Category: Quality

Six Sigma: Better Root Cause Analysis and Corrective Actions

June 22nd, 2017 by

I remember first learning about root cause analysis during Six Sigma training. The main methods we used were 5 Whys and Fishbone diagrams, but somehow we had a hard time arriving at good corrective actions. It took time and testing to get there, and still the fixes were not always robust.

Since then, I have learned a lot more about RCA. Unguided deductive reasoning tools like 5 Whys or Fishbones rely heavily on the knowledge and experience of the investigator. Since nobody can be an expert in every contributing field, this leads to investigator bias. Or, as the old adage goes: “If a hammer is your only tool, all your problems will start looking like nails”.

Other issues with deductive reasoning are investigations identifying only single causes (when in reality there are several), or ignorance of generic root causes that have broader quality impacts. Results will also be inconsistent; if several teams analyze the same issue, results can be wildly divergent. Which one is correct? All of them? None?

This is where the TapRooT® methodology has benefits over other tools. It is an expert system that guides investigators to look at a range of potential causal factors, like human engineering, management systems and procedures. There are no iterations of hypotheses to prove or disprove so investigator bias is not a problem.

The process is repeatable, identifies all specific and generic causes and guides the formulation of strong corrective actions. It is centered on humans, systems and processes, and the decisions they make every day.

The supporting TapRooT® Software is designed to enable investigators to keep efforts focused and organized:

  1. define the problem in a SnapCharT®
  2. identify Causal Factors and Root Causes with the Root Cause Tree®, and
  3. formulate sustainable corrective actions using the Corrective Action Helper® module

The TapRooT® process avoids blame, is easy to learn and quickly improves root cause analysis outcomes.

In Six Sigma parlance, the SnapCharT® is used for problem definition (Define), the Root Cause Tree® and trending for root cause identification (Measure and Analyze), and the corrective action process to define effective fixes (Improve).

#TapRooT_RCA

To Hypothesize or NOT to Hypothesize … that is the Question!

May 16th, 2017 by

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Yet again, another article in Quality Progress magazine (May 2017 – Solid Footings) suggests that the basis for a root cause analysis is a hypothesis.

We have discussed the problems of starting a root cause analysis with a hypothesis before but it is probably worth discussing it one more time…

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Don’t start with the answer.

Starting with the answer (a hypothesis) is a bad practice. Why? Because of a human tendency called “confirmation bias.” You can read about confirmation bias in the scientific literature (do a Google search) but the simple answer is that people focus on evidence that proves their hypothesis and disregard evidence that conflicts with their hypothesis. This is a natural human tendency that is difficult to avoid if you start with a hypothesis.

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I’ve seen many root cause experts pontificate about investigators “keeping an open mind” and disprove their own hypothesis. That’s great. That’s like saying, “Don’t breath.” Once you propose an answer … you start to believe it and PROVE it.

What should you do?

Use a system that doesn’t start with a hypothesis.Try TapRooT® Root Cause Analysis.

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You will learn to use a SnapCharT® to collect information about what happened without jumping to conclusions.

Once you understand what happened and identify the Causal Factors, you will then be ready to analyze why the Safeguards failed (find the root causes) without jumping to conclusions by using advanced tools: the Root Cause Tree® Diagram and the Root Cause Tree® Dictionary.

This system gets you to think beyond your current knowledge!

The system has been proven to work at major companies and different industries around the world.

Want to learn more to improve quality and safety at your company? Attend one of our public root cause analysis courses. See the list of upcoming courses at:

http://www.taproot.com/store/Courses/

Healthcare Professionals! Please come visit the TapRooT® Booth at the NPSF Conference

May 10th, 2017 by

If you are coming to the conference (May 17 – 19), please stop by and see us at Booth 300; Per Ohstrom and I will both be there.

Of course TapRooT® can help you with patient safety and reducing Sentinal Events. But there are many more ways to use TapRoot® in your hospital:

Improve Employee Safety and reduce injuries

Improve Quality, reduce human error, and make your processes more efficient

We hope to see you there. We have a free gift for the first 500 people, so don’t miss out!

