Category: Performance Improvement

Monday Accidents & Lessons Learned: A Taxiway by Any Other Name

July 23rd, 2018 by

An EFB, or electronic flight bag, is portable electronic hardware, increasingly utilized for flight deck or cabin use to facilitate flight crews perform flight management tasks easier and more efficiently. At a basic level, EFBs can perform flight-planning calculations and offer a variety of digital documentation, such as navigational charts, operations manuals, and aircraft checklists.

NASA’s Aviation Safety and Reporting System (ASRS) has received reports that describe various kinds of EFB anomalies. This report illustrates how complications between EFBs and human operators develop into precursor events:

“A B737 Captain encountered frustration while using his moving map. Although the specific incident is not cited, the Captain clearly identifies an EFB operational problem and offers a practical solution for the threat.

‘In [our] new version of [our EFB chart manager App], … a setting under Airport Moving Map (AMM) … says, “Set as default on landing,” [and I cannot] … turn it off. If [I] turn it off, it turns itself back on. This is bad.… It should be the pilot’s choice whether or not to display it at certain times—particularly after landing. Here’s the problem with the AMM: When you zoom out, the taxiway names disappear.

‘Consider this scenario: As you turn off the runway at a large airport, you look down at the map (which is the AMM, not the standard taxi chart, because the AMM comes on automatically, and [I] cannot turn that feature off). You get some complicated taxi instructions and then zoom out the AMM [to] get a general, big-picture idea of where you’re supposed to go. But when [I] zoom out the AMM, taxiway names disappear.… [I] have to switch back to the standard taxi chart and zoom and position that chart to get the needed information. That’s a lot of heads-down [tablet] manipulation immediately after exiting the runway, and it’s not safe.

‘[Pilots should have] control over whether or not to automatically display the AMM after landing. The AMM may work fine at a small airport, but at a large airport when given taxi instructions that are multiple miles long, the AMM is useless for big-picture situational awareness.'”

The award-winning publication and monthly safety newsletter, CALLBACK, from NASA’s Aviation Safety Reporting System, shares reports, such as the one above, that reveal current issues, incidents, and episodes.

Circumstances can crop up anywhere at any time if proper sequence and procedures are not planned and followed. We encourage you to learn and use the TapRooT® System to apprehend situations and find and fix problems. Attend one of our courses. Among our offerings are a basic 2-Day Course and an advanced 5-Day Course. You may also contact us about having a course at your site.

Learn TapRooT® in Edmonton

July 23rd, 2018 by

Register here for TapRooT® Training on August 2, 2018, in Edmonton, Alberta, Canada: 2-Day TapRooT® Root Cause Analysis Training

Exposure to the 2-Day TapRooT® Root Cause Analysis Training course in Edmonton will expand your professional knowledge. In two days, learn the TapRooT® Essentials to find and fix the root causes of incidents, accidents, quality problems, precursors, operational errors, hospital sentinel events, and other types of problems. Essential Techniques include: SnapCharT®, Root Cause Tree® & Corrective Action Helper®. A TapRooT® course is a career booster and can be a professional game changer for you. You’ll be amazed at how much you learn that you can immediately apply!

While in Edmonton, you will want to get out and about. Below, to route you on the road to Edmonton, we’ve included highlights of this Canadian city. Be sure to discover even more gems to explore on our Edmonton Pinterest board.

5 Fun Things To Do in Edmonton, Alberta, Canada

Experience Edmonton

Edmonton, capital of Alberta, is home to the largest expanse of urban parkland in Canada, the North Saskatchewan River Valley Parks System. Back-to-back parks along both sides of the river make urban Edmonton a delightfully green space for all kinds of outdoor recreation. In Edmonton, you’ll also have access to North America’s largest shopping mall, art museums and galleries and street art, hockey games, farmers markets, world-class skiing and biking, and a burgeoning foodie scene. You can easily get around the city via buses and light rail trains, and also Uber and taxis. Among your “discovering,” try to explore 124th and 104 streets. In that area, you will find Sir Winston Churchill Square and the Art Gallery of Alberta. Jasper Avenue hosts several cool coffee spots, such as Lock Stock Coffee.

edmonton-2

Four shimmering glass pyramids pinpoint iconic Muttart Conservatory on Edmonton’s skyline. The biomes house more than 800 species of plants from all over the world. Photo ops are rich from the roof.

You may hear it referred to as “The Leg” in Western Canada. The Alberta Legislature Building is the place for watching the sun set, with its gardens, pools and fountains.

Walk, stroll, bike, hike, paddle–get out and take advantage of the urban stretch that encompasses 20 major parks, the North Saskatchewan River Valley, that runs through downtown Edmonton.

Taste Edmonton

Duchess Bake Shop, Edmonton, Canada

At an incredible bakery, Duchess, you can’t go wrong with any selection from its classic French pastries: macarons, croissants, eclairs, butter tarts, and more. Made from scratch daily. The desserts on display are bewitchingly tempting!

Ampersand 27: An interesting, palate-pleasing mix of traditional and international flavors have earned this restaurant its cool factor.

Fumaca Brazilian Steakhouse: Come hungry and dine gaucho-style! During dinner, you will offered about 15 cuts of meat, grilled pineapple, the salad bar, and more. All that and a fabulous view of Edmonton overlooking Waterdale Bridge and the skyline.

Central Social Hall: The menu beckons you to try more than you can eat, and it’s all delicious. Try Belgian waffles at brunch; Texas rub wings with drinks; and the salad with grilled herb chicken is good anytime.

