Author Archives: Ed Skompski
My grandmother (with whom I spent many of my childhood weekends) would say to us grandkids, “You can’t see the forest for the trees!” That usually came right after something bad happened or we did something that was not considered “right” by the adults. I always wondered what that meant, I have thought about it for years and I believe from an adult perspective I finally get it… Granny Lillie, if you can hear this, “I FINALLY GET IT!” (I hear her saying, “It is about time……sheesh.”)
As I have worked with healthcare organizations over the past 20 years working to improve performance and improve their systems we always talked about examining failures and finding the causes. Finding the “Whys” is the step necessary for you to fix issues that existed. Those issues that underlie our systems and turn into incidents, accidents and breed adverse behaviors have to be removed following a problem so that we can prevent reoccurrence. This is preached, taught, and required by all organizations in today’s business world. But why do we wait, why do we have to fail to learn? That question has always concerned me. This is where my grandmother fits in…
When as kids we would go out, make decisions to do things that had adverse outcomes, she would always say to us “you can’t see the forest for the trees” and we would just nod our heads and say “ok” then continue on our merry way. Not only would we not learn from our mistakes but we could not see the mistakes and incidents they happened. The correlation in today’s adult world from an organizational perspective relates to making decisions without considering the consequences. The “Trees” from the statement above is the change you are going to make. If you focus on the “Trees” in front of you and do not consider the future beyond that “the Forest” you are taking unnecessary risk and possibly creating problems. Do you “get it”?
What got me thinking about this today came from an article I read which dealt with an investigation by the State’s Office of Inspector General at a Louisville, KY hospital. This along with the TJC visit which found many problems at the facility prompted concerns. The investigation was prompted by complaints by staff (that survived the downsizing) regarding health and safety issues due to the decreased staffing. After reading the article I immediately began thinking about our Proactive Flow within the TapRooT® process.
Notice that when we get to step 3 in the Proactive flow we take the observed issues or problems and ask the simple question, “What could result from this?” We would pose this question against our view of the future system. Let’s suppose that they had recognized these future conditions:
- A reduction in staffing would create a significantly higher workload for existing staff
- Hospital maintained customer/patient throughput with reduced staffing
- Using traveling nurses with little or no facility or system related training to supplement staffing levels
- Reduced staffing could cause difficulty in maintaining the Quality Control standards due to pressure based on census
We can now take this information and use that “What could result from this?” and we could have had this conclusion:
a) Training – No Training – Decided not to Train
b) Management System – Standards, Policies and Administrative Controls NI – Not Strict Enough
c) Work Direction – Preparation – Scheduling NI
d) Work Direction – Selection of Worker – Not Qualified
And there certainly could have been others. At this point you have the ability to re-evaluate the changes you are about to make and ensure that the programs put in place following this down-sizing remove these potential problems. This allows you to evaluate the “Forest” behind those “Trees” and ensure the safety of your future patients and staff while working through the “Forest.” If this one hospital had performed this analysis the outcome and where they are today could have been significantly different.
By using this thought process and by being Proactive we can all create safer systems, create a more effective and acceptable working environment, and protect those around us that depend on us… just as Granny Lillie tried to do for us kids so many years ago. Sometimes the simplest, most practical viewpoint is the best. If you have any questions about the TapRooT® process for Proactive assessments please contact me directly at email@example.com.
I was teaching a class (not in the healthcare arena) and had some interesting discussions around the use of procedures during work. First let’s recap the TapRooT® Definition of a procedure:
A procedure is a written step-by-step description of how a particular task is to be performed that is read and followed during performance of the work by the person performing the work.
A checklist is considered a procedure in our system. For this company there were two perceptions regarding procedures and their uses:
- Those are only necessary if there are people who are not knowledgable on the task.
- Those procedures always make work more difficult.
Now, I have heard these comments before from folks in the healthcare field when the work procedure is used not for a medical “procedure” but when it is used as a checklist. Many doctors and nurses don’t like having to follow a specific path towards medical treatment. And I agree because each human is different, each course of treatment is different, and every scenario is different that it is more difficult to set procedures for every medical treatment. But can tasks and scenarios benefit from the use of checklists within healthcare?
The following article talks about the use of checklists and examined 10,700 surgical procedures. The results although only showing small decreases did show that the implementation of quality checklists dealing with Surgical Safety reduced the following:
Length of Stay from 10.4 to 9.6 days
30-day Readmission Rates from 14.6 to 14.5%
90-day Death Rates from 2.4 to 2.2%
Small numerical changes equate to large numbers in the overall scheme of healthcare. From a 2010 National Hospital Discharge Survey and the National Center for Health Statistics showing some 51.4 million inpatient surgeries performed, that means that we can reduce the number of readmissions by 51,400 patients, and the 90-day death rate means we lower the number of deaths by 102,800 patients. Now I am not sure if you agree but that is a SIGNIFICANT impact on patient care. Those are numbers that could provide pause for those who don’t think checklists can be used in healthcare!
Now going back to our two objections above, let’s now think about why procedures, when implemented and designed properly, can improve performance.
Those are only necessary if there are people who are not knowledgeable on the task.
Procedures can be built to contain a level of information that can be helpful to both experienced and non-experienced practitioners. The idea that just because you have a lot of experience that you cannot make a mistake is unacceptable today. We are fallible, we are human, so why can’t we accept help? I believe it is perception, see comment 2 above:
Those procedures always make work more difficult.
Perception is reality and if people don’t believe or understand why you implement these checklists and don’t implement them effectively then this is understandable.
Here is what checklists help you do:
- Not rely on short-term memory
- Become more consistent in an approach to a job
- Remind and caution against unsafe behaviors
- Document the way work is “expected” to be performed
These four items alone are work an additional 2-3 minutes of time it takes to address and use the checklist, don’t you think?
From the numbers above, and the possible impact on patient care the use of checklists where reasonable is a very simply and effective way to raise the level of performance of your staff and have a very positive impact on patient care. If you would like more information on this or other topics around the TapRooT® system and how it impacts human and equipment performance please feel free to contact me at firstname.lastname@example.org.
Today’s article is meant to create a discussion. We all know that Electronic Medical Records (EMR) are taking the place of written orders in healthcare (providing their own set of issues), so where does the written word fall on the Root Cause Tree®?
The cartoon below illustrates the issue we are discussing:
So thinking about written communication, if we have a Causal Factor dealing with a nurse or physician did something wrong due to a misunderstanding of a written communication…where would we go under the “Human Performance Difficulty” section?
One question that would most likely be a yes is the second question under the Team Performance Section: Did failure to agree about the who/what/when/where of performing the job play a role in this problem?. This leads us to Training, Communications, and Work Direction but does that really match?
For this week please provide your insight into where you believe this issue would fit. Thank you for reading and for providing your insight! I will write about our results in next week’s article! Have a great week……
(P.S. Don’t forget to sign up for my Medical track at the 2016 Global TapRooT® Summit, San Antonio, August 3-5, 2016.)
So many times when I review Sentinel Event (SE) analyses for companies, I struggle to find the link between a Root Cause and the data on the SnapCharT®. But at the same time, the Corrective Action provided for that cause makes sense to reduce the likelihood of recurrence. This is perplexing as I did not want to say that the analysis was done poorly or was not correct simply because the outcome would probably be a positive one. Then it hit me, many people when going through the Root Cause Tree® were focusing more on the outcome desired than what the data told them.