Are you attending the ASQ World Conference on Quality in Charlotte?

April 19th, 2017 by

If you are attending the conference, please stop by the TapRooT® Booth (#213) and say hello. Chris Vallee, Per Ohstrom, and I will be there.

The first 500 visitors will receive a special gift, the world’s fastest root cause analysis tool!

Bring a business card and enter the drawing for cool TapRooT® stuff during the Tuesday exhibit hall extravaganza.

Want to see the new TapRooT® VI 6.2.0 software? Come by on Tuesday from 09:00-1:30 and we’ll be happy to walk through a quality example for you.

See you then!

Why do Audits fail and why do I have so many repeat findings? Take a detour!!!

March 27th, 2017 by

Have you ever performed an audit and got frustrated when you found the same issues as the last audit? I feel your pain….we all have. Why does this happen so much? Because most companies audit programs look a little like this:

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Q: What is missing from this picture?

A: Root Cause Analysis, of course!!

Many companies actually have good programs for FINDING problems without having a good program for FIXING problems. If you want problems fixed, root cause analysis has to be part of it. So on the road to improvement, take a DETOUR to Root Cause Land!

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For your program to be effective, it should look more like this:

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The best way to do root cause analysis on audits? TapRooT®.

We have a new course, TapRooT® for Audits, that we will be holding in Charlotte, NC on May 4-5. Why not join us? For more information and to register, click HERE

What’s Wrong with this Data?

March 20th, 2017 by

Below are sentinel event types from 2014 – 2016 as reported to the Joint Commission (taken from the 1/13/2017 report at https://www.jointcommission.org/assets/1/18/Summary_4Q_2016.pdf):

Summary Event Data

 Reviewing this data, one might ask … 

What can we learn?

I’m not trying to be critical of the Joint Commissions efforts to collect and report sentinel event data. In fact, it is refreshing to see that some hospitals are willing to admit that there is room for improvement. Plus, the Joint Commission is pushing for greater reporting and improved root cause analysis. But, here are some questions to consider…

  • Does a tic up or down in a particular category mean something? 
  • Why are suicides so high and infections so low? 
  • Why is there no category for misdiagnosis while being treated?

Perhaps the biggest question one might ask is why are their only 824 sentinel events in the database when estimates put the number of sentinel events in the USA at over 100,000 per year.

Of course, not all hospitals are part of the Joint Commission review process but a large fraction are.  

If we are conservative and estimate that there should be 50,000 sentinel events reported to the Joint Commission each year, we can conclude that only 1.6% of the sentinel events are being reported.

That makes me ask some serious questions.

1. Are the other events being hidden? Ignored? Or investigated and not reported?

Perhaps one of the reasons that the healthcare industry is not improving performance at a faster rate is that they are only learning from a tiny fraction of their operating experience. After all, if you only learned from 1.6% of your experience, how long would it take to improve your performance?

2. If a category like “Unitended Retention of a Foreign Body” stays at over 100 incidents per year, why aren’t we learning to prevent these events? Are the root cause analyses inadequate? Are the corrective actions inadequate or not being implemented? Or is there a failure to share best practices to prevent these incidents across the healthcare industry (each facility must learn by one or more of their own errors). If we don’t have 98% of the data, how can we measure if we are getting better or worse? Since our 50,000 number is a gross approximation, is it possible to learn anything at all from this data?

To me, it seems like the FIRST challenge when improving performance is to develop a good measurement system. Each hospital should have HUNDREDS or at least DOZENS of sentinel events to learn from each year. Thus, the Joint Commission should have TENS or HUNDREDS of THOUSANDS of sentinel events in their database. 

If the investigation, root cause analysis, and corrective actions were effective and being shared, there should be great progress in eliminating whole classes of sentinel events and this should be apparent in the Joint Commission data. 