Blue Plate Diner: In the trendy Warehouse district, the diner is retro, with a artsy ambience. Open for breakfast, lunch, dinner, and also for brunch on weekends. Great salads, soups, breakfasts.

Register here for our Edmonton 2-Day TapRooT® Root Cause Analysis Training course.

TapRooT® is global to meet your needs. If you need other times or locations, please see our full selection of courses.

If you would like for us to teach a course at your workplace, please reach out to discuss what we can do for you, or call us at 865.539.2139.

The Best Incident Investigation Performance Indicator

July 18th, 2018 by

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If an incident investigation and the corrective actions are effective, it will prevent, or significantly reduce the likelihood or consequences of, a repeat incident.

If we want to monitor the effectiveness of our incident investigation, root cause analysis, and corrective action processes, probably the best performance indicator is monitoring the rate of repeat incidents.

If an incident (or even a Causal Factor) is a repeat, it indicates that there was a problem with the previous investigation. For example:

  • Was the root cause analysis inadequate?
  • Were the corrective actions ineffective?
  • Why didn’t management or peer review catch the problem with the previous investigation?

Of course, the question that is tough to answer is … What is a repeat incident (or Causal Factor).

Judging repeat incidents takes some soul searching. The real question is, should have the previous incident investigation prevented the current incident.

Here are two examples:

  • Should the investigation and corrective actions for the Challenger Space Shuttle accident have prevented the Columbia Space Shuttle accident?
  • Should the BP Texas City fire and explosion accident investigation have prevented the BP Deepwater Horizon accident?

You be the judge.

What is the rate for your facility? Do you have 80% repeats? 10%? 0.1%?

Each repeat incident provides a learning opportunity to improve your incident investigation, root cause analysis, corrective action, and incident review processes. Are you using these opportunities to improve your system?

Join TapRooT® at Noon EST Today for Facebook Live!

July 18th, 2018 by

 

For news you can use, join TapRooT® professionals Dave Janney and Michelle Wishoun in our Facebook Live discussion. Our topic today is: Why Is SnapChart® So Important? As always, feel free to ask questions or comment on our Facebook page during the session.

We look forward to being with you on Wednesdays! Here’s how to connect with us for today’s Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

When? Today, Wednesday, July 18

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Do your own investigation into our courses and discover what TapRooT® can do for you.

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

Welcome Marcus Miller!

July 13th, 2018 by

TapRooT® is growing! We are pleased to welcome Marcus Miller, Vice President of Business Development.

Marcus has hit the ground running, and you may have already read some of his informative healthcare-focused posts on the Root Cause Analysis Blog:

  • Using TapRooT® to Prevent Medicare Payment Reduction (Read post.)
  • QAPI and TapRooT®: The Bridge to Operational Excellence and Quality Care in our Nursing Homes (Read post.)
  • Joint Commission Focuses Surveys to Assess Safety Culture (Read post.)
  • Winners and Losers in Healthcare’s Shift to Value-Based Payments (Read post.)
  • Bias and Blame in Healthcare’s Culture has to Change (Read post.)

We hope you will join us in welcoming him to the TapRooT® team. To learn more about Marcus, click here.

 

 

 

 

Winners and Losers in Healthcare’s Shift to Value-Based Payments

July 9th, 2018 by

 

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The 2010 Affordable Care Act (ACA) was established to shift payment away from the volume of services provided toward the quality of those services. The ACA directed the Department of Health and Human Services to create a budget neutral payment model. CMS (Centers for Medicare & Medicaid Services) published an ACA fact sheet in 2015 that can be found here.

What does budget neutral mean in this case? A very smart healthcare executive explained it to me.  She said that budget neutral means you will have losers and you will have winners. The Department of Heath and Human Services had to put a payment model in place that takes money away from the losers and gives it to the winners so Medicare doesn’t see an increase in costs but still incentivizes providers to focus on quality. If you don’t have positive outcomes, money will be taken away and given to the providers that do show positive outcomes (the winners). So the difference between winners and losers is the quality of their outcomes. TapRooT® should be the quality improvement process healthcare organizations use to ensure they are on the winning side by improving quality and safety which also protects their revenue and margins. To find out more how your organization can improve your outcomes and protect your reimbursement, please contact me at marcus.miller@taproot.com.

Ever have trouble with root cause analysis during batch production with impurities?

July 6th, 2018 by

We received the question below in our TapRooT® Root Cause Analysis Users & Friends Group on LinkedIn, please join the discussion with your experiences and best practices.

How would one do a SnapCharT® for intermittent product quality issues that span weeks/months?

The only way to detect the product impurity is to use the product. Even so, the impurity seems random in the same batch or lot, at different weeks or months, with different upstream raw material suppliers, with different personnel. Past root cause analysis was not systematic enough to find the rc. Fixes did not solve.

Practice, Feedback, & Improve (Develop Skills)

June 27th, 2018 by

With any new skill that you learn, you need practice to implant the skill into long term memory. To get better at the skill, you need more practice and feedback (coaching).

The same is true of the skills you learn in a TapRooT® Course. You need to practice your new investigation and root cause analysis skills and get feedback (coaching) on ways to improve what you are doing.

Who will provide you with that feedback? Here are some ideas:

  1. Set up a peer review group. The members of this group should attend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training and have experience doing investigations.
  2. Have a senior manager become an expert in root cause analysis and provide feedback on investigations when performing senior manager reviews.
  3. Have experts from System Improvements review your incident investigations as they progress, CONTACT US to find out how to get these reviews scheduled.