Our ultimate goal is to fix a problem, reduce risk, and keep our patients, patients’ families and staff safe. To do so we have to present a very coherent, logical argument back to our administration regarding our analysis and findings. I represent this with the following diagram:
The issue that prompted this article relates to how people go through the Root Cause Tree®. As the user gets down to the Root Cause level I begin hearing people making declarations, “We could fix this issue by labeling the medication better” and with that statement the team puts a positive checkmark by Labels NI. What is wrong with this statement and action? Nothing upon first glance if it is true that a better label could prevent recurrence.
Digging deeper, these types of thought processes are actually working in reverse of what we teach. We teach to look at the data on the SnapCharT®, read the definitions to determine if the data supports selecting Labels NI. Based on our teachings we should hear statements such as, “Do I have an evidence (on my SnapCharT®) that tells me that the labeling present at the time of the event contributed to this Causal Factor (and thereby to the Incident)?” Notice that one quote is a question and one is a statement and therein lies a key difference. As we work through the analysis we should be questioning our data versus the definitions and items in the Root Cause Tree® not stating how we could fix the issue. Once we have the Root Cause, we can then work on a Corrective Action to fix the Root Cause.
In conclusion if we choose the Corrective Action first followed by a cause that justifies that action, the investigative team has created a break in that “Specific Relationship” from top to bottom. That break is between the Causal Factor/Root Causes and the data collected on our SnapCharT®. Without data on the SnapCharT® to support the Root Causes you present to your management team, you put your analysis in question. Without belief in the analysis management will be less likely to provide you the resources you need to fix issues and improve performance.
If you would like more information on this or any topic relating to the use of TapRooT® in Healthcare feel free to contact me directly at email@example.com or at (865) 539-2139.
I attended the Ohio Association of Healthcare Quality (OAHQ) Conference in Columbus last week and gave a talk on this subject. In any industry there is always some level of impact that senior leadership has on every process and system. From their expectations for the staff through their desire for the organization and business, these expectations become the guidelines within which we work.
When I talk to healthcare professionals I always hear the positive and the negative (usually in reverse order), and it is very rare that anyone is only on one side or the other. There is usually a mix. Some of the things I hear about are as follows:
- Unreasonable expectations for timelines in determining root causes
- Not providing a charter or guideline that provides the responsibilities of the team and communicates the abilities of the team/team leader
- Messages communicated from the Administration do not match with the “reality” of our working environment
- Corrective Actions that are recommended are not always implemented or followed and are substituted with managements own ideas that are not in alignment with the findings
- Our team feels like we are provided the necessary support to gather what we need to gather to understand the event
- Management supports our efforts to implement corrective and preventative measures following an adverse outcome
- The organization is very much a proactive group who truly want and desire to make our systems the best they can be
Now, looking at this list, we truly see how these issues are polar in ways. Different organizations have the opposite opinions from their counterparts. This is to be expected as each organization is different.
Looking at these comments and thinking towards TapRooT® and our Root Cause Tree®/Dictionary, where would these issues (if found to be causal factors) show up in the analysis? Well there is one primary area where I believe these truly match:
Management System – How Policies and the Actions of the Management System Impact the System
Of course this is not the only area that could show up as every investigation is different but these most certainly could have impact. And in addition to that, when investigating events you have to look at the outcomes (not root causes necessarily) from previous similar events. This portion of the analysis will gather data that could lead you to multiple root causes:
Management System->Corrective Actions->Corrective Action NI or Trending NI: If it is found that previous corrective actions were never implemented, or were not as effective as they could be you might be led to and those decisions were directly related to management decisions to change alter or not follow-up to see if the actions worked.
Management System->SPAC Not Used->Enforcement and/or Accountability: When examining events, if it is found that due to a lack of support from senior leadership to uphold investigative charters or uphold the level of responsibility given to the investigative team, then this could most certainly be a Management System issue.
These are just a few examples of how past performance can impact the events you investigate today. My recommendation is to always talk to people in your Management System to understand their expectation and compare that expectation to the actual messages received and heard throughout the organization. Then compare those messages to what happened during the event analysis to assess the actual impact. You might be surprised at what you uncover.
If you would like to know more about the TapRooT® process and our investigative philosophy please contact me directly at firstname.lastname@example.org or attend one of our training courses held worldwide www.taproot.com/courses and learn how TapRooT can help you improve performance. Thank you for reading!
This week’s article is not so much based on RCA principles but on the decisions that senior leaders make and the consequences of those actions. I always highlight from an RCA perspective the impact of the messages and communications from senior leadership down through the organization and the possible negative consequences. But this takes the cake… or the donut, if you will.
Saw an article today about the University of North Carolina’s decision to remove the name of their newest (7-month-old) corporate sponsor off of their UNC Children’s Clinic. That corporate sponsor… wait for it…
Now, I am surely no marketing genius (my strengths are more in the training and RCA world) but could anyone associated with the organization see past the $$$$ to know that this was not a good idea? In today’s money driven society there are reasons that sponsors are invited, and in most cases these are due to a lack of funding and a desire to continue doing good deeds and good work. But sometimes the word “NO” is very much underutilized.
What message was sent to all those Doctors and Nurses? To all the parents bringing their children for care to the clinic? Is it the health, care and safety of their young loved ones? Or is it something else? I certainly don’t want to be treated for a clogged artery in the “Beef it’s What’s For Dinner Cath lab”, or be treated for a peanut allergy in the “Peanut M & M’s Allergy Center.”
Now if you read the full article the name was tied to a fund-raising race and the Clinic and UNC’s dedication to it. But always remember that what you perceive the message to be may not be what is received. I have worked with investigations where too many times the Administration says one thing and a totally different message is received. From an RCA perspective in the diagram below you will see that the Administration/Management interview circle is dotted… in TapRooT® circles that means an assumption or unknown.
From a data gathering perspective, this means that I need to compare what Administration/Management believes/says/communicates is what is understood by the masses. To understand if the true message has reached those who need it. And in the case of this article I believe that they totally missed the mark with all the right intentions. Let me know what you believe in the comments below.
If you would like to know more about TapRooT® or if you have any questions you can contact me at email@example.com or you can find out about our public course offerings at:
Can a Difference in Opinions from the Top to the Bottom of a Healthcare Organization Impede Performance?Posted: May 9th, 2016 in Medical/Healthcare, Root Cause Analysis Tips
I love reading about current events to stimulate the mind and to be in tune with what is happening in the world. Sometimes you simply stumble across an article and it immediately hits home and speaks to you. This article spoke to me and resonated with many questions I am asked during our Root Cause Analysis courses.
When we begin discussing the “Management System” category on our Root Cause Tree®, and get to the “Oversight/Employee Relations” Near Root Cause, I always get a lot of what I will call “Automated” nods. So, I always lead into the discussion talking about how when investigating we need to get a gauge on the messages being sent from the top, and the beliefs at the bottom. In so doing, we end up measuring both sides of a conversation. And many times the messages are the same, with the normal personal spin. But sometimes you come across data that suggests otherwise.
The article discusses the issues with changing EHR systems and impact on care. The discussion has perceptions from different groups within the polling group and there is a startling disjoint from the top down to the organization. See the following two statements:
Nursing staff reported being highly affected by the EHR replacement, but had virtually no say in the replacement decision, according to the survey. While 90 percent of nurses said EHR replacements reduced their ability to effectively provide hands-on care, 96 percent of nurses said they were not included in EHR replacement planning.
However, just 5 percent of hospital leaders said the EHR replacement process had a negative impact on care, which Mr. Brown said suggests executives are reticent to address the issues. ‘In our experience polling, most executives will not admit they were oversold or that their IT decisions had adverse bearing on patient care,’ Mr. Brown said. ‘On the other hand, workflow changes and productivity issues may have added to the disappointment nurses felt after being left out of replacement EHR product evaluations.’