This improved performance would be extremely important to the patients that avoided harm and we should see an overall decrease in the cost of medical care as mistakes are reduced.

This isn’t happening.

What can you do to get things started?

1. Push for full reporting of sentinel events AND near-misses at your hospital.

2. Implement advanced root cause analysis to find the real root causes of sentinel events and to develop effective fixes that STOP repeat incidents.

3. Share what your hospital learns about preventing sentinel events across the industry so that others will have the opportunity to improve.

That’s a start. After twelve years of reporting, shouldn’t every hospital get started?

If you are at a healthcare facility that is

  • reporting ALL sentinel events,
  • investigating most of your near-misses, 
  • doing good root cause analysis, 
  • implementing effective corrective actions that 
  • stop repeat sentinel events, 

I’d like to hear from you. We are holding a Summit in 2018 and I would like to document your success story.

If you would like to be at a hospital with a success story, but you need to improve your reporting, root cause analysis and corrective actions, contact us for assistance. We would be glad to help.

Top 3 Reasons for Bad Root Cause Analysis and How You Can Overcome Them…

February 7th, 2017 by

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I’ve heard many high level managers complain that they see the same problems happen over and over again. They just can’t get people to find and fix the problems’ root causes. Why does this happen and what can management do to overcome these issues? Read on to find out.

 

1. BLAME

Blame is the number one reason for bad root cause analysis.

Why?

Because people who are worried about blame don’t fully cooperate with an investigation. They don’t admit their involvement. They hold back critical information. Often this leads to mystery accidents. No one knows who was involved, what happened, or why it happened.

As Bart Simpson says:

“I didn’t do it.”
“Nobody saw me do it.”
“You can’t prove anything.”

Blame is so common that people take it for granted.

Somebody makes a mistake and what do we do? Discipline them.

If they are a contractor, we fire them. No questions asked.

And if the mistake was made by senior management? Sorry … that’s not how blame works. Blame always flows downhill. At a certain senior level management becomes blessed. Only truly horrific accidents like the Deepwater Horizon or Bhopal get senior managers fired or jailed. Then again, maybe those accidents aren’t bad enough for discipline for senior management.

Think about the biggest economic collapse in recent history – the housing collapse of 2008. What senior banker went to jail?

But be an operator and make a simple mistake like pushing the wrong button or a mechanic who doesn’t lock out a breaker while working on equipment? You may be fired or have the feds come after you to put you in jail.

Talk to Kurt Mix. He was a BP engineer who deleted a few text messages from his personal cell phone AFTER he had turned it over to the feds. He was the only person off the Deepwater Horizon who faced criminal charges. Or ask the two BP company men who represented BP on the Deepwater Horizon and faced years of criminal prosecution. 

How do you stop blame and get people to cooperate with investigations? Here are two best practices.

A. Start Small …

If you are investigating near-misses that could have become major accidents and you don’t discipline people who spill the beans, people will learn to cooperate. This is especially true if you reward people for participating and develop effective fixes that make the work easier and their jobs less hazardous. 

Small accidents just don’t have the same cloud of blame hanging over them so if you start small, you have a better chance of getting people to cooperate even if a blame culture has already been established.

B. Use a SnapCharT® to facilitate your investigation and report to management.

We’ve learned that using a SnapCharT® to facilitate an investigation and to show the results to management reduces the tendency to look for blame. The SnapCharT® focuses on what happened and “who did it” becomes less important.

Often, the SnapCharT® shows that there were several things that could have prevented the accident and that no one person was strictly to blame. 

What is a SnapCharT®? Attend any TapRooT® Training and you will learn how to use them. See:

TapRooT® Training

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2. FIRST ASK WHAT NOT WHY

Ever see someone use 5-Whys to find root causes? They start with what they think is the problem and then ask “Why?” five times. Unfortunately this easy methods often leads investigators astray.

Why?

Because they should have started by asking what before they asked why.