If you have only attended the 2-Day TapRooT® Root Cause Analysis Course, consider attending the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. You will get more practice with the essential TapRooT® Techniques and learn the advanced techniques including:

  • Cognitive interviewing techniques
  • Critical Human Action Profile (CHAP)
  • Change Analysis
  • Proactive use of Safeguard Analysis
  • Equifactor® Equipment Troubleshooting

Plus you will discuss human error and ways to improve human performance.

Here is a link to the upcoming public 5-Day TapRooT® Training schedule for courses held around the world:

http://www.taproot.com/store/5-Day-Courses/

For anyone interested in advanced root cause analysis training, CLICK HERE for more information.

Join TapRooT® tomorrow at noon EST for Facebook Live

June 26th, 2018 by

Join us tomorrow when TapRooT® professionals Barb Carr and Benna Dortch discuss the topic, “What are extension techniques and why are they so important?” This is the third part of the investigative interviewing series. In the first installment, Barb discussed a powerful but underutilized technique: building rapport. Last week’s tip presented another powerful interviewing technique: effective listening.

Take a read through Barb’s recent articles for more context: Evidence Collection: Top 3 Tips for Improving your Investigative Interviewing Skills Series and Investigative Interviewing Series, (Part 2 of 3): Effective Listening. As always, please feel free to chime in on the discussion in real time. Or leave a comment and we’ll get back to you.

Here’s how to join in for tomorrow’s Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

When? Tomorrow, Wednesday, June 27

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Last week on TapRooT®’s Facebook Live in the Effective Listening session, we learned that only through effective listening will you learn to pick up on the “right” questions to ask. Barb gave us a beginning point:”The first question is the only one you need to know going in: ‘Tell me, from start to finish, what you observed the day of the incident.’” Barb also advises that the next step is to “sit back, listen, and identify which follow-up questions need to be asked.”

Since our listening skills develop with practice, everyone can use help becoming better investigators. Use the video and Vimeo below to review your skills:

Joint Commission Focuses Surveys to Assess Safety Culture

June 26th, 2018 by

 

 

Healthcare is catching up to other industries that have strong continuous improvement programs like mining, gas and oil. Joint Commission is leading that charge by implementing survey process improvements this month for how it assesses the safety culture in hospitals and critical access hospitals.  These improvements will be implemented for all other programs by October of this year. See this article for more details: (Read article.) Continuous Quality Improvement has become a major focus for payers.

In addition, the value-based payment model is replacing the fee for service payment model faster than anticipated. Healthcare organizations must find a comprehensive continuous quality improvement process for patient safety and to strengthen clinical and financial outcomes. Healthcare organizations must protect their revenue by limiting the financial impacts of poor clinical outcomes through a strong continuous quality improvement program. Survival is at stake. Medicare sequestration and payment penalties can easily erase already slim margins.

TapRooT® is that comprehensive continuous quality improvement process that Joint Commission or State Survey teams love to see as part of your QAPI program. TapRoot® trains safety, compliance and quality teams on complete investigation/auditing techniques, finding why incidents occur and identifying the root cause of those mistakes, errors or failures, identifying and implementing corrective actions and ensuring they are effective. TapRooT® has remarkable software that guides teams through the process and helps create impressive reports for management or survey teams.

If you would like to learn more to decide if TapRooT® is the right continuous quality improvement process for your organization, you can contact me at marcus.miller@taproot.com.

 

 

Monday Accident & Lessons Learned: What Does a Human Error Cost? A £566,670 Fine in the UK!

June 25th, 2018 by

Dump truck(Not actual truck, For illustration only.)

The UK HSE fined a construction company £566,670 after a dump truck touched (or came near) a power line causing a short.

No one was hurt and the truck suffered only minor damage.

The drive tried to pull forward to finish dumping his load and caused a short.

Why did the company get fined?

“A suitable and sufficient assessment would have identified the need to contact the Distribution Network Operator, Western Power, to request the OPL’s were diverted underground prior to the commencement of construction. If this was not reasonably practicable, Mick George Ltd should have erected goalposts either side of the OPL’s to warn drivers about the OPL’s. “

That was the statement from the UK HSE Inspector as quoted in a hazarded article.

What Safeguards do you need to keep a simple human error from becoming an accident (or a large fine)?

Performing a Safeguard Analysis before starting work is always a good idea. Learn more about using Safeguard Analysis proactively at our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. See the upcoming public course dats around the world at:

http://www.taproot.com/store/5-Day-Courses/

Career Opportunities for Candidates with TapRooT® Skills

June 25th, 2018 by

When you have the expertise of TapRooT® training on your resume, you’re communicating the level of your career development. Professional training and skill sets in investigation, problem-solving, and root cause analysis convey competency to the prospective employer. If you have TapRooT® training and skills, explore your professional advancement through one of these global opportunities.

Safety & Rail Safety Coordinator

Environmental Health & Safety Manager

Quality & Compliance/EHS Lead

HES Drilling Specialist

Associate – Sr. Engineer Nuclear

Sr. Engineer

EH&S Manager

Patient Safety Analyst

Environmental Manager

Field Professional I-Drilling

Safety & Health Specialist

HSE Manager

Patient Safety Program Coordinator

Division Order Analyst

Field Engineer

Drilling Performance Engineer

If you are not yet TapRooT® trained, becoming proficient in troubleshooting and identifying root causes of issues and incidents is the proven path to develop your skills and training. Pursue your goals through these TapRooT® courses to advance your professional development.

