideas and concepts

Are used by a team to identify system related problems

Are also known as Affinity Diagrams

RCA Tools

Tree Diagram

RCA Tools

QUOTE WORK DO WORK DELIVER WORK

Ship Parts

Bill Customer Receive OrderReceive PartsSpecify Job RequirementsProcess PartsAudit Completed PartsPackage PartsLabel Parts

Get Sample from CustomerEstimate Cost for the JobSend Quote to CustomerReceive Customer Response

Interrelationship Digraphs

Used to represent inputs and outputs between different items

Assist in identifying communication and information flow paths between functional areas

Help a team understand how activities in a process or processes in a system interact with each other

Assist a team organize ideas and concepts Also are referred to as system relationship

maps

RCA Tools

Interrelationship Digraph

RCA Tools

Leadership

QualityResults

StrategicPlanning

Information& Analysis

ProcessQuality

WorkforceExcellence

CustomerSatisfaction

Interrelationship Digraph

RCA Tools

Quote Work Output/Input Do Work

Get Sample from Customer

Estimate Cost for the Job

Send Quote to the Customer

Receive Customer Response

Receive Order

Receive Parts

Specify Job Requirements

Process Parts

Audit Completed Parts

Package Parts

Label Parts

Part Requirements

Problems with Parts

Order Details

Planning Matrix

Helps a team organize multiple tasks Provides a visual display of individual

assignments Can be used to show tasks vs time or

tasks vs responsibility Scales used must be clearly defined and

agreed to Is often used to track task performance

RCA Tools

Planning Matrix

Manager Employee Payroll

Identify work

Get Resources

Do Work

Evaluate Work

Cut Pay Check

Cash Check

Be Happy

Planning Matrix / Swim Lane Diagram

Man

agem

ent

Em

plo

yee

Pay

roll

ID Work

Get Resources

Do Work

EvaluateWork

Cut PayCheck

Cash Check

Be Happy

Checksheets

Are used primarily as a tool for collecting data

Identify the data needed by type and source

Provide space for recording data and information

Help ensure all required information is obtained

RCA Tools

Questioning attitude to guide process

Questions (6 categories) help guide team

Human Factors Communication Human Factors Training Human Factors Fatigue Environmental/Equipment Rules/Polices/Procedures Barriers

RCA Tools

RCA Process Steps

Define the problem Collect data Analyze problems for cause Identify solutions to prevent

recurrence Plan implementation of solution Present results Monitor and evaluate actions taken

RCA Process

Problem Definitions

Need to be clear and concise Should use outcome based wording Should be process or system

focused Must have everyone’s buy-in

RCA Process

Collecting Data

Is used to complete the problem definition

Is critical for determining causes and potential solutions

Provides the basis for sound decision making

Helps establish a baseline for improvement

Must be planned

RCA Process

Problem Analysis

Provides a method for determining the actual cause from many possible

Helps a team reach consensus on the root cause for a given problem

Helps to sort causes from symptoms

RCA Process

Contributing Factors

Additional reasons, not necessarily the most basic reason

Bottom line: if eliminated, would it prevent a similar adverse event or close call

RCA Process

Root Cause Statements

The staff violated a procedure by not performing an environmental assessment resulting in construction problems and project delays.

RCA Process

Root Cause Statements (cont)

Examples

An informal norm had been created where procedures related to environmental assessments were not followed, which increased the likelihood this procedure was violated, resulting in problems laying the foundation and delaying the project.

RCA Process

Root Cause Statements (cont)

Further refined by the team

An informal norm had been created where procedures related to environmental assessments were not followed, which increased the likelihood this procedure was violated.

The norm was created due to lack of positive incentives (e.g., allowing time in the schedule); and negative incentives (e.g., completion of these tasks part of performance review)

RCA Process

Litmus test of Causation

Ensure that system or process rather than blame is in the root cause statements.

RCA Process

Identifying Solutions Provides a way to finalize the results of

analysis Needs to clearly define the recommendation

or change Needs to tie back into the process or system

being analyzed Needs to include measures for determining

if the solution was successful in solving the problem

Usually includes the results of barrier analysis or cost/benefit information

Provides input to implementation planning

RCA Process

Action Plan

May be the most important step Develop & implement improvement

strategies Should address system/process

deficiencies Includes measures

RCA Process

Action Plan (cont’d)

Example:Align the incentives to change the informal norm: provide more time in schedule for completing environmental assessment tasks; make completion of safety related surveillance part of the performance review.

RCA Process

Action Plan Follow-up

Assign responsibility for each action item Develop a “tickler” system for tracking Assess effectiveness of each action item

RCA Process

Action Plan Follow-up

Example outcome (action follow-up)

90% of staff will have been scheduled time to do assessments

95% of staff will have new performance review measures

RCA Process

Implementation Planning

Helps a team plan implementation of a proposed solution

Provides a visual display of tasks, responsibilities, and resources

Helps a team hand-off an activity to another team or to management

Is also used to track activity/task completion

RCA Process

Presenting Results

Used to “sell” the solutions or implementation plans developed by the team

Must be planned and supported by data and analysis

Must have the full support of all team members

Are usually organized around four major concepts - building trust, establishing need, filling the need, and obtaining commitment

RCA Process

What does a good RCA look like?

The Root Cause is

Internally Consistent

Thorough, and

Credible

RCA Process

What does a good RCA look like?

The Complete Root Cause Analysis is 1. Inter-disciplinary, involving experts from the

frontline services 2. Involving of those who are the most familiar

with the situation 3. Continually digging deeper by asking why,

why, why at each level of cause and effect. 4. A process that identifies changes that need to

be made to systems 5. A process that is as impartial as possible

RCA Process

What does a good RCA look like? (Cont)

To be thorough a Root Cause Analysis must include:

1. Determination of human & other factors 2. Determination of related processes and systems 3. Analysis of underlying cause and effect systems

through a series of why questions 4. Identification of risks & their potential contributions Determination of potential improvement in

processes or systems

RCA Process

What does a good RCA look like? (Cont)

To be Credible a Root Cause Analysis must:

1. Include participation by the leadership of the organization & those most closely involved in the processes & systems

2. Be internally consistent

3. Include consideration of relevant information and related literature

RCA Process

How are the RCAs Used?

Example:

VHA Correct Surgery Directive

National Center for Patient Safety reviewed Incorrect Surgery RCAs

RCA Examples

How are the RCAs Used? (Cont)

NCPS Synopsis of reported incorrect surgery in VA:

44% left-right mix-ups on the correct patient

36% wrong patient 14% wrong implant or procedure on

correct patient 7% wrong site (not left-right issue) on

correct patient

RCA Examples


VA evaluated events reported in RCAs and found that:

1. 45% of the incorrect surgery cases studied would have been prevented if the informed consent process included site (w/laterality), name, and reason for the procedure

1.

2. 65% of the incorrect surgery cases would have been prevented if the surgeon or other privileged provider marked the site in concert with the patient

RCA Examples


3. 75% of the cases would have been prevented by having staff ask the patient to say his name, social security number or birth date, and the site of the procedure – and checking the given answers against the mark and records

4. 85% of the cases would have been prevented by taking the “time-out” in the OR

RCA Examples


5. 20% of the incorrect surgery cases would have been prevented by having two members of the OR team check the diagnostic images.

.

RCA Examples

RCA Group Project

A - 1986 Space Shuttle Challenger ExplosionB - 1999 Texas A&M Bonfire TragedyC - 2007 I-35 Bridge CollapseD - 2004 Paris Airport Collapse

Documents

Root Cause Analysis GRBUS 611, Quality Management Duquesne University Instructor: Hank Sobah