Many investigators start asking why before they understand what happened. This causes them to jump to conclusions. They don’t gather critical evidence that may lead them to the real root causes of the problem. And they tend to focus on a single Causal Factor and miss several others that also contributed to the problem. 

How do you get people to ask what instead of why?

Once again, the SnapCharT® is the best tool to get investigators focused on what happened, find the incidents details, identify all the Causal Factors and the information about each Causal Factor that the investigator needs to identify each problem’s root causes.

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3. YOU MUST GO BEYOND YOUR CURRENT KNOWLEDGE

Many investigators start their investigation with a pretty good idea of the root causes they are looking for. They already know the answers. All they have to do is find the evidence that supports their hypothesis.

What happens when an investigator starts an investigation by jumping to conclusions?

They ignore evidence that is counter to their hypothesis. This problem is called a:

Confirmation Bias

It has been proven in many scientific studies.

But there is an even bigger problem for investigators who think they know the answer. They often don’t have the training in human factors and equipment reliability to recognize the real root causes of each of the Causal Factors. Therefore, they only look for the root causes they know about and don’t get beyond their current knowledge.

What can you do to help investigators look beyond their current knowledge and avoid confirmation bias?

Have them use the SnapCharT® and the TapRooT® Root Cause Tree® Diagram when finding root causes. You will be amazed at the root causes your investigators discover that they previously would have overlooked.

How can your investigators learn to use the Root Cause Tree® Diagram? Once again, send them to TapRooT® Training.

THAT’S IT…

The TapRooT® Root Cause Analysis System can help your investigators overcome the top 3 reasons for bad root cause analysis. And that’s not all. There are many other advantages for management and investigators (and employees) when people use TapRooT® to solve problems.

If you haven’t tried TapRooT® to solve problems, you don’t know what you are missing.

If your organization faces:

  • Quality Issues
  • Safety Incidents
  • Repeat Equipment Failures
  • Sentinel Events
  • Environmental Incidents
  • Cost Overruns
  • Missed Schedules
  • Plant Downtime

You need to be apply the best root cause analysis system: TapRooT®.

Learn more at: 

http://www.taproot.com/products-services/about-taproot

And find the dates and locations for our public TapRooT® Training at:

 http://www.taproot.com/store/Courses/

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How can TapRooT® help with your ISO programs (or other management system issues)?

January 25th, 2017 by

Happy Wednesday and welcome to this week’s root cause analysis tips.

Many companies are ISO certified and some of those that are not have some type of management system. There are too many different systems and standards out there to discuss individually, but one of the common themes is continuous improvement.

Whether you use a commonly known management system or developed your own, one of your goals should be to improve your system/business. When I think of a management system, I think of it as a framework for how you manage your business. Whether required or not, incorporating continuous improvement is a smart thing to do.

While ISO has hundreds of standards, some of the most commonly known are 9000 (Quality) and 14000 (Environmental); coming down the pike soon is 45001 (Safety). There are also numerous industry specific standards. Many of the ISO standards use a common framework that includes the PDCA (plan, do, check, act) cycle. This is where TapRooT® can help.

PDCA is a simple process that has been in use widely since the 1950’s. I do not know many processes that have endured that long. So why? Because it is easy and it works.

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As part of PDCA, you have to determine what to fix, how to fix it, and whether it works. Sounds a little like root cause analysis and corrective action, doesn’t it? So if you were going to use PDCA to help solve your problems, what would you use for root cause analysis? If I were you, I would use TapRooT®. Need help with corrective actions? Use the Corrective Action Helper®, SMARTER Matrix, and Safeguards hierarchy. You can incorporate TapRooT® tools into any improvement framework you use.

Also, don’t forget the importance of auditing. This should be part of your management system as well. We’ve taught auditing with TapRooT® for years, but we recently developed a new course specifically for Auditors, TapRooT® for Audits, and wrote a new book, TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement. The primary topic of the book is auditing, but we also have a short section on PDCA. We’ll be teaching this course in Charlotte, NC in May if you would like to join us. Or, if you are already TapRooT® trained, you can get the book on our store.