Nairobi, Kenya, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Portland, Oregon, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Auckland, New Zealand, July 16, 2018: 2-Day TapRooT® Root Cause Analysis Training

Milwaukee, Wisconsin, July 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Dallas, Texas, August 6, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Adelaide, Australia, August 21, 2018: 2-Day TapRooT® Root Cause Analysis Training

Monterrey, Mexico, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Newcastle, Australia, September 12, 2018: 2-Day TapRooT® Root Cause Analysis Training

Calgary, Canada, September 24: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Amsterdam, Netherlands, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Manchester, United Kingdom, October 1, 2018: 2-Day TapRooT® Root Cause Analysis Training

Aberdeen, Scotland, October 8, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Dubai, UAE, October 14: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Kuala Lumpur, Malaysia, October 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Brisbane, Australia, November 12, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

The History of the Definition of a Root Cause

June 20th, 2018 by

 

When I started digging into problem-solving back in 1985, people used the term “root cause” but I couldn’t find a definition for the term. I knew some pretty knowledgable people so I asked them for their definition. They explained what they called a root cause but I found significant variation between these experts’ definitions.

Therefore, David Busch and I (Mark Paradies) started doing research to develop a definition for a root cause. And this is the definition we created back in late 1985 or early 1986:

ROOT CAUSE

The most basic cause(s) that can reasonably be identified
and that management has control to fix.

As TapRooT® was being developed by Mark Paradies and Linda Unger in the early 1990’s, we added to this early definition and the definition was “improved” to:

ROOT CAUSE

A root cause is
the most basic cause (or causes)
that can reasonably be identified
that management has control to fix
and, when fixed, will prevent
(or significantly reduce the likelihood of)
the problem’s recurrence.

That definition was starting to be a mouthful.

Some have added our terminology “management system” into the definition to show that the most basic cause must be a management system cause. We never really thought that was necessary.

By 2005, Linda Unger and Mark Paradies realized that the definition that they had developed for a root cause made an incident investigation look negative. We were looking for causes of problems. People would get into arguments about “management’s ability to fix a problem” when what we really meant was that the problem was fixable. We needed a better definition that was focused on improvement. Therefore, in 2006, we published this version of a definition of a root cause:

ROOT CAUSE

A Root Cause is
the absence of a best practice
or the failure to apply knowledge
that would have prevented the problem.

What is the difference between our old (and some would say industry standard) definition and our 2006 definition?

The new definition focuses more on the positive. We are searching for best practices and knowledge to prevent problems. We aren’t looking for people to blame or management failures. We are going to find ways to perform work more reliably. This is a focus on improvement.

One more note … The new definition is rather absolute. The words “would have prevented” should probably also include the phrase “or significantly reduced the likelihood of” because, in real life, it is probably impossible to guarantee that a problem will be prevented from EVER happening again. But we have’t modified the definition because we wanted the emphasis to remain as definite as possible even though we realize that a 100% guarantee probably is NOT possible.

So, now when you see the definition of a root cause and it looks very similar to the first two definitions, you will know who the original authors were and where the ideas came from.

You will also know that there is a more advanced definition that focuses on improvement.

TapRooT® Users have always been a step (or maybe many steps) ahead of other problem solvers. Even when it comes to the definition of a root cause.

Want to learn more about the TapRooT® Root Cause Analysis System? Attend one of our courses:

http://www.taproot.com/courses

TapRooT® Users – Use It ALL

June 13th, 2018 by

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I had an interesting question from a TapRooT® user the other day.

“When will you be adding something to TapRooT® to deal with human performance issues?”

I had to stop and think. Of course, our whole design effort was to make TapRooT® the world’s best system for analyzing and fixing problems due to human error. But I realized that we had made the use of TapRooT® so transparent that this user, and probably others, didn’t know what they had.

They might not know that TapRooT® can them help fix:

  • human errors
  • human performance issues
  • company culture problems
  • behavior issues
  • management system failures
  • simple incidents
  • complex accidents
  • audit findings

TapRooT® can be used reactively (after an accident) or proactively (before a major accident). The application of TapRooT® is really flexible.

We’ve made this flexibility and applicability completely transparent. You don’t have to be a human performance expert (a Certified Ergonomist – like I am) to use the system and get great results.

We’ve made difficult analysis so easy that people don’t know all the power they have.

How can a TapRooT® User learn more about what they have?

  1. Read the blog and the weekly TapRooT® Friends & Experts Newsletter. Sign up for the newsletter HERE.
  2. Join the TapRooT® LinkedIn discussion group HERE.
  3. Attend advanced TapRooT® Training – the 5-Day TapRooT® Advanced Team Leader Training.
  4. Attend the annual Global TapRooT® Summit.
  5. Read TapRooT® Root Cause Analysis Leadership Lessons.

That’s a good start and two of the ideas are free.

Get as much as you can from the tools and processes that you already know – TapRooT®.

And if you have any questions, leave them as a comment here or contact us by CLICKING HERE.

We have a sneak peek for you on today’s Facebook Live!

June 13th, 2018 by

TapRooT® professional Barb Carr will be featured on today’s Facebook Live session. To get a sense of the subject, look at Barb’s recent article.

As always, please feel free to chime in on the discussion in real time. Or leave a comment and we’ll get back to you.