If I were investigating an incident at one of these hospitals and was interviewing both Administrators and Nurses around a Sentinel Event, this would raise some very large concerns in the organization. Why is there such a large chasm in beliefs here and what kind of impact could this have on performance. In our system this would likely lead us to the Management System->Oversight/Employee Relations->Employee Communications Root Cause. With Management having such a different perspective on how work is being performed, we might answer yes to the following question from our Root Cause Tree® Dictionary:
Did management’s employee communications program fail to communicate management’s concerns for quality workmanship, safety, and the environment?
When a message that is sent from the top of the organization does not support the actual work performance of the organization, employees would certainly believe that the top tier does not show the correct level of commitment to being a high performance organization.
If you would like more information on how TapRooT® can help your hospital or health system become more efficient and provide safer patient care please attend one of our TapRooT® training courses or contact me directly at firstname.lastname@example.org.
When we investigate events in healthcare, we are looking for the systemic causes of failures, both human performance based and equipment based. When looking at individual events we cannot exclude other related or similar events in our data gathering process as we should be learning from those as well. So if it takes research to see that staffing levels are affecting patient care, then we need to look at our long standing RCA programs and ask are we doing everything we can to understand the bigger picture?
A recent article highlighted this issue with true clarity. The research told us that there is a link between Nurse staffing levels and the quality of care provided. Now, I could go through and show you how TapRooT® helps you find the “Scheduling NI” root cause or the “SPAC NI-> Confusing or Incomplete” root cause and how it fits these types of events. Looking at this I see it in the bigger context of an organization and the bigger picture is understanding and “listening” to the data and what our process is communicating to the organization.
Looking back at the original research and tying things back to RCA it became clear that we have some larger systemic issues that we are not addressing. These may include Trending of RCA data, communication of issue within our hospitals, and data collection during event analyses. Any of these three puzzle pieces could lead us towards the same conclusions found in the above article. So why does it take us so long to see “Generic Issues”? Well here are a couple of my ideas or hunches, if you will, on this issue:
1. Do we truly want to learn or are we satisfying a “requirement”?
Regulation is a necessary evil in our society… many times it seems that doing the “right” things are not as commonplace as it once was. So through regulation we “require” diligence, we require analysis, we legislate what should be done anyway. With this there truly are two trains of thought, compliance mentality and improvement mentality. The compliance mentality is what I highlight here. If we have the compliance mentality we only do because we have to, which usually means meeting the letter of the law and no more. Checking a box does not mean we listen to the data or what our systems are telling us and many times it leads to only the corrective measures we can get away with at a minimum. Is this acceptable when adverse outcomes can cost the lives of the ones we commit to serve, aid and protect?
How do we change this mentality? Understand the value of the use of Root Cause Analysis within the organization and work to make it part of the everyday job of each employee to improve their jobs, their productivity, and empowering them to bring about change in an organization. This means tackling the everyday issues with RCA and not waiting to fulfill a requirement. Expand the scope through empowerment for change.
2. What is our commitment to “listening” versus “hearing”?
Confronted with my own personal family issues around this very issue has brought this to the forefront of my mind. When people are recovering from traumatic injuries and are being helped by others there is a tendency to be overwhelmed by the “claustrophobic” nature of personal care from a loved one. The feeling is that they are complaining at me so much that I am overwhelmed, and am listening but can’t take all this information. When in fact they are “hearing” everything said, but truly are not listening to the messages for various reasons.
This can be like a corporate culture, are they “hearing” or “listening”. There is a huge difference in these two things that many people simply don’t get. Too many times we have people report issues or problems or near-misses because we say “We are Listening to you”, but we truly are only “Hearing you” in the absence of acting on the data. Generic issues (which I have written about before) are something that you have to be willing to “listen” for through your RCA and Report data. Data provided to your organization will tell you a story, it will provide you with indicators or precursors that help you predict the future. Now is it an exact science, no, but it doesn’t have to be if you “listen”. In my opinion too many organizations want to make their employees and clients feel “heard” but are not willing to actually listen and act upon what they are being told.
Changing this behavior is not as simple as it may sound. It is truly a change in the corporate culture of an organization, the “walk the walk” versus “talk the talk” mentality. This can be started simply by the communication from management through to the folks on the front lines of how RCA data and corrective actions are handled. Allowing people to see that they have the ability to enact change. Then making sure that the proper trending and “listening” tools are in place to understand what the reported data is telling you. These two pieces can paint a very cohesive picture of how the organization is performing. Process Behavior Charts, Pareto Charting, and other basic data analysis tools are built into the TapRooT application to aid in doing this.
Within this discussion there are probably many other reasons why we can’t or won’t see the bigger picture and I would love to hear your theories and thoughts on this issue. The two issues I raise above are two good starting points to making your organization more efficient. But improvement opportunities abound throughout your organization, but they can only be found if you are “listening” and heed the messages being sent to you from your employees and from your systems. Don’t wait for research to tell you where your problems are, listen and act upon what you already know and bring your organization ahead of the curve.
If you would like more information about the Trending tools recommended and provided by TapRooT® please feel free to contact me directly at email@example.com or plan to attend our 2-day Trending Course held before our TapRooT® Summit this August in San Antonio TX.
In our classes we talk about enforcement, changing behavior, and creating the workplace we all envision we should have. Through all these discussions around behavior we talk about moving from Infrequent, Uncertain Negatives, to the use of Soon Certain Negatives to quickly change behavior. Producing a culture of “Reluctant Compliance” because no one is happy with this negative change but are forced to comply to avoid negative reinforcement. This “Reluctant Compliance” over time will turn into the norm, the reality of working in a strictly run workplace. Once the compliance is the norm and deviation is the oddity we can then transition to the next critical step… moving on to the use of Soon Certain Positives to create a long-term positive environment.
Within this Soon Certain Positive phase there is the discussion of using rewards in place of discipline to enforce the correct behaviors. So what is a reward? According to Merriam-Webster online dictionary, a reward is the following:
“to give money or another kind of payment to (someone or something) for
something good that has been done”
So by that definition we can look at the following rewards:
- Money or financial incentive
- Cash, donation
- Some kind of gift or recognition
- Coffee mug, plaque, pizza for lunch
When I look at the list above and I think of even simpler rewards that can be provided in the workplace. On that brings my mind back to a simpler time in life… kindergarten. Thinking back, how were we rewarded then? With one simple phrase,”Great Job!”
Being told that you are performing well along with a pat on the back or pat on the head meant the world. If we translate that into adulthood, that same phrase (although it can be used in the same way) is usually translated into a much more infrequently used comment, ”Thank you!” Truly the simplest form of recognition is to be told, “Great job, and thank you.”
This kind of recognition if used genuinely can be one of the greatest forms of behavioral modification. Both for the thank-er and for the thank-ee. Both benefit from the recognition of a job well done and the simple note that someone truly has seen and recognizes that, and even more importantly appreciates it.
If you would like to read a great article on the use of this simple form of behavior modification and humanity, read the following article:
The article talks about the Healthcare environment but can translate into any workplace in the world. The simplest of things can have the greatest of impacts.
If you enjoy articles like these, please sign up for our weekly Friends & Experts eNewsletter, delivered to your inbox every Tuesday morning. Email Barb at firstname.lastname@example.org to subscribe today!
As we on focus patient safety during this week, I thought it prudent to examine one of the more important aspects of providing a safe environment of care for our patients, the use of Root Cause Analysis (RCA) to prevent future events. If we perform very thorough objective analysis, we can build corrective and preventative measures that will improve our systems and reduce or remove the chances for future similar events.