Audits Kit

Thanks for reading the blog, and best of luck with your improvement efforts.

Avoid Known Problem-Solving Weaknesses in Process Improvement with TapRooT® Quality Problem-Solving

May 27th, 2016 by

LEARN MORE!

Register for this Pre-Summit Course AND the Quality Track at the 2016 Global TapRooT® Summit and maximize your success!

Using TapRooT® for Audits

May 18th, 2016 by

pablo (96)

Happy Wednesday, and welcome to this week’s root cause analysis column.

This week I wanted to share an excerpt from our new book which will be coming out on August 1st, TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement. I hope this small part of the book will help you start to think about being more proactive.

“An Ounce of Prevention is Worth a Pound of Cure.”
Ben Franklin

Around the world, professionals and companies have sought to find a better way to perform investigations on problems and losses. Many of the smartest people and leading companies use TapRooT®.

The TapRooT® Root Cause Analysis System is a robust, flexible system for analyzing and fixing problems. The complete system can be used to analyze and fix simple or complex accidents, difficult quality problems, hospital sentinel events, and other issues that require a complete understanding of what happened and the development of effective corrective actions. However, wouldn’t it be better if you never had to do investigations in the first place?

Many companies do perform audits. Unfortunately, in some cases, this work does not yield improvements. Why? There are many reasons, but the primary reason is lack of good root cause analysis. A company can actually be very good at finding problems, but not be effective at FIXING problems.

Beyond auditing, proactive improvement can take many forms, and when effective, becomes an overall mindset and can put an organization on the path to excellence. If that is the case, why are more companies not proactive? Here are just a few reasons:

  • Time (perceived at least)
  • They don’t have a reason to (not enough pain)
  • They do not have the buy-in (management and employee support)
  • Procrastination (human nature!)
  • They don’t know how (this is where TapRooT® comes in!)

TapRooT®, when used with auditing and proactive improvement programs, can help lead to organizational excellence and reduce the number of investigations required.

Would you like to be one of the first people to get the new book? If so, attend our new course, TapRooT® for Audits, at the Global TapRooT® Summit, August 1-2, in San Antonio. To register for the course (and the summit on August 3-5, click HERE

Calling all Quality People!

May 9th, 2016 by

I had a couple of things I wanted to share with our clients who work in quality:

First, Chris Vallee and I will be at the ASQ World Conference on Quality and Improvement starting Sunday. We will be in Booth 507, so please come and see us!

Second, we will be launching our new course, TapRooT® for Audits, at our 2016 Global TapRooT® Summit. The course will be on August 1-2 in San Antonio. I hope you can join us, and don’t forget to stick around for the summit itself on August 3-5. To register, visit HERE

The course will include a copy of our new book, TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement.

By the way, the new course is not just for quality people, it is for anyone who wants to learn to use TapRooT® for audits. Safety, Quality, Food Safety, Operations, it does not matter. And you do not to be previously trained in TapRooT® to attend.

If you already know how to use TapRooT® for auditing, but work in Quality and want to learn more about process improvement, Chris will be teaching the TapRooT® Quality Process Improvement Facilitator Course at the summit as well.

New TapRooT® for Audits course to debut August 1-2, 2016

March 21st, 2016 by

We are pleased to announce the first TapRooT® course for auditors. We will debut this course as a pre-summit offering before the 2016 Global TapRooT® summit.

TapRooT® is the best method for performing investigations and doing root cause analysis. But wouldn’t it be better if you never had to do the investigations in the first place? Of course, and that is why auditing is so important.

Sadly, most companies take the time and resources to do audits but do not get the desired results. Why? Because corrective actions are developed without proper root cause analysis. That is where TapRooT® comes in.