We look forward to being with you on Wednesdays! Here’s how to join us today:

Where? https://www.facebook.com/RCATapRooT/

When? Today, Wednesday, June 13

What time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

If you missed last week’s Facebook Live discussion with Mark Paradies and Benna Dortch, catch it below on Vimeo or here on video.

Why do we still have major process safety accidents from TapRooT® Root Cause Analysis on Vimeo.

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

Get a sneak peek tomorrow on TapRooT®’s Facebook Live!

June 12th, 2018 by

Not to give too much away here but you have the unique opportunity to gather very useful information tomorrow during TapRooT’s Facebook Live session.

We can announce that TapRooT® professionals Barb Carr and Benna Dortch will be the facilitators for the session. To get a glimmer of the subject, take a look at Barb’s recent article. As always, please feel free to chime in on the discussion in real time. Or leave a comment and we’ll get back to you.

Here’s how to get your sneak peek for tomorrow’s Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

When? Tomorrow, Wednesday, June 13

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

 

Is Blame Built Into Your Root Cause System?

June 6th, 2018 by

Blame

If you want to stop good root cause analysis, introduce blame into the process.

In recent years, good analysts have fought to eliminate blame from root cause analysis. But there are still some root cause systems that promote blame. They actually build blame into the system.

How can this be? Maybe they just don’t understand how to make a world-class root cause analysis system.

When TapRooT® Root Cause Analysis was new, I often had people ask:

“Where is the place you put ‘the operator was stupid?'”

Today, this question might make you laugh. Back in the day, I spent quite a bit of time explaining that stupidity is not a root cause. If you hire stupid people, send them through your training program, and qualify them, then that is YOUR problem with your training program.

The “stupid people” root cause is a blame-oriented cause. It is not a root cause.

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What is a root cause? Here is the TapRooT® System definition:

Root Cause
The absence of best practices
or the failure to apply knowledge
that would have prevented the problem. 

Are there systems with “stupid people” root causes? YES! Try these blame categories:
    • Attitude
    • Attention less than adequate
    • Step was omitted due to mental lapse
    • Individual’s capabilities to perform work less than adequate
    • Improper body positioning
    • Incorrect performance due to a mental lapse
    • Less than adequate motor skills
    • Inadequate size or strength
    • Poor judgment/lack of judgment/misjudgment
    • Reasoning capabilities less than adequate
    • Poor coordination
    • Poor reaction time
    • Emotional overload
    • Lower learning aptitude
    • Memory failure/memory lapse
    • Behavior inadequate
    • Violation by individual
    • Inability to comprehend training
    • Insufficient mental capabilities
    • Poor language ability
    • In the line of fire
    • Inattention to detail
    • Unawareness
    • Mindset

You might laugh at these root causes but they are included in real systems that people are required to use. The “operator is stupid” root cause might fit in the “reasoning capabilities less than adequate,” the “incorrect performance due to mental lapse,” the “poor judgment/lack of judgment,” or the “insufficient mental capabilities” categories.

You may ask:

“Couldn’t a mental lapse be a cause?”

Of course, the answer is yes. Someone could have a mental lapse. But it isn’t a root cause. Why? It doesn’t fit the definition. It isn’t a best practice or a failure to apply knowledge. We are supposed to develop systems that account for human capabilities and limitations. At best, a memory lapse would be part of a a Causal Factor.

To deal with human frailties, we implement best practices to stop simple memory lapses from becoming incidents. In other words, that’s why we have checklists, good human engineering, second checks when needed, and supervision. The root causes listed on the back side of the TapRooT® Root Cause Tree® are linked to human performance best practices that make human performance more reliable so that a simple memory lapse doesn’t become an accident.

What happens when you make a pick list with blame categories like those in the bulleted list above? The categories get overused. It is much easier to blame the operator (they had less than adequate motor skills) than to find out why they moved the controls the wrong way. Its easy to say there was a “behavior issue.” It is difficult to understand why someone behaved the way they did. TapRooT® looks beyond behavior and simple motor skill error to find real root causes.

We have actually tested the use of “blame categories” in a system and shown that including blame categories in an otherwise good system causes investigators to jump to conclusions and select these “easy to pick” blame categories rather than applying the investigative effort required to find real root causes.

You may think that if you don’t have categories, you have sidestepped the problem of blame. WRONG! Blame is built into our psyche. Most cause-and-effect examples I see have some blame built into the analysis.

If you want to successfully find the real, fixable root causes of accidents, precursor incidents, quality issues, equipment failures, cost overruns, or operational failures, don’t start by placing blame or use a root cause system with built-in blame categories. Instead, use advanced root cause analysis – TapRooT®.

The best way to learn about advanced root cause analysis is in a 2-Day TapRooT® Root Cause Analysis Course or a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. See the list of upcoming public courses here: http://www.taproot.com/store/Courses/.

QAPI and TapRooT®: The Bridge to Operational Excellence and Quality Care in our Nursing Homes

June 1st, 2018 by

 

TapRooT® and QAPI

 

The Center for Medicare and Medicaid Services (CMS) defines QAPI as the coordinated application of two mutually reinforcing aspects of quality management systems:  Quality Assurance (QA) and Performance Improvement (PI) = QAPI.  Every nursing home in the U.S. is required to have a well documented QAPI program to be compliant with the Affordable Care Act.  Nursing homes are required to continuously identify and correct quality deficiencies as well as sustain performance improvements.