In the case study below, we’ll examine a medication error that affected one patient, could have affected two patients (due to swapped medications) but did not due to the quick response by the treatment team. Learn to better analyze and create a safer environment for our patients, staff, and community.
DOWNLOAD this white paper.
I often wonder about the thought process that goes into corrective and preventative measures. My gut feeling is that many times we go straight to the same old ideas because they are comfortable, we have knowledge of them due to past use, or simply because they are easy. Whatever the reason, I think we need to remember as TapRooT® users we have many tools at our disposal (SMARTER, Corrective Action Helper®, and Safeguards) to aid us in building better fixes.
A friend told me a story about the death of a relative due to a Unintended Retained Foreign Object (URFO). Due to the object, he ultimately succumbed to an infection and died. So I did some digging and found an article (http://www.beckershospitalreview.com/quality/4-strategies-to-prevent-unintended-retention-of-foreign-object.html) that talked about four strategies from TJC to help reduce URFO’s and started thinking about our Safeguard Hierarchy. When evaluating corrective actions we need to think in terms of protection, protecting the Target from the Hazard. In this case the Target is the Patient and the Hazard is the URFO.
So in line with this, let’s examine our hierarchy of Safeguards and see how it compares to our strategies:
With that in mind let’s look at the 4 strategies proposed by TJC:
Count process: Standardize policies for all procedures, not just those involving an open chest or abdomen. It should be the entire team’s responsibility to reconcile the count. If one member wants the count repeated, the team should comply.
Team communication in the OR: Call out when and instrument is placed in the body cavity and not promptly removed. When a policy deviation occurs, all staff should be capable and comfortable with speaking out and driving issues up the chain of command.
Tools: Items like white boards, sponge trees, radio-frequency identification technology and others should be available whenever invasive procedures are performed. Staff should be held accountable in regards to consistently utilizing these tools.
Standardize the layout: The physical space of a procedural areas should be as close to replicable as possible. While locations may vary, the equipment available should be consistent. Also, cap the number of people allowed in the procedure room. An excess of individuals in the procedural space can increase noise levels, alter visibility and ultimately distract staff.
With a simple analysis we can squarely see that these all fall within the scope of items 4-6 on the Safeguard list above with two of the recommendations falling within the scope of #4 (Standardize the layout) which deals with workspace design. The other two deal with standards and policies for both communication and the process for counting. Even one of the items (Tools) is a crossover action between standards and policies and holding folks accountable. So truly we are 1.5 actions dealing with the workspace, and 2.5 dealing with policies and procedures.
One thing that is a common thread amongst all these items is that they all depend on Human Performance to be truly effective. And although we do not want to see it or believe it, this is the weakest of all safeguards, the reliance on people. But, the fact is, our caregivers are ultimately responsible. Is it any wonder that we see the following comments regarding URFO’s?
While the frequency of URFOs dipped in 2013 after holding the No. 1 position of most frequently reported sentinel event in 2011 and 2012, the numbers trended upward in 2014 and in 2015 they emerged again as the most frequently reported sentinel event.
When we implement safeguards near the bottom of the safeguard hierarchy they will quickly raise the awareness on the issue, thus the dip in URFO’s, but over time they will not be effective (alone or in part) in truly changing the behaviors that cause these issues. We need to shift our focus to the top of the hierarchy if at all possible to truly impact performance.
If topics like this interest you, I’m leading a medical track at the 2016 Global TapRooT® Summit. Breakout sessions include:
- 7 Deadly Sins of Human Performance
- TapRooT® Changes for the Medical Community
- Human Error Causes of Quality Problems
- Writing TapRooT® Driven Preventative & Corrective Actions Workshop
- Anatomy of a Medical Investigation & more!
GO HERE to view or download a .pdf brochure.
Read a recent study that stated only 17.4% of ambulatory care nurses (surveyed) comply with all 9 precautions for infection control. Now first, for those who didn’t click above to see how the data was collected, I will let you know that this is SELF-REPORTED data (glean what you will from that tidbit of information). I would bet that compliance is actually much lower causing even greater concern.
To be fair, we are evaluating 9 different precautions. I will say that any statement that includes “wash hands” has low compliance … just walk into any men’s restroom to see that. But what would drives this? Let’s examine the items because it must be impossible to complete all of these, right? Here is the list:
- Provide care considering all patients as potentially contagious
- Wash hands after removing gloves
- Avoid placing foreign objects on my hands
- Wear gloves when exposure of my hands to bodily fluids is anticipated
- Avoid needle recapping
- Avoid disassembling a used needle from a syringe
- Use a face mask when anticipating exposure to air-transmitted pathogens
- Wash hands after providing care
- Discard used sharp materials into sharp containers
As a non-healthcare professional I don’t see a whole lot I disagree with. I mean, you are working with sick people, washing hands, wearing gloves, watch out for bodily fluids… can’t argue with that. So why do we have such low compliance? And remember this is “infection control,” so keeping healthcare professionals and other patients and staff safe.
Well, on our Root Cause Tree® we have a root cause under Management System->SPAC Not Used named, “No way to implement.” I bring this up simply to examine what we request in this list versus the very very dynamic environment in the hospital.
Can it be reasonable (except for the human self-preservation gene) to expect all of these to happen when working to save a coding patient? Or in a situation when an ER has very high census with multiple traumas (a situation I witnessed myself yesterday)?
I guess the answer truly is no. We are providing a SPAC that as written is reasonable, but can be difficult to implement during certain times. Thus, the very honest self-reported numbers.
Interestingly enough, I know the TapRooT®ers out there are all saying, “Hey dude, this is more of an Enforcement NI thing,” (you know you just did that, don’t act like you didn’t), but is it really Enforcement NI? I don’t believe in any way shape or form that you could enact an enforcement mechanism for all nine of these things, all at the same time, and give healthcare professionals the ability to perform timely patient care. The process would be so burdensome that it would crumble under the weight of its own scrutiny and patient care would suffer.
So is 17.4% compliance enough? Probably not, but let’s also remember what we are asking for people to do for that compliance. The number may not be acceptable, or palatable, but is what we can expect based on what is asked of these courageous folks working in this very difficult environment.
What do you think? Leave your comments below.
If this topic interests you, check out our medical track at the 2016 Global TapRooT® Summit. Breakout sessions include:
- 7 Deadly Sins of Human Performance
- TapRooT® Changes for the Medical Community
- Human Error Causes of Quality Problems
- Writing TapRooT® Driven Preventative & Corrective Actions Workshop
- Anatomy of a Medical Investigation & more!
GO HERE to download a .pdf brochure!
Communication has always been an issue within healthcare. From the earliest days of TJC alerts and the Event RCA guidance, communication has been a focus. There are multiple communication threads between practitioners, nurses, patients and family that create many avenues for possible problems.
As an example, I will use a story told to me by a friend regarding a recent surgical procedure. I will not try to recount the actual surgery as it is not truly relevant to this discussion. I will, however, start this story in Recovery after the person underwent surgery with no complications. During post-surgery recovery, they were provided with their formal discharge instructions from the nurse which included the following:
1) No lifting over 25 lbs for 1 week.
2) May return to work the next day.
3) Other medicine related and wound care information included.
After getting these instructions but before being discharged the surgeon came by to check on the patient and briefly discuss the procedure. During the discussion the following exchange occurred:
Patient asked the surgeon “Can I go back to work Monday?”
Surgeon asked, “What do you do?”
Patient answered, “Course setup and planning.”