TapRooT® can be used to perform root cause analysis on any problem, so why not find the problem and do root cause analysis before these problems manifest themselves into incidents? We decided to develop a course for auditors and audit participants to see how TapRooT® works, both reactively, and with audits. Regardless of your role in the audit process, you must understand the entire TapRooT® process to be effective, so this course is for anyone involved in auditing, from auditors themselves, to auditees, to management who is responsible for improvements. Here is the agenda:

DAY ONE

TapRooT® Process Introduction and Initial Audit
SnapCharT® and Exercise
Causal Factors, Significant Issues and Exercise
Root Cause Tree® and Exercise
Generic Causes
Corrective Actions and Exercise

DAY TWO

The Root Cause Tree® and Preparing for Audits with Root Cause Exercise
Audit Programs, Trend and Process Root Cause Analysis
TapRooT® Software Introduction
Frequently Asked Questions about TapRooT®
Final Audit Observation Exercise

Participants in the course will receive a copy of the new book, “TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement.”

We hope to see you in the course! To register:

REGISTER for this course and the 2016 Global TapRooT® Summit (August 1 – 5, 2016).

REGISTER for this 2-day course only (August 1 – 2, 2016).

Error Proofing: Learn Best Practices and Industry Secrets

March 11th, 2016 by

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What is the error proofing here?

 

“Easier than making a mistake” … now that is good Human Engineering!

While listening to a radio commercial recently, I heard the announcer say, “Easier than making a mistake!” As a TapRooT® Root Cause Instructor with a quality and human engineering (Human Factors) background, all that I could think about is mistake-proofing, Poka-yoke.

The concept was formalized, and the term adopted, by Shigeo Shingo as part of the Toyota Production System. It was originally described as baka-yoke, but as this means “fool-proofing” (or “idiot-proofing”) the name was changed to the milder poka-yoke. (From Wikipdia)

Now, I did not learn about Dr. Shigeo Shingo during my Human Factors study, even though a large part of training dealt 100% with design and usability from products, to controls and to user graphic user interfaces. On the flip side, Human Factors and Usability was rarely discussed during my Lean Six Sigma certification either, even though Poka-yoke was covered.

Why are two major interactive topics such as Human Factors and Poka-yoke kept in isolation, very dependent on where and what you study? Simple, shared best practices and industry secrets are not always the norm.

Where can you learn about both topics? In San Antonio, Texas during our TapRooT® Summit Week August 1-5.

In the pre-summit 2-Day TapRooT® Quality Process Improvement Facilitator Course, we cover the error of making weak preventative or corrective action items that are not based on the actual root causes found and not optimizing and understanding mistake-proofing that will impact your success in continuous process improvements.

For those that need a deeper understanding of why mistake-proofing should be considered, you should look into signing up for the 2-Day Understanding and Stopping Human Error Course.

Does A Good Quality Management System equate to Compliance?

March 8th, 2016 by

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If it is written down, it must be followed. This means it must be correct… right?

Lack of compliance discussion triggers that I see often are:

  • Defective products or services
  • Audit findings
  • Rework and scrap

So the next questions that I often ask when compliance is “apparent” are:

  • Do these defects happen when standard, policies and administrative controls are in place and followed?
  • What were the root causes for the audit findings?
  • What were the root causes for the rework and scrap?

In a purely compliance driven company, I often here these answers:

  • It was a complacency issue
  • The employees were transferred…. Sometimes right out the door
  • Employee was retrained and the other employees were reminded on why it is important to do the job as required.

So is compliance in itself a bad thing? No, but compliance to poor processes just means poor output always.

Should employees be able to question current standards, policies and administrative controls? Yes, at the proper time and in the right manner. Please note that in cases of emergencies and process work stop requests, that the time is mostly likely now.

What are some options to removing the blinders of pure compliance?

GOAL (Go Out And Look)

  • Evaluate your training and make sure it matches the workers’ and the task’s needs at hand. Many compliance issues start with forcing policies downward with out GOAL from the bottom up.
  • Don’t just check off the audit checklist fro compliance’s sake, GOAL
  • Immerse yourself with people that share your belief to Do the Right thing, not just the written thing.
  • Learn how to evaluate your own process without the pure Compliance Glasses on.