TapRooT® is used to identify root causes of potential and actual risk to quality performance and prescribes corrective actions that will eliminate the risk or significantly reduce risk and consequences of incidents.  TapRooT® training, tools and software are perfect solutions to implementing and maintaining a strong, compliant QAPI program.   

Let’s first look at the QA portion of QAPI.  QA is defined by CMS as the specification of standards for quality of service and outcomes, and a process throughout the nursing home for assuring that care is maintained at acceptable levels in relation to those standards.  QA is ongoing, both anticipatory and retrospective in it’s efforts to identify how the organization is performing, including where and why facility performance is at risk or has failed to meet standards.  TapRooT® processes ensure specification of standards by prescribing proven best practices for the root cause of any problem affecting quality of service, outcomes or breakdown of processes that assure  quality of care.  TapRooT® training, tools and software ensure the real root cause is identified by honing the teams’ skill in auditing and investigations practices that meet the criteria for both anticipatory and retrospective efforts in quality assurance. The TapRooT® Corrective Action Helper Guide will lead the team to proven best practices once root causes are identified and ensures the actions are effective. TapRooT®  will also help teams measure and compare current performance against performance standards and goals.

CMS defines PI as the continuous study and improvement of processes with the intent to better services or outcomes, and prevent or decrease the likelihood of problems or barriers to improvement.  TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement training, tools and software will lead QAPI teams through implementation of a continuous improvement program.  There are countless good QAPI teams out there that are great at identifying problems but struggle with prescribing, implementing and measuring the effectiveness of corrective actions.  They typically prescribe the weakest of corrective actions which generally include the “re” actions:

  • Re-train
  • Re-write the procedure or process
  • Re-mind
  • Re-emphasize
  • Re-evaluate
  • Re-view
  • Re-peat warnings, discipline training, etc.

The strongest corrective actions include putting new or additional safeguards in place, or even better, removing the risk or removing the patient from harms way.

Using TapRooT® to identify the real root causes of quality and performance issues through strong audit and investigation techniques and implementing effective corrective actions that lead to continuous improvement will help the QAPI team achieve Operational Excellence.  The big winners are our loved ones who took care of us and now need our commitment to providing them the quality care they deserve.

Want to learn more? You can contact us through the website Taproot.com, call into our office at 865.539.2139 or attend one of our public TapRooT® Courses or contact us to schedule an onsite course.

 

 

Why do we still have major process safety accidents?

May 30th, 2018 by

I had an interesting argument about root cause analysis and process safety. The person I was arguing with thought that 5-Whys was a good technique to use for process safety incidents that had low consequences.

Let me start by saying that MOST process safety incidents have low actual consequences. The reason they need to be prevented is that they are major accident precursors. If one or more additional Safeguards had failed, they would become a major accident. Thus, their potential consequences are high.

From my previous writings (a sample of links below), you know that I consider 5-Whys to be an inferior root cause analysis tool.

If you don’t have time to read the links above, then consider the results you have observed when people use 5-Whys. The results are:

  • Inconsistent (different people get different results when analyzing the same problem)
  • Prone to bias (you get what you look for)
  • Don’t find the root causes of human errors
  • Don’t consistently find management system root causes

And that’s just a start of the list of performance problems.

So why do people say that 5-Whys is a good technique (or a good enough technique)? It usually comes down to their confidence. They are confident in their ability to find the causes of problems without a systematic approach to root cause analysis. They believe they already know the answers to these simple problems and that it is a waste of time to use a more rigorous approach. Thus, their knowledge and a simple (inferior) technique is enough.

Because they have so much confidence in their ability, it is difficult to show them the weaknesses in 5-Whys because their answer is always:

“Of course, any technique can be misused,
but a good 5-Whys wouldn’t have that problem.”

And a good 5-Whys is the one THEY would do.

If you point out problems with one of their root cause analyses using 5-Why, they say you are nitpicking and stop the conversation because you are “overly critical and no technique is perfect.”

Of course, I agree. No technique is perfect. But some are much better than others. And the results show when the techniques are applied.

And that got me thinking …

How many major accidents had precursor incidents
that were investigated using 5-Whys and the corrective
actions were ineffective (didn’t prevent the major accident)?

Next time you have a major accident, look for precursors and check why their root cause analysis and corrective actions didn’t prevent the major accident. Maybe that will convince you that you need to improve your root cause analysis.

If you want to sample advanced root cause analysis, attend a 2-Day or a 5-Day TapRooT® Course.

The 2-Day TapRooT® Root Cause Analysis Course is for people who investigate precursor incidents (low-to-moderate consequences).

The 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course is for people who investigate precursor incidents (low-to-moderate consequences) AND perform major investigation (fatalities, fires, explosions, large environmental releases, or other costly events).

See the schedule for upcoming public courses that are held around the world HERE. Just click on your continent to see courses near you.

Two Incidents in the Same Year Cost UK Auto Parts Manufacturer £1.6m in Fines

May 22nd, 2018 by

Screen Shot 2018 05 22 at 4 37 39 PM

Faltec Europe manufactures car parts in the UK. They had two incidents in 2015 related to health and safety.

The first was an outbreak of Legionnaires’ Disease due to a cooling water system that wasn’t being properly treated.

The second was an explosion and fire in the manufacturing facility,

For more details see:

http://press.hse.gov.uk/2018/double-investigation-leads-to-fine-for-north-east-car-parts-manufacturer-faltec-europe-limited/

The company was prosecuted by the UK HSE and was fined £800,000 for each incident plus £75,159.73 in costs and a victim surcharge of £120.

