Author Archives: Ed Skompski
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.
Want to learn more?
Our 5-Day TaprooT® Advanced Root Cause Analysis Team Leader Training provides all of the essentials to perform a root cause analysis plus advanced techniques. You also receive a single user copy of TapRooT® software in the 5-day course. The software combines incident identification, analysis, and dynamic report writing into one seamless process.
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.
This is a question that is raised a lot, and that all of our instructors have heard and/or answered. So I thought, why not provide some guidance? We teach so many different courses that it can sometimes be overwhelming to our clients and potential clients to decide what is best to receive the knowledge they need. Below you will find descriptions of different users, the course that would meet the need, and a short description of what the course provides. I hope this helps everyone decide.
Investigator/Team Member – Needs the basics of TapRooT®, may or may not be using software, will be called upon from time to time to participate on investigation teams.
2-day TapRooT® Training Course: This course provides the basics of TapRooT®, including the “Core Techniques”; SnapCharT®, Root Cause Tree®, and Corrective Action Helper®, along with proactive use of the system and Safeguards analysis. This course will provide the basic knowledge to work on and perform analyses using TapRooT®. This course is not intended to provide training on the TapRooT® Software, but the software can be used if participants feel so inclined. TapRooT® Public 2-day Courses can be found here.
Team Leader or TapRooT® Expert – Those who are called upon to lead TapRooT® investigations or who are viewed as the site/location expert in TapRooT®.
5-day TapRooT® Training Course: The 5-day training course is our “Team Leader” training course. This provides an expert level of knowledge on all of the TapRooT® techniques and on the TapRooT® Software. This course targets those investigators that will be system experts and team leaders and provides the knowledge to manage and utilize the TapRooT® process for any kind of investigation. The software is included with purchase of this training course and is used throughout the 5 days. When leaving this training course, the investigator will have experience analyzing issues, performing interviews, leading and investigative team, and using the TapRooT® software as an aid and tool. TapRooT® Public 5-day Courses can be found here.
1-day Equifactor® Training Courses: Many of our customers are great investigators, but don’t have a background in equipment related failures or troubleshooting. This is where the Equifactor® Course can be invaluable. Equifactor® is an equipment failure analysis and troubleshooting tool that is built for the everyday investigator, not the equipment expert. We have a partnership with Heinz Bloch to utilize his expansive array of equipment related tables with our Equifactor® technique. The tables with our technique provide the everyday investigator with tools to identify “Possible Causes” to equipment related issues and provides the knowledge to ask the proper questions to identify the true root causes of equipment related failures. This course requires that the attendees have previously attended a 2-day or 5-day TapRooT® course. This 1-day Session (usually held consecutive to a 2-day Public training course) focuses on the use of Equifactor® within the framework of a TapRooT® investigation. If a student purchases both the 2-day TapRooT® course with the 1-day Equifactor® training course, the TapRooT® Software is also included and is used extensively in the 1-day portion so the investigator will understand the use of the embedded tables. TapRooT® 1-day Equifactor® Courses can be found here.
Root Cause Tip: Using Corrective Action Helper® to Meet The Joint Commission (TJC) Recommendations for Document ReviewPosted: February 9th, 2012 in Root Cause Analysis Tips
When healthcare professionals perform root cause analysis (RCA), they want to define “What” happened, “Why” it happened, and then how to “Fix” the problem. These three pieces are considered core pieces to a “Thorough and Credible” RCA as coined and defined by the TJC. The TapRooT® process meets and, quite honestly, exceeds these requirements in many ways. Today, I want to spend a little bit of time focusing on one of the ancillary questions raised on TJC’s matrix that deals with Document Searches.
The key to responding to findings with solid corrective actions is understanding the root cause from every angle. It requires an open mind, creativity and tools to aid the investigator in understanding how to fix both Human Performance and Equipment related issues. Within the TapRooT® process, we have what is called Corrective Action Helper®. This tool provides guidance for identifying “Generic” issues, provides ideas for fixing the Root Causes, as well as providing a ready-made list of References for each root cause. The list of references provides both general industry and healthcare related documents that the investigator should consider reading or referencing as part of the fix. This provides the investigator with documents to review and to answer the question, “Cite any books or journal articles that were considered in developing this analysis and action plan:” from page 5 of the matrix.