Surgeon answered without hesitation, “You should be able to go back to work and perform that job without an issue”.
End of discussion.
See any potential problems with this communication? Any conflicting information? Very interesting isn’t it? Now, if we examine the duties within “Course setup and planning”:
1) Packing boxes
2) Shipping boxes
3) Lifting boxes
4) Computer work
5) Course Documentation
We can immediately determine that this job should be restricted based on the original instructions provided by the RN in the formal discharge instructions. But as with most people the words and advice from the surgeon were the ones that were heeded. My friend went to work on the next work day and continued to lift boxes that were in fact greater in weight than what was allowed. Now, in this case there was no additional injury, there were no complications, but this showed me in a glaring way how communications could cause a problem.
Now, had my friend had a complication and was forced to go back and receive an additional surgery, would this issue have been found as part of the RCA (if one were performed)? Did the communication have a role in the event? Here is a possible causal factor:
So during the examination of any event whether high or low risk, it is important to consider the impact of the spoken word. Looking into all communications that are involved to ensure that the messages sent match the messages heard. And that there are no conflicting communications that can cause confusion or set the patient or family up for failure. If you would like more information on how to consistently analyze healthcare related events using TapRooT® please feel free to contact me at: email@example.com.
Learn more about Healthcare RCA at the 2016 Global TapRooT® Summit.
Although technology has made medicine better and more consistent, this is probably something you never want to hear your doctor say.
This article raises a very fundamental question, are industries different when it comes to the causes of accidents? And even simpler, are job functions so different that they cannot have similar issues or problems?
Before we discuss this issue I want to start with a personal story. Many years ago I was giving a talk on Root Cause Analysis to a group of Physicians for a health system in Florida (about 50 if I remember correctly). The questions and discussion from the group had worked its way around to the difference in classes (jobs) within a hospital and the types of mistakes that are made. Understanding Human Performance as I do, I made what I thought was a simple statement of fact (and I quote),
Doctors and janitors make mistakes for the same reasons.
After the blank stares turned to surprise, contempt, then anger, I am sure you know the response I received. Later, once I escaped the room and was safely on a plane home, I thought about the reaction and came to the following conclusion. People truly believe that their job is different, different from any other, more important and difficult than any other. Is this perception? Or is this reality? Let’s find out …
Now, on the surface, I believe most people would say the answer to the question “Can the Cause of a Surgical Error be the Same as the Cause of an Oil Spill?” will be a stern “No”. The widely-held belief is that the causes of these two issues have to be different. A surgical error made by a physician or nurse in a surgical suite has to be different from the errors made by a highly skilled tradesman causing an environmental release. They appear as different as night and day until you dig down deep into Human Performance and realize that both situations hinge on similar human factors. Let’s begin this search by looking at these two events along with causal factors for each:
Our Sentinel Event is: Surgery is performed on the wrong patient
Our Spill accident is: 500 gallons released environment
Here are a couple of causal factors, one for each. Looking at these two different situations do you see any similarities?
Both of these causal factors, although from different industries and different situations and job types, have similar causes to them. Both deal with Management System->SPAC Not Used->Enforcement NI. Both situations show a series of behaviors that have not been addressed or fixed by supervision or management, that have happened multiple times and have become common practice. Looking at our Root Cause Tree® Dictionary, we would get a yes to the following question in the Enforcement NI Definition for both:
- Has failure to follow SPAC in the past gone uncorrected or unpunished?
I think that shows that both of these situations have common systemic problems that have led to similar behaviors. There may also be other root causes based on other causal factors and other conditions presented here. But there is at least one common thread above.
One more example from the same incident, here are two additional causal factors:
Again, both of these deal with misidentification of a critical part of the system, one the patient receiving surgery and one a valve in a process. Now before I get emails saying that you can’t equate a human life to a valve, I understand that point and that is not what I am doing. I am simply showing that the quality of the “label” used to ID something (no matter what it is) can impact the end result. There are also other root causes here that may be different based on the data presented, but there are similar Human Factors that apply to both.
And just to make sure you understand the label in the industrial example used, here is the font and the label used:
So in the end, no matter what you do for a living, no matter how educated or experienced the person is, mistakes happen because of Human Performance based issues. The same issues affect us all no matter how different we believe our systems can be. This is exactly why our system is based on Human Performance and Equipment Performance principles and not based on industry variables and conditions. Our TapRooT® system has been proven to work in any industry equally as well. The only limitation that is put on the use of TapRooT® is the one we impose on ourselves based on our own professional bias.
If you would like to learn more about how TapRooT® can work in your industry please feel free to contact me at firstname.lastname@example.org or attend one of our public seminars. Our courses can be found at www.taproot.com/courses.
Read an article this past week discussing a hospital system investing $55 million to implement an EHR platform to improve efficiency within their hospital system (15 counties across all hospitals, offices and outpatient care facilities). They stated that the $55 million would be recouped by efficiency within 6 years of implementation. My first thought was, “Man that is smart”, being able to recoup almost $10 Million a year that is good business. Then the investigator in me thought, “Why don’t healthcare companies view RCA the same way?” Interesting question isn’t it? Is RCA, its Return on Investment (ROI) and its impact within healthcare undervalued?
Every healthcare professional understands the risks involved with patient treatment and patient care. These risks many times manifest themselves as Sentinel Events which are required to be analyzed through to Root Cause, and associated corrective actions. These are very visible issues that not only are known to the hospital but to the neighboring communities (at a minimum in today’s fast paced social network society). Doing some research I found some very interesting numbers provided by various sources that made me think, are we undervaluing the ROI from good root cause analysis of Events and issues in Healthcare.
From the Sentinel Event Alert #55 issued in Sep 2015 the following data on falls in healthcare is provided:
- Since 2009 there have been 465 reports of falls with injury (Sentinel Event Database)
- 63% of these reported falls (Sentinel Event Database) resulted in death
- The average cost of a fall with injury is approximately $14,000 (Industry research)
The alert above did not provide the cost of an actual fatality related event, but from general industry research that provided data over multiple industries (NIOSH) the average cost of a workplace fatality is approximately $944,000 dollars including all associated costs. I am not equating the two costs to be equal, but for this discussion I would believe this number to be commiserate with costs in healthcare for a Sentinel Event related fatality if you include damage to reputation, legal fees, compensation, and lost future business (to name a few).
So doing some basic math, over the time of this study the cost to healthcare organizations for reported patient falls would be:
- 63 * 465 = 293 fall related deaths
- 465 – 293 = 172 falls with injury
- 172 * $14000 = $2.41 Million
- 293 * $944000 = $276 Million
Total $278.41 Million
So reported falls with injury or fatality to TJC cost the healthcare industry approximately $279 Million dollars from 2009 to the present. The numbers when calculated across all Sentinel Event types are staggering. So by performing a very simple cost analysis, I believe it would be fair to say that stopping these types of events would be of value to any healthcare organization. So why are we failing? Why are we not investing more into these RCA systems and education to see greater returns?
Through years of talking and working with healthcare professionals I have heard the following:
- It is hard to put a cost on what has not happened
- Being both a Risk Manager, Patient Safety Manger and wearer of many hats I don’t have time to analyze everything
- We are only required to analyze Sentinel Events
- Healthcare is a very complicated process with many inherent hazards, things just happen
- We are performing well above average as compared to the healthcare industry
- We in healthcare can’t be compared to other industries… we are different
- RCA training and processes are too expensive when I get these tools for free
Although many of these statements are at their core true, the idea that “things just happen”, or that “we are different” in my mind are not reasons, they are excuses. A harsh answer I know but that is the reality I see. If failure is considered acceptable then I can certainly understand why money is not put into effective RCA and tools for better corrective actions.