The machine that exploded had had precursor incidents, but the company had not taken adequate corrective actions.

Are you investigating your precursor incidents and learning from them to prevent major injuries/health issues, fires, and explosions?

Perhaps you should be applying advanced root cause analysis to find and fix the real root causes of equipment and human error related incidents? Learn more at one of our courses:

2-Day TapRooT® RooT® Cause Analysis Course

5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Want to see our courses in Europe? CLICK HERE.

You can attend our training at our public courses anywhere around the world. See the list by CLICKING HERE.

Would you like to sponsor a course at your site? Contact us for a quote by CLICKING HERE.

Avoid Big Problems By Paying Attention to the Small Stuff

May 16th, 2018 by

Almost every manager has been told not to micro-manage their direct reports. So the advice above:

Avoid Big Problems By Paying Attention to the Small Stuff

may sound counter-intuitive.

Perhaps this quote from Admiral Rickover, leader of the most successful organization to implement process safety and organizational excellence, might make the concept clearer:

The Devil is in the details, but so is salvation.

When you talk to senior managers who existed through a major accident (the type that gets bad national press and results in a management shakeup), they never saw it coming.

A Senior VP at a utility told me:

It was like I was walking along on a bright sunny day and
the next thing I knew, I was at the bottom of a deep dark hole.

They never saw the accident coming. But they should have. And they should have prevented it. But HOW?

I have never seen a major accident that wasn’t preceded by precursor incidents.

What is a precursor incident?

A precursor incident is an incident that has low to moderate consequences but could have been much worse if …

  • One of more Safeguards had failed
  • It was a bad day (you were unlucky)
  • You decided to cut costs just one more time and eliminated the hero that kept things from getting worse
  • The sequence had changed just a little (the problem occurred on night shift or other timing changed)

These type of incidents happen more often than people like to admit. Thus, they give management the opportunity to learn.

What is the response by most managers? Do they learn? NO. Why? Because the consequences of the little incidents are insignificant. Why waste valuable time, money, and resources investigating small consequence incidents. As one Plant Manager said:

If we investigated  every incident, we would do nothing but investigate incidents.

Therefore, a quick and dirty root cause analysis is performed (think 5-Whys) and some easy corrective actions that really don’t change things that are implemented.

The result? It looks like the problem goes away. Why? Because big accidents usually have multiple Safeguards and they seldom fail all at once. It’s sort of like James Reason’s Swiss Cheese Model…

SwissCheese copy

The holes move around and change size, but they don’t line up all the time. So, if you are lucky, you won’t be there when the accident happens. So, maybe the small incidents repeat but a big accident hasn’t happened (yet).

To prevent the accident, you need to learn from the small precursor incidents and fix the holes in the cheese or add additional Safeguards to prevent the major accidents. The way you do this is by applying advanced root cause analysis to precursor incidents. Learn from the small stuff to avoid the big stuff. To avoid:

  • Fatalities
  • Serious injuries
  • Major environmental releases
  • Serious customer quality complaints
  • Major process upsets and equipment failures
  • Major project cost overruns

Admiral Rickover’s seventh rule (of seven) was:

The organization and members thereof must have the ability
and willingness to learn from mistakes of the past.

And the mistakes he referred to were both major accidents (which didn’t occur in the Nuclear Navy when it came to reactor safety) and precursor incidents.

Are you ready to learn from precursor incidents to avoid major accidents? Then stop trying to take shortcuts to save time and effort when investigating minor incidents (low actual consequences) that could have been worse. Start applying advanced root cause analysis to precursor incidents.

The first thing you will learn is that identifying the correct answer once is a whole lot easier that finding the wrong answer many times.

The second thing you will learn is that when people start finding the real root causes of problems and do real root cause analysis frequently, they get much better at problem solving and performance improves quickly. The effort required is less than doing many poor investigations.

Overall you will learn that the process pay for itself when advanced root cause analysis is applied consistently. Why? Because the “little stuff” that isn’t being fixed is much more costly than you think.

How do you get started?

The fastest way is by sending some folks to the 2-Day TapRooT® Root Cause Analysis Course to learn to investigate precursor incidents.

The 2-Day Course is a great start. But some of your best problem solvers need to learn more. They need the skills necessary to coach others and to investigate significant incidents and major accidents. They need to attend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training.

Once you have the process started, you can develop a plan to continually improve your improvement efforts. You organization will become willing to learn. You will prove how valuable these tools are and be willing to become best in class.

Rome wasn’t built in a day but you have to get started to see the progress you need to achieve. Start now and build on success.

Would you like to talk to one of our TapRooT® Experts to get even more ideas for improving your root cause analysis? Contact us by CLICKING HERE.

Admiral Rickover’s 7 Rules

May 9th, 2018 by

Hyman Rickover 1955

Rule 1. You must have a rising standard of quality over time, and well beyond what is required by any minimum standard.
Rule 2. People running complex systems should be highly capable.
Rule 3. Supervisors have to face bad news when it comes, and take problems to a level high enough to fix those problems.
Rule 4. You must have a healthy respect for the dangers and risks of your particular job.
Rule 5. Training must be constant and rigorous.
Rule 6. All the functions of repair, quality control, and technical support must fit together.
Rule 7. The organization and members thereof must have the ability and willingness to learn from mistakes of the past.

Are you using advanced root cause analysis to learn from past mistakes? Learn more about advanced root cause analysis by CLICKING HERE.