If you see yourself acting on the suggestions above, this would be a perfect Compliance Awareness Trigger to join us out our 2016 TapRooT® Summit week August 1-5 in San Antonio, Texas.

Go here to see the tracks and pre-summit sessions that combat the Compliance Barriers.

Stop Normalization of Deviation with Normalization of Excellence

March 3rd, 2016 by

There is no Normalization of Deviation. Deviation IS NORMAL!

If you don’t think that is true, read this previous article:

There is no such thing as “Normalization of Deviation”

In 1946, Admiral Rickover was one of a small group of naval officers that visited the Manhattan Project in Oak Ridge, Tennessee, to learn about nuclear power and to see if there were ways to apply it in the US Navy. He had the foresight to see that it could be applied as a propulsion for submarines – freeing subs from the risky proposition of having to surface to recharge their batteries.

Rickover

But even more amazing than his ability to see how nuclear power could be used, to form a team with exceptional technical skills, and to research and develop the complex technologies that made this possible … he saw that the normal ways that the Navy and industrial contractors did things (their management systems) were not robust enough to handle the risk of nuclear technology.

Rickover set out to develop the technology to power a ship with the atom and to develop the management systems that would assure excellence. In PhD research circles these new ways of managing are often called a “high performance organization.”

Rickover’s pursuit of excellence was not without cost. It made him the pariah in naval leadership. Despite his accomplishments, Rickover would have been forced out of the Navy if it had not been for strident support from key members of Congress.

Why was Rickover an outcast? Because he would not compromise over nuclear safety and his management philosophies were directly opposed to the standard techniques used throughout the Navy (and most industrial companies).

What is the proof that his high performance management systems work? Over 60 years of operating hundreds of naval nuclear reactors ashore and at sea without a single process safety accident (reactor meltdown). And his legacy continues even after he left as head of the Nuclear Navy. The culture he established is so strong that it has endured for 30 years!

Compare that record to the civilian nuclear power industry, refinery process safety incidents, or off shore drilling major accidents. You will see that Rickover developed a truly different high performance organization that many with PhD’s still don’t understand.

In his organization, deviation truly was abnormal.

What are the secrets that Rickover applied to achieve excellence? They aren’t secret. He testified to his methods in front of Congress and his testimony is available at this link:

http://www.taproot.com/content/wp-content/uploads/2010/09/RickoverCongressionalTestimony.pdf

What keeps other industries from adopting the Rickover’s management systems to achieve equally outstanding performance in their industries? The systems Rickover used to achieve excellence are outside the experience of most senior executives and applying the management systems REQUIRES focussed persistence from the highest levels of management.

To STOP the normalization of deviation, the CEO and Presidents of major corporations would have to insist and promote the Normalization of Excellence that is outlined in Rickover’s testimony to Congress.

Sometimes Rickover’s testimony to Congress may not be clear to someone who has not experience life in the Nuclear Navy. Therefore, I will explain (translate from Nuclear navy terminology) what Rickover meant and provide readers with examples from my Nuclear Navy career and from industry.

Read Part 3:  Normalization of Excellence – The Rickover Legacy – Technical Competency

What is the Difference Between a Safety Related Incident and a Quality Problem when using TapRooT®?

September 30th, 2015 by

Quality ControlWelcome to this week’s root cause analysis tips column.

This week I would like to ask the question…what is the difference between a safety incident and a quality problem?

Before you answer that, let me tell you that this is a trick question.

The answer is……drum roll please: there is NO DIFFERENCE. The difference in a safety problem vs. a quality problem is the consequence; there is no difference in the approach you take in investigating.

In TapRooT®, the first thing we always do is to create a SnapCharT®. And the first thing we do when creating a SnapCharT® is to define the incident with a circle. This defines the scope of your investigation. Your circle could contain anything that creates pain for your company and that you would like to prevent from happening again. Examples of things that might go in your circle:

Safety
• Fatality
• Lost time injury
• Recordable injury
• Vehicle accident
• Facility damage
• etc. etc.