But if I look at the cost of one fall with injury (not even a fatality), I believe that there is a very good justification for a better investment into your RCA. I will use the cost I am familiar with which is the cost of our public 5-day training. One seat at a TapRooT® 5-day Course (includes Software) is $2895. You invest that money, produce a high quality RCA including measureable and trackable corrective actions and prevent 1 fall with injury ($14000), you have an ROI of 3.84 on your investment immediately.
I know that your administration might not be impressed by saving $14,000, but an ROI of 3.84 is incredible! And extrapolate the $14,000 savings out across all the Sentinel Events, or the incidents that have a high potential risk, and the possible savings from a pure cost savings could be huge. And the return is not 5 to 6 years away… it is almost immediate. Reducing your rate of falls, or medication errors, or any other Sentinel Event type by even a small percentage can show an IMMEDIATE return on that investment. Having multiple people trained and experienced in your RCA program simply becomes a multiplier towards that ROI and the improvements to Patient Safety and lowering risk.
The old saying, “Getting out what you put in” is very true when it comes to your RCA program. Don’t undervalue the impact of what a bad RCA is costing you and prove what good RCA tools can save your organization immediately. If you provide your employees with the best tools, the right level of training and knowledge, and put those tools to work, there will be a return on that investment for both your organization and for your clients/patients. If you have any questions about improving your RCA program please contact me at email@example.com or call me at 865-539-2139.
I have been teaching RCA now for almost 20 years and have found that Generic Cause is many times the simplest yet most confusing step in our RCA process. The first 4 steps from Getting Started (reporting) through Root Cause Analysis (Root Cause Tree®) move very efficiently. But transitioning from “Specific” root causes linked to Causal Factors to “Generic” causes that tie multiple events together seems to trip up many professionals.
What is a Generic Cause?
First let me start with a quick discussion of our philosophy on Generic Cause. Step 5 in the process flow above addresses this issue prior to developing your Corrective Actions. We need to first understand the “Specific” root causes from Step 4, and the “Generic” causes before we begin developing Corrective Actions so both can be addressed.
The definition of a “Generic” cause in our system is as follows:
The Systemic problem that allows a root cause to exist, across multiple incidents or sites or systems.
This is a bigger picture issue that is allowing the same root causes to exist across multiple events. So that being said, let’s dig into the article above to provide a description of a “Generic” issue.
The Duodenoscope Example
The article discusses a particular type of duodenoscope produced by one manufacturer used across the healthcare industry. This particular scope had been linked to multiple cases where infection had been spread to patients. So similar infections, when investigated by individual hospitals, provided data showing that this particular type of scope was involved. Breaking down that statement, we have the following:
- Same brand and model duodenoscope
- Used in multiple facilities over a term of 5 years
- Multiple instances of infection transmission following use of this scope
Are you seeing the pattern in this list? Something is similar in all these instances… the scope itself. Now, from the article (which does not provide any RCA data), I can only speculate on the Root Causes for this “spread of infection” as it relates to the scope… from the Corrective Actions taken by the manufacturer it looks as if there could be any of the following issues:
. . . A. Equipment Difficulty->Design->Specs NI
. . . B. Equipment Difficulty->Preventative/Predictive Maintenance-> PM NI-> PM for Equip NI
. . . . . .1. If you assume the cleaning procedures and recommendations to be Preventative Maintenance
…………..on the scope
. . . C. Human Performance->Procedures->Wrong->Facts Wrong
. . . . . .1. If here you assume the cleaning instructions are procedures and they did adequately provide
…………..information on cleaning the scope.
Any of these could relate back to the Corrective Actions which include the recall, a redesign of the scope as well as changes to the cleaning requirements.
Finding Generic Causes in Your Organization
Now looking at these causes, and the list of items that meet the definition of a Generic cause, I have to ask everyone reading this article:
How would you as an organization know that you are having Generic problems?
The answer to that question will probably vary from organization to organization but there is probably one key element. That key element is consistent Classification of events, consistent Root Cause Analysis, linking your Causal Factors (on the Causal Factor Editor) to specific Equipment types and Departments, and effective trending and data analysis. Without a clear, well defined classification schema for all investigations or incidents within a healthcare facility/system it would be nearly impossible to trend your RCA data and determine where similar causes and events are happening.
Once you get a standard Classification list together, and consistently classify your events, you can now perform a couple of different Trending functions (from the TapRooT® Software v5.3) to determine Generic Causes:
- Search your data using our Root Cause Distribution Report by filtering Classification and over a date range to see all causes produced. If you find a particular root cause across those RCA’s you may have a generic cause.
- Run a Pareto Chart using Equipment as your X-axis and Counts as your Y-axis on the chart to look at counts. See if one piece of equipment is linked to 70-80% of your causes… this might give you a clue to a Generic Issue
- Run a Process Behavior Chart looking at a Specific Classification, and run an “Instant Rate” chart or an “Interval Chart”. These would cue you in on if your rate of failure is increasing or if your time between occurrences is decreasing respectively and may provide some insight into your overall Equipment or program health.
If you have any questions about Generic Cause or any additional Trending functions please feel free to contact me at firstname.lastname@example.org
For many years, the culture within healthcare has been focused on reducing medical errors, minimizing impact on the patient through sentinel event analyses, performing proactive analyses on high risk processes using FMEA and raising awareness about risk reduction and patient safety.
All of these efforts have huge merit and a very high visibility within and outside of the healthcare community. When we enter a hospital we (as clients and patients) have the expectation to leave in better shape than we arrive. We certainly do not expect harm to come to ourselves or our loved ones but when things can and do happen the expectation is that the organizations will learn and improve. Thus resources and money are applied to the RCA programs around these visible events.
So with all these programs and efforts put towards the “clients” within healthcare I have always wondered, “Are there resources or efforts left for workplace safety within healthcare?”.
The article on “10 top safety issues for 2016” by Becker’s Infection Control and Clinical Quality Newsletter brought this thought back to me by listing the following 2 items as risks towards Patient Safety:
1) Workplace Safety, focused on the safety of healthcare workers
2) Hospital Facility Safety, focused on building or maintenance type issues
When I read the entire list it was so in line with our philosophy on the impact of systems and the workplace on healthcare professionals themselves. When we think of performing root cause analysis we think of problem solving, fixing what was wrong by implementing corrective/preventative measures and thereby creating a safer environment. If we create a safer environment for those who work in a healthcare setting, our caregivers, wouldn’t we also be creating a safer environment for patients and visitors within the same framework? I believe so.
One of the first principles we teach in all of our TapRooT® training programs involves defining the “incident” or in healthcare terms the “Event.” This becomes the circle on our SnapCharT® and by its nature is the focus of the investigation and the issue or occurrence we want to prevent in the future. The incident can be ANY problem you wish to solve, ANY adverse event or occurrence needing evaluation… it does not have to solely sit at the top of the Patient Safety or Risk hierarchy.
Let’s take a quick quiz, here is the question:
Which of these issues could be investigated using the TapRooT® Methodology?
A) Medication error resulting in long-term harm to a patient
B) Nurse strains their back trying to reposition a patient causing lost time
C) Patient spouse slips on a loose tile in the main hallway outside the Pharmacy
D) Hospital administrator slips on water leaking from the fire system in admin wing
E) Backup generator does not start in time to provide uninterrupted power
F) All of the above
Well what do you think?
If you answered “F – All of the above” you are correct! All of these problems or issues can cause adverse impact to your organization. All of these problems can cause a cascading effect on both patient care as well as employee safety.