Hazards and Targets

May 7th, 2018 by

Most of us probably would not think of this as a on the job Hazard … a giraffe.

Screen Shot 2018 05 07 at 9 40 49 AM

But African filmmaker Carlos Carvalho was killed by one while working in Africa making a film.

Screen Shot 2018 05 07 at 9 42 38 AM

 Do you have unexpected Hazards at work? Giant Asian hornets? Grizzly bears? 

Or are your Hazards much more common. Heat stroke. Slips and falls (gravity). Traffic.

Performing a thorough Safeguard Analysis before starting work and then trying to mitigate any Hazards is a good way to improve safety and reduce injuries. Do your supervisors know how to do a Safeguard Analysis using TapRooT®?

What is Senior Leadership’s Role in Root Cause Analysis

May 2nd, 2018 by

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Senior leadership wants root cause analysis to uncover the fixable root causes of significant accidents and precursor incidents AND to recommend effective fixes to stop repeat incidents.

But what does senior leadership need to do to make sure the happens? What is their role in effective root cause analysis? Here’s a quick list:

  • Best root cause system
  • Insist that it is used
  • Be involved in reviews
  • Insist on timely implementation of fixes
  • Check status of the implementation of fixes
  • Use trends to manage
  • Steer system to be more proactive

Let’s look at these in slightly more detail.

Best root cause system: Because so much is riding on the effective performance of a root cause system, leaders knows that second best systems aren’t good enough. They don’t want to bet their company’s future on someone asking why five times. That’s why they feel assured when their team uses advanced root cause analysis to find and fix the real root causes of problems. CLICK HERE to find out more about advanced root cause analysis.

Insist that it is used: One common theme in companies that get the most from their performance improvement programs is that senior leaders ASK for investigations. When they see a problem, they insist that the advanced root cause analysis process is used to get to the root causes and develop effective fixes. When middle management and employees see senior leadership asking for investigations and root cause analysis, they want to be involved to help the company improve.

Be involved in the reviews: When senior leaders ask for investigations, it’s only logical that they would want to review the outcome of the investigation they asked for. But it goes beyond being present. Senior management knows what to look for and how to make the review process a positive experience. People often get rewarded for good investigations. When the review process is a positive experience, people want to participate and have pride in their work.

Insist on timely implementation of fixes/Check status of the implementation of fixes: You might not believe this but I’ve seen many examples of companies where they performed root cause analysis, developed fixes, and then were very slow to implement them. So slow that the incident repeated itself, sometimes several times, before any fix was implemented. Good senior leadership insists on prompt implementation of fixes and makes sure they are kept up to date on the progress of implementation.

Use trends to manage: Good root cause analysis efforts produce statistics that can help leaders manage. That’s why senior leadership understands the use of advanced trending techniques and gets reports on the latest root cause trends.

Steer system to be more proactive: Would you rather wait for an accident or incident to find your next improvement opportunity? Or would you rather target and audit or assessment and have them apply advanced root cause analysis to develop effective improvements? The best senior leaders know the right answers to these questions.

That’s it! Senior leaders use proactive improvement and investigations of precursor incidents and major accidents (which rarely happen) to find where improvement needs to happen. They are involved with the system and use it to keep their company ahead of the competition. They are updated about the status of fixes and current trends. They reward those who make the system work.

Does that sound like your facility? Or do you have an improvement opportunity?

How many precursor incidents did your site investigate last month? How many accidents did you prevent?

April 25th, 2018 by

A precursor incident is an incident that could have been worse. If another Safeguard had failed, if the sequence had been slightly different, or if your luck had been worse, the incident could have been a major accident, a fatality, or a significant injury. These incidents are sometimes called “hipos” (High Potential Incidents) or “potential SIFs” (Significant Injury or Fatality).

I’ve never talked to a senior manager that thought a major accident was acceptable. Most claim they are doing EVERYTHING possible to prevent them. But many senior managers don’t require advanced root cause analysis for precursor incidents. Incidents that didn’t have major consequences get classified as a low consequence event. People ask “Why?” five times and implement ineffective corrective actions. Sometimes these minor consequence (but high potential consequence incidents) don’t even get reported. Management is letting precursor incidents continue to occur until a major accident happens.

Perhaps this is why I have never seen a major accident that didn’t have precursor incidents. That’s right! There were multiple chances to identify what was wrong and fix it BEFORE a major accident.

That’s why I ask the question …

“How many precursor incidents did your site investigate last month?”

If you are doing a good job identifying, investigating, and fixing precursor incidents, you should prevent major accidents.

Sometimes it is hard to tell how many major accidents you prevented. But the lack of major accidents will keep your management out of jail, off the hot seat, and sleeping well at night.

Screen Shot 2018 04 18 at 2 08 58 PMKeep Your Managers Out of These Pictures

That’s why it’s important to make sure that senior management knows about the importance of advanced root cause analysis (TapRooT®) and how it should be applied to precursor incidents to save lives, improve quality, and keep management out of trouble. You will find that the effort required to do a great investigation with effective corrective actions isn’t all that much more work than the poor investigation that doesn’t stop a future major accident.

Want to learn more about using TapRooT® to investigate precursor incidents? Attend one of our 2-Day TapRooT® Root Cause Analysis Courses. Or attend a 5-Day TapRooT® Root Cause Analysis Course Team Leader Course and learn to investigate precursor incidents and major accidents. Also consider training a group of people to investigate precursor incidents at a course at your site. Call us at 865-539-2139 or CLICK HERE to send us a message.

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