Quality
• Defective product (not sent to customer)
• Defective product (sent to customer)
• Customer complaint
• Delayed shipment
• Returns
• etc. etc.

Once you have defined the incident, you map out what happened, define the causal factors, perform root cause analysis, and develop corrective actions.

So start thinking about different ways your company can use TapRooT®. I’ve mentioned Safety and Quality, but there are many more. equipment reliability, environment, security, project delays; the list is really endless.

The more ways you can use TapRooT®, the better ROI you will get from your training. I know from experience when different disciplines in an organization start speaking the same language, there are some great intangible benefits as well. So if you are a safety manager, drag your quality manager with you to training next time. You will be glad you did.

Thanks for visiting the blog and best wishes for your improvement efforts.

Would you like to receive tips like these in your inbox? Our eNewsletter is delivered every Tuesday and includes root cause tips, career development tips, current events and even a joke. Contact Barb at editor@taproot.com to sign up for the TapRooT® Friends & Experts eNewsletter.  

Get More from TapRooT®: Follow our Pages on LinkedIn

August 13th, 2015 by

Do you like quick, simple tips that add value to the way you work? Do you like articles that increase your happiness?  How about a joke or something to brighten your day? Of course you do! Or you wouldn’t be reading this post.  But the real question is, do you want MORE than all of the useful information we provide on this blog?  That’s okay – we’ll allow you to be greedy!

A lot of people don’t know we have a company page on LinkedIn that also shares all those things and more.  Follow us by clicking the image below that directs to our company page, and then clicking “Follow.”

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We also have a training page where we share tips about career/personal development as well as course photos and information about upcoming courses.  If you are planning to attend a TapRooT® course or want a job for candidates with root cause analysis skills, click the image below that directs to our training page and then click “Follow.”

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Thank you for being part of the global TapRooT® community!

Robot Made a Human Error and a Worker was Killed

July 8th, 2015 by


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The 22-year-old man died in hospital after the accident at a plant in Baunatal, 100km north of Frankfurt. He was working as part of a team of contractors installing the robot when it grabbed him, according to the German car manufacturer. Volkswagen’s Heiko Hillwig said it seemed that human error was to blame.

A worker grabs the wrong thing and often gets asked, “what were you thinking?” A robot picks up the wrong thing and we start looking for root causes.

Read the article below to learn more about the fatality and ask why would we not always look for root causes once we identify the actions that occurred?

http://www.bbc.co.uk/newsbeat/article/33359005/man-crushed-to-death-by-robot-at-car-factory

 

Product Safety Recall…… one of the few times that I see Quality and Safety Merge

June 22nd, 2015 by

We can all remember some type of major product recall that affected us in the past (tires, brakes, medicine….) or recalls that may be impacting us today (air bags). These recalls all have a major theme, a company made something and somebody got hurt or worse. This is a theme of “them verses those” perception.

Now stop and ask, when is the last time quality and safety was discussed as one topic in your current company’s operations?

You received a defective tool or product….

  1. You issued a defective tool or product….
  2. A customer complained….
  3. A customer was hurt….
  4. ???….

Each of the occurrences above often triggers an owner for each type of problem:

  1. The supplier…
  2. The vendor…
  3. The contractor…
  4. The manufacturer….
  5. The end user….

Now stop and ask, who would investigate each type of problem? What tools would each group use to investigate? What are their expertise and experiences in investigation, evidence collection, root cause analysis, corrective action development or corrective action implementation?

This is where we create our own internal silo’s for problem solving; each problem often has it’s own department as listed in the company’s organizational chart:

  1. Customer Service (Quality)
  2. Manufacturing (Quality or Engineering)
  3. Supplier Management (Supply or Quality)
  4. EHS (Safety)
  5. Risk (Quality)
  6. Compliance (?)

The investigations then take the shape of the tools and experiences of those departments training and experiences.

Does anyone besides me see a problem or an opportunity here?

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