The TapRooT® process has tools and a language that fits all these situations without having to change your RCA approach or methodology. The same thought process applies to both the clinical and non-clinical issues facing your organization. The 7-step Process Flow used in the Sentinel Event training course is the same that we use in our Equifactor® (Equipment Troubleshooting) training course, as well as our public RCA seminars. Human Performance and Equipment performance are the same from the investigative perspective no matter what the problem you are trying to solve.
So as we enter 2016, I want you think about others inside your organizations outside of the clinical organizations that can benefit from the same tools Patient Safety and Risk Management use in TapRooT®. Maximize your use of the process to maximize your return on investment in training… your facility maintenance personnel, your facility administration personnel… anyone who is tasked with problem solving and troubleshooting can benefit as well. Create a safe work environment for those closest to you (your employees), and you also create a safer environment for your clients (patients and our loved ones).
If you would like information on our training courses for Root Cause Analysis, Equipment Troubleshooting, Evidence Collection or any other TapRooT® courses please contact me at email@example.com or call me at (865) 539-2139. I would love to help you create the total environment for patient care.
Found this cartoon and truly laughed out loud (or as the Millennials put it, “LOL” or “Hahaha”). Working with healthcare has truly shown me the complexity of the business including making very educated judgments in a very complicated environment (physical and physiological). I thought this might just provide our healthcare TapRooT® users a respite from an otherwise serious job… and maybe a few interviewing questions to boot when performing the next RCA… such as “did the patient have 100+% limbs?”
What do you think? Leave your comments below.
While reading Sentinel Event Alert 55 (SEA-55) from TJC issued September 28, 2015 on Fall Prevention, it occurred to me that TapRooT® can be used to aid in finding the root causes of the fall. Even more importantly, TapRooT® can be used to aid in maintaining your fall prevention program to ensure long-term success. The TJC lists the following common contributing factors (in TapRooT® these would be called “Causal Factors“):
- Inadequate assessments
- Communication Failures
- Lack of adherence to protocols and safety practices
- Inadequate staff orientation, supervision, staffing levels and skill mix
- Deficiencies in the physical environment
- Lack of Leadership
While these are good guidelines for what to look for and what data to gather, to us these do not represent root causes. These 6 items almost match up with most of the 7 Basic Categories on the back of our Root Cause Tree®. So as TapRooT® investigators, know you have to dig a bit deeper to find the true causes and define those at the Root Cause level not at the causal or contributing level.
All this being said, the more important reason I wanted to write this article is to highlight the use of your TapRooT® tools by using them for Proactive measures. How to examine and improve your fall management program and maintain continued success. Too many times we don’t think about the power of observation and the idea of raising awareness through communication. Each of these can be highlighted through the Proactive Process Flow below:
In SEA-55, two of the actions suggested by TJC were to 1) Lead an effort to raise awareness of the need to prevent falls resulting in injury and 2) Use a standardized, validated tool to identify risk factors for falls. These two items can benefit from the TapRooT® tools directly.
Starting with step 1 above in the Proactive Flow, use the SnapCharT® tool to outline the steps in patient assessment, highlight the steps that can or will affect the fall prevention portion of patient care, then use this flow as the basis for an observation program. By getting out and observing actual performance in the field you can do two things, show your concern for patient safety (and falls in this case) and gather actual performance data. These observations can be performed both in a scheduled and/or random fashion and can be done in any setting (ambulatory, non-ambulatory, clinic et cetera).
During the observation, document findings on the SnapCharT® and identify potential “Significant Issues” as they apply to fall prevention. This data can then be either evaluated using the Root Cause Tree® to define the areas of need for that single observation, or the data can be combined with other fall prevention observation data for use in an aggregate analysis or common cause analysis. With the aggregate analysis data from multiple observations can be combined, and “Significant Issues” can be identified based on multiple observations before an analysis using the Root Cause Tree® is performed. This could give you an overall bigger picture view of your processes.
Once the RCA is performed (in either situation), Steps 5-7 can be simply followed to produce some recommended actions to be implemented and measured using Corrective Action Helper® and SMARTER. And the beauty of this Proactive process is that you have not waited for a fall to learn. You and your organization are preventing future issues before they manifest thus showing your patients and staff that you truly care about their safety.
If you would like to learn more about using your TapRooT® tools proactively you can contact me at Skompski@taproot.com for more information or you can attend any of our public seminars, 2-day or 5-day to learn more on both the reactive and proactive use of the TapRooT® tools!
- Training. Retrain everyone, not just those involved.
- Policies/Procedures. Write new policies or procedures or make the current ones longer.
- Discipline. Send a message to everyone else that a behavior is unacceptable whether or not there is fault.
When these are the standard actions, many times we have recurrence of events. I am not saying these actions can’t work, but many times if they are default answers it is much like putting a round peg in a square hole.
In this article a hospital in Hong Kong presents an overview of their findings and recommended actions to a Sentinel Event at the hospital. Review the Corrective Actions and ask these two questions:
1. Do they meet the needs of the system based on the findings?
2. Do you see a correlation with our three standard corrective actions above?
Maybe there is a pattern… let us know your thoughts.
For many years now the TJC and other governing bodies have required root cause analysis (RCA) on Sentinel events as well as analyses on near misses with high potential. To remain accredited, organizations have put together teams to perform analyses to find the causes and to recommend, implement and track corrective actions. Throughout this time of focus and effort there continue to be repeat sentinel events. So the question that arises is, why are these RCA’s failing?
This question may appear very complex but the root of the problem is actually very simple. From reading many Event reports and examining how many organizations perform these analyses two things stand out to me:
- Many analyses stop at too high a level due to a lack of information and do not reach true root causes. They stop at what we define as a Causal of Contributing factor.
- Many corrective actions don’t address the root cause due to the limited analysis or because the corrective actions created are not specific to changing a particular behavior or system.
What truly makes this even simpler is the fact that these two issues are interrelated. If you don’t thoroughly gather the correct information and identify the true root causes the corrective actions may not be focused enough to fix the problem. We will then fall into the trap of implement general or employee focused corrective actions that don’t address system problems. This can result in wasted time and resources and can have a very negative impact on the people involved in the event.
Here you see an example where the investigator stopped gathering data at a Causal or Contributing Factor.
In this example there was a mistake made by the nurse when retrieving a medication for a particular patient. With no additional information gathered, the investigator is forced to stop at this level. No more analysis can be performed without many assumptions and opinions being used. In this case, when the team moves to corrective actions, how do you fix someone retrieving the wrong medication? Well, without any additional information, we counsel the employee to be more careful, we punish the nurse for making the wrong choice, and/or we retrain everyone to make sure there is an overall understanding of this issue. None of these truly change the system and address the causes of the issue (as you will see below).
If the investigator gathers much more information on the issue there is at least a chance to more thoroughly examine the issue using your RCA tools and dig deeper to a root cause level.
Having this additional data available allows the investigator to dig deeper into the issue to identify the underlying system root causes that contribute to this mistake by the nurse. This changes the focus to the organizational systems and not solely on the individual. Knowing that it has become common practice during high census to not follow the second check rule (or 5 Rights) and there have been no negative consequences consistently provided by management for this issue we would be able to identify system related causes such as Management System ->SPAC Not Used ->Enforcement NI (from the Root Cause Tree®) and other causes. By getting to this level of analysis and understanding the system cause(s), we can now build corrective actions to address specific system issues. By addressing the specific causes and in this case changing the rules or terms around times with a higher than normal census, the requirements for following and consequences for not following this policy we are changing the systems in the organization. By changing the systems we can enact long lasting positive change in the organization and build sustained success and change the behaviors of our employees.