Here is an example of what is included in the Documents section in Corrective Action Helper® for just one of our root causes, “Arrangement/Placement.” (This has to do with the physical location of equipment, displays, and controls):
* ANSI/HFES 100-2007, Human Factors Engineering of Computer Workstations, (2007), published by The Human Factors Society.
* KODAK’s Ergonomic Design for People at Work, (2004) by Eastman Kodak Company, published by John Wiley & Sons, Hoboken, NJ.
* Handbook of Human Factors and Ergonomics, Third edition (2006), by G. Salvendy, ISBN 0-471-44917-2, published by John Wiley & Sons, New York.
* Industrial Ergonomics: A Practitioner’s Guide, (1985) by D. C. Alexander and B. M. Pulat, published by Industrial Engineering & Management Press, Atlanta, GA.
* Handbook of Human Factors and Ergonomics in Health Care and Patient Safety, (2007) by Pascale Carayon, published by Eribaum, Mahwah, NJ.
* International Encyclopedia of Ergonomics and Human Factors, Second edition (2006), edited by Waldemar Karwowski, 3 volume set. ISBN 978-0415304306.
* Medical Error and Patient Safety: Human Factors in Medicine, (2007) by George and Barbara Peters, published by CRC.
* Medical Device and Equipment Design: Usability Engineering and Ergonomics, (1995) by Michael E. Wiklund, published by CRC.
With this kind of reference list directly available through our system, why would you use anything else to find root causes? Not only can you provide a thorough and credible RCA, you also have a ready-made list of documents and references for review.
Read a disturbing article from The Washington Post entitled, “The Pain of Wrong Site Surgery,” and it truly made me pause.
Seven years have passed since TJC provided a “universal protocol” outlining changes in pre-surgery routine. These included surgical site verification, and what was termed a “timeout” prior to any surgery. Based on data collected through self-reported events (not the most reliable data due to inconsistent reporting), and state provided information, there are still wrong site surgeries occurring at an estimated rate of 40 per week in the US. That is a staggering number, approximately 2,100 per year.
The article referenced Peter Pronovost, the Medical Director of the John Hopkins Center for Innovation in Quality Patient Care, stating that studies of wrong-site errors have consistently revealed a failure by physicians to participate in a timeout. This lack of participation is ritualized compliance or doctor’s lip service to the rules. That statement while true shows that even with the new protocols in place, there was little or no change in performance.
Comparing the TJC actions with the statements from Mr. Pronovost, it is clear to me that these actions are being implemented without an understanding of the Root Causes. These are all policy-based initiatives that in the end are dependent upon people following and adhering to policies and procedures. This shows that if we do not analyze situations and find root causes, we will simply implement weak safeguards that do not fix the issue or change behavior.
From the TapRooT® perspective, let’s evaluate the “universal protocol” implemented in 2004:
1) Verification of preoperative details – Quasi-Safeguard … admin control dependent on a human action.
2) Marking of the surgical site – Quasi-Safeguard … admin control or “label” if you will, dependent on a human action.
3) Timeout prior to procedure – Quasi-Safeguard … admin control or policy dependent on a human action.
All of these placed into current surgical systems and simply placed “over” the current processes have simply not worked. You are now seeing, based on the statements from Mr. Pronovost and the alarming numbers of wrong site surgeries still occurring, that we have a “SPAC Not Used.” This based on the current medical culture makes sense if people working in the process feel they are above the rules.
If TJC had performed a more thorough analysis of the actual causes, you might find that there are many other possible causes to these issues:
1) Enforcement NI – if the attitude that “I am above this” or “I should not have to do this” has become an ACCEPTED practice amongst healthcare providers. Thus, allowing the culture to grow without or with little consequence except to the patient.
2) Accountability NI – if it is believed that others are responsible for detecting these errors or are responsible for ensuring proper performance.
And there are likely others. I am not stating that I have those answers. I have not gathered the data or analyzed it. But I can tell you that without a more thorough analysis these problems will continue to happen. Simply applying Quasi-safeguards as listed in the 2004 protocol, without any additional measures to identify or address the actual root causes means you are addressing the Causal Factor without actually knowing the causes. These weak fixes that read well, are not based on actual root causes and, as they are showing, are not having a lasting affect on performance.
