Author Archives: Ed Skompski
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!
Ready to learn more? The 5-day course includes TapRooT® software, essential TapRooT® techniques and advanced techniques. Visit our course page.
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.