Many people ask “What makes a good RCA?”. This question as stated is difficult to answer due to the fact that “good” is a very subjective term. What is good for one may not be good enough for another and vice versa. But, if we replace one simple word in that question we can make it a much more objective question. By changing that term to “credible” and/or “effective,” now we have a good starting point as both these terms have investigative standards and principles behind them. Let’s start with some definition:
Credible: This term is defined as “able to be believed; convincing.” Let’s focus on an investigation for our example and ask what would make our investigation able to be believed? One simple answer comes to mind, the ability to see the relationship between our Root Causes, our Causal Factors, and our Incident. That “Specific” relationship as we call it is dependent on the data collected in an investigation and ability for your audience to be able to connect those “dots” if you will.
Effective: This term is defined as “successful in producing a desired or intended result”. This focuses on the outcome of an action and what the desired results or end point is. For investigations the outcome or desired result is to implement fixes and Corrective Actions that will in the future reduce the risk of or remove the risk of a reoccurrence. The audience’ ability to see the effectiveness of the Corrective Actions is key.
So if we add both these words together and use them in combination to define an investigation we can now see how to answer the initial question.
Credible Root Cause Analyses
Let’s begin with the word credible and provide some guidance for our TapRooT® Users. When I look at and review any investigation the credibility is established for me in two techniques, the SnapCharT® and the Root Cause Tree®.
Let me put this as simply and as plainly as I can, when building your chart the team should put ALL information into that SnapCharT®. No matter how insignificant something may seem, or how common place something may be it should be on the chart for transparency and for use during the analysis on the Root Cause Tree®. Anytime you make a conscious effort to leave information off the chart you open yourself up for questions and you reduce the ability of your audience to “connect the dots” as mentioned above. This lowers your credibility significantly.
This can also lead to issues when your audience tries to understand the relationship between the Root Causes you have chosen on the Root Cause Tree® and the information on the SnapCharT®. This relationship should be as “transparent” as possible and the audience should not have to work to figure out the relationship. There should be a direct link between data on the chart and the Root Causes from the Root Cause Tree®.
Root Cause Tree®
Once the thorough “transparent” SnapCharT® is completed and the investigation move into the Root Cause Tree® to analyze your Causal Factors, documentation is the key to credibility. Three statements that can kill credibility are: “I believe,” “I think,” and “I am pretty sure,” Each one of these statements provides your audience with doubt as to what you truly know. This is why I always recommend the use of the Root Cause Tree® Dictionary and Analysis Comments in the Root Cause Tree® for documentation. This provides the connection and the defendable path for you and your audience.
As the Tree is analyzed the investigation should have data from the SnapCharT® to confirm each selection on the Root Cause Tree® as well as one or many questions answered as a yes from the Dictionary. Take that data (cut and paste) and put that into the Analysis Comments in the TapRooT® Software to document “why” you answer yes, and to show the audience your reasoning.
We have explored the “Credibility” of analyses so now we need to look at the Effective portion. We concluded that this measure is tied to the effectiveness of the Corrective Actions we present and implement. An analysis by itself cannot be effective without corrective and preventative actions that solve the Root Causes and prevent or reduce the likelihood of recurrence in the future.
When developing our Corrective Actions for the Root Causes we find during our analyses we have to consider the following items for each action:
Implementation: The act of putting the specific action in place in our systems and organization
Verification: This is a short-term measure of implementation. How are we going to ensure that what we proposed as the Corrective Action was implemented properly.
Validation: This is a long-term measure of effectiveness. This plan is based around the question, “What will success look like?” built with a plan to measure the progress (or regression) towards that outcome.
Most companies do a pretty effective job of the Implementation phase, implementing actions for every root cause. But in follow-up to these actions they do nothing; seemingly they wash their hands of the issue and say they are done. Implementation by itself does not ensure success. The two measurements above are very important because the provide some level of oversight for the actions and are a quality control check to make sure the actions hit the mark. If for any reason the Validation shows that the action is not having the desired effect the action needs to be revisited and revised if necessary starting the cycle again.
If Corrective Actions are implemented and not measured you increase the risk of the implementation falling short, or the action itself not actually having a positive impact on your systems and employees.
In the end, the credibility of your analysis is dependent on the data you collect, the quality (not quantity) of the data, and how it is used to confirm any answers found on the Root Cause Tree®. The effectiveness is dependent on the success of the corrective actions implemented and the longer term sustained success of the changes in the system to stop future recurrence. By following the 7-Step Process flow, and the Core techniques highlighter here within the TapRooT® process the system will guide you through these steps and aid you in successfully providing your management with a very Credible and Effective Investigation.
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One of the first dilemmas facing any investigator is deciding what data you need and what you have to have. There are many theories on this topic, but one rule of thumb I like to use is to, work your way around the target.
In the 7-Step Process Flow, Step 1 + 2 comprise the “What” portion of the investigation where we begin the process of trying to understand what our Incident is, and what let up to and followed it. During this time we work with our SnapCharT® to aid us in organizing and understanding the data we collect.
Data comes in many forms including our 3P’s + R; People, Paper, Plant, and Recordings. All of these forms of data are important to helping us understand the initiation of and the genesis of an incident. These different data types fit together to weave a picture of the incident and provides us with the basis for our analyses moving forward. For most, the first place we start is with anyone involved with the incident to get their first hand accounts of “What” happened and “Why”. By taking this very simplistic approach we can begin the process of vetting out truth and fiction, fact and opinion. But this is only one subset of people we must interview to fully understand an incident.
Working your way around the target means thinking about anyone who might have influence on an incident and making sure we interview and gather all perspectives.
Think of the incident/accident as a target, with concentric rings moving outward from the center. Each ring further from the center has less direct knowledge but can provide very valuable perspective. We need to understand everything surrounding the incident to fully evaluate for and understand the root causes. So there are various levels of knowledge and influence that we should consider.
Inner Circle – Those Involved: These people will give you your best starting point and the most information directly related to the incident/accident. Most direct knowledge will be found here.
Second Circle – Those Around or Near the Incident: This group can provide interesting information that might help you piece together what you know. They may or may not have any direct knowledge but can provide things such as what was heard, felt, smelled, tasted and sensed. Much of this can be used by the investigator understand information provided by those involved and can many times provide very simple yet important pieces to the investigative puzzle.
Third Circle – Subject Matter Experts (SMEs): When trying to understand a process or failure, SMEs provide an invaluable resource. Their knowledge can allow the investigator to understand successful performance and what should have happened. This can be used to understand both Equipment and Human Performance related failures. By understanding proper performance the investigator can more easily identify where potential failures exist. By understanding how processes or systems fail we can more easily identify Causal Factors.
Fourth “Dotted” Circle – Those with Influence on the Incident: Working with many investigative teams I have found that many facilitators only consider those members of management with direct involvement in the incident. That could include a direct line supervisor or a local area manager. By approaching this group in this manner the investigator can lose sight of a very important piece of work culture. That missing piece is the “Expectation”. What is communicated and expected can many times be in opposition and create confusion or problems in the work place. I believe to fully understand an incident and its causes the investigator should reach out to differing layers of management and talk about what is the “Expectation” for performance of whatever jobs are involved. This “Expectation” can not be used as fact but can aid in the understanding of decisions made and actions taken by those involved in the incident.
If the investigator works their way around the target, and ensure that these different perspectives are understood, they will have a better more thorough understanding of the incident and can perform a more thorough and complete root cause analysis.
To learn more about interviewing techniques, register for our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training.