When similar events continue to occur (average of 40 per week), and we continue to try the same things over and over again, isn’t that the definition of insanity? And should it not also point out that the corrective actions and measures taken have not worked, were not effective, and we need to revisit not only the fixes, but the analysis as well? Food for thought …
- Open the investigation or audit you are working on by highlighting it in the My Documents section of the User Landing Page and selecting OPEN.
- Through the 7-Step Process Menu select OPEN for the investigation you are working on under Manage Documents by any SnapCharT® step. Then selecting NEW on the Associated Documents Screen.
- Add a shape to the chart by selecting the proper shape under Create Chart and then double clicking in the editor.
- With the shape selected, select the Shape Color drop-down and select the desired color, and select OK.
- While the shape is selected, click inside the shape once the color is added (this ensures the shape is selected).
- Simply hit CTRL-V and you will be able to duplicate that shape with colors. Do this multiple times to add as many shapes as you like.
- Repeat this process for other shapes as added.
- Move shapes where needed and add text using the Text editor at the top center.
Many users have asked us, “How can I create a template SnapCharT® for use each time I do an investigation?”. Well you can do that in v5 and it is very easy to do. Follow the steps listed below for creating, then using that template.
To create a SnapCharT® that can be re-used anytime as a “Template”:
Create the base Chart:
- Choose the Tools->New->SnapCharT® menu item. This will open up the flowchart editor.
- Add Shapes to the Chart: Most folks simply want a number of shapes already on the base SnapCharT® so that they simply begin adding information into the shapes. In the upper left of the editor there is a Create Chart section, select the shape type you want to add to the SnapCharT®.
- Double-click on the chart window to add that shape.
- Repeat these steps for each shape type (Events, Conditions, Incidents) to add as many shapes as you wish to have in your base chart.
Saving the SnapCharT® as a re-usable file or Template: Use the Unassociated Document function
- Select SAVE in the lower left corner of the editor.
- Provide a title for the chart (i.e. Template), this is required.
- Select the SAVE button.
- When asked “Do you wish to associate this SnapCharT® to an Audit/Investigation?”, select NO. Now the chart can be found on the User Landing Page, under Unassociated Documents, in the SnapCharT® folder. The chart is not associated with an investigation but is an individual document.
Location of the Template Chart
- Open the application and on the User Landing Page find the Unassociated Document Folder.
- Open the Unassociated Documents Folder.
- Open the SnapCharT® sub-folder, there will be the Template create.
Using the Template
- Create and save your Investigation or Audit.
- Use Activities->Home to return to your User Landing Page.
- Find the Template as listed above, highlight the file and select the OPEN button.
- Select the SAVE AS button in the lower left of the SnapCharT Editor.
- Provide a Title and Season and select save.
- When prompted to “Associate” the document select YES.
- Highlight the appropriate Investigation/Audit from the list provided and select DONE, now you are working on that new chart in the proper investigation or audit using the Template!
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In v5 we have enhanced both the Link and Comment features in SnapCharT®. When working in a SnapCharT one of the most important things for an investigator to do is to document, provide as much data as possible to understand “What” happened to be able to identify causal factors and good root causes. In the new SnapCharT tool found in the v5 application this is possible by using our new “Attach” function. This allows the user to attach multiple documents and pictures directly to shapes on the SnapCharT. This allows the investigation team to immediately access pertinent information that describes a step or process.
First to get to a new SnapCharT for an audit or an investigation, Highlight the investigation and select OPEN on the User Landing Page, this will take the user to the 7-Step Process Flow.
From the appropriate step, select the NEW button next to SnapCharT, this will open the SnapCharT Editor. Place a shape on the chart, and with the shape selected choose the ATTACH button. This will allow the user to select the file to attach to this particular shape. Word documents, Excel documents, PowerPoint document, pictures, any file the user has that helps describe that action (or condition) can be attached.
Once the file is selected, a “document tag” can be found in the lower right corner of the shape. If multiple documents are attached, multiple tags will be seen. To open the documents that are attached, simply double-click on the document and it will be opened for immediate viewing or editing.
This feature expands the old v4 “Comment” function by allowing full documents to be attached and expands the v4 “Linking” function by allowing multiple documents to be attached to a single shape and by copying the document to the database. This insures that in any situation the document link will not be broken if the original file is deleted or moved.