Category: Root Cause Analysis Tips

Investigating Healthcare Events: Do We Want to Learn? Are We Committed to Listening?

April 15th, 2016 by

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Research Shows Nurse Staffing Levels Affecting Patient Care.
Is Research Really Necessary to Understand This?

When we investigate events in healthcare, we are looking for the systemic causes of failures, both human performance based and equipment based. When looking at individual events we cannot exclude other related or similar events in our data gathering process as we should be learning from those as well. So if it takes research to see that staffing levels are affecting patient care, then we need to look at our long standing RCA programs and ask are we doing everything we can to understand the bigger picture?

A recent article highlighted this issue with true clarity. The research told us that there is a link between Nurse staffing levels and the quality of care provided. Now, I could go through and show you how TapRooT® helps you find the “Scheduling NI” root cause or the “SPAC NI-> Confusing or Incomplete” root cause and how it fits these types of events. Looking at this I see it in the bigger context of an organization and the bigger picture is understanding and “listening” to the data and what our process is communicating to the organization.

Looking back at the original research and tying things back to RCA it became clear that we have some larger systemic issues that we are not addressing. These may include Trending of RCA data, communication of issue within our hospitals, and data collection during event analyses. Any of these three puzzle pieces could lead us towards the same conclusions found in the above article. So why does it take us so long to see “Generic Issues”? Well here are a couple of my ideas or hunches, if you will, on this issue:

1. Do we truly want to learn or are we satisfying a “requirement”?

Regulation is a necessary evil in our society… many times it seems that doing the “right” things are not as commonplace as it once was. So through regulation we “require” diligence, we require analysis, we legislate what should be done anyway. With this there truly are two trains of thought, compliance mentality and improvement mentality. The compliance mentality is what I highlight here. If we have the compliance mentality we only do because we have to, which usually means meeting the letter of the law and no more. Checking a box does not mean we listen to the data or what our systems are telling us and many times it leads to only the corrective measures we can get away with at a minimum. Is this acceptable when adverse outcomes can cost the lives of the ones we commit to serve, aid and protect?

How do we change this mentality? Understand the value of the use of Root Cause Analysis within the organization and work to make it part of the everyday job of each employee to improve their jobs, their productivity, and empowering them to bring about change in an organization. This means tackling the everyday issues with RCA and not waiting to fulfill a requirement. Expand the scope through empowerment for change.

2. What is our commitment to “listening” versus “hearing”?

Confronted with my own personal family issues around this very issue has brought this to the forefront of my mind. When people are recovering from traumatic injuries and are being helped by others there is a tendency to be overwhelmed by the “claustrophobic” nature of personal care from a loved one. The feeling is that they are complaining at me so much that I am overwhelmed, and am listening but can’t take all this information. When in fact they are “hearing” everything said, but truly are not listening to the messages for various reasons.

This can be like a corporate culture, are they “hearing” or “listening”. There is a huge difference in these two things that many people simply don’t get. Too many times we have people report issues or problems or near-misses because we say “We are Listening to you”, but we truly are only “Hearing you” in the absence of acting on the data. Generic issues (which I have written about before) are something that you have to be willing to “listen” for through your RCA and Report data. Data provided to your organization will tell you a story, it will provide you with indicators or precursors that help you predict the future. Now is it an exact science, no, but it doesn’t have to be if you “listen”. In my opinion too many organizations want to make their employees and clients feel “heard” but are not willing to actually listen and act upon what they are being told.

Changing this behavior is not as simple as it may sound. It is truly a change in the corporate culture of an organization, the “walk the walk” versus “talk the talk” mentality. This can be started simply by the communication from management through to the folks on the front lines of how RCA data and corrective actions are handled. Allowing people to see that they have the ability to enact change. Then making sure that the proper trending and “listening” tools are in place to understand what the reported data is telling you. These two pieces can paint a very cohesive picture of how the organization is performing. Process Behavior Charts, Pareto Charting, and other basic data analysis tools are built into the TapRooT application to aid in doing this.

Within this discussion there are probably many other reasons why we can’t or won’t see the bigger picture and I would love to hear your theories and thoughts on this issue. The two issues I raise above are two good starting points to making your organization more efficient. But improvement opportunities abound throughout your organization, but they can only be found if you are “listening” and heed the messages being sent to you from your employees and from your systems. Don’t wait for research to tell you where your problems are, listen and act upon what you already know and bring your organization ahead of the curve.

If you would like more information about the Trending tools recommended and provided by TapRooT® please feel free to contact me directly at skompski@taproot.com or plan to attend our 2-day Trending Course held before our TapRooT® Summit this August in San Antonio TX.

The Power of Positive Rewards (and It’s Not What you Think!)

April 1st, 2016 by

In our classes we talk about enforcement, changing behavior, and creating the workplace we all envision we should have. Through all these discussions around behavior we talk about moving from Infrequent, Uncertain Negatives, to the use of Soon Certain Negatives to quickly change behavior. Producing a culture of “Reluctant Compliance” because no one is happy with this negative change but are forced to comply to avoid negative reinforcement. This “Reluctant Compliance” over time will turn into the norm, the reality of working in a strictly run workplace. Once the compliance is the norm and deviation is the oddity we can then transition to the next critical step… moving on to the use of Soon Certain Positives to create a long-term positive environment.

Within this Soon Certain Positive phase there is the discussion of using rewards in place of discipline to enforce the correct behaviors. So what is a reward? According to Merriam-Webster online dictionary, a reward is the following:

“to give money or another kind of payment to (someone or something) for
something good that has been done”

So by that definition we can look at the following rewards:

  • Money or financial incentive
    1. Cash, donation
  • Some kind of gift or recognition
    1. Coffee mug, plaque, pizza for lunch

When I look at the list above and I think of even simpler rewards that can be provided in the workplace. On that brings my mind back to a simpler time in life… kindergarten. Thinking back, how were we rewarded then? With one simple phrase,”Great Job!”

Being told that you are performing well along with a pat on the back or pat on the head meant the world. If we translate that into adulthood, that same phrase (although it can be used in the same way) is usually translated into a much more infrequently used comment, ”Thank you!” Truly the simplest form of recognition is to be told, “Great job, and thank you.”

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Recognition, if used genuinely, can be one of the greatest forms of behavioral modification.


This kind of recognition if used genuinely can be one of the greatest forms of behavioral modification. Both for the thank-er and for the thank-ee. Both benefit from the recognition of a job well done and the simple note that someone truly has seen and recognizes that, and even more importantly appreciates it.

If you would like to read a great article on the use of this simple form of behavior modification and humanity, read the following article:

http://www.beckershospitalreview.com/hospital-management-administration/the-two-words-you-need-to-use-more-in-your-hospital.html

The article talks about the Healthcare environment but can translate into any workplace in the world. The simplest of things can have the greatest of impacts.

If you enjoy articles like these, please sign up for our weekly Friends & Experts eNewsletter, delivered to your inbox every Tuesday morning.  Email Barb at editor@taproot.com to subscribe today!

 

3 Things You MUST Do When Finding an Incident’s Root Causes?

March 30th, 2016 by

Hello and welcome to this week’s root cause analysis tips column. So what are the 3 Things You MUST Do When Finding an Incident’s Root Causes?

  • You must know WHAT happened before you can determine why.
  • You must know WHY before you can write corrective actions.
  • You must FIX the root causes.

Let me elaborate:

You must know WHAT happened before you can determine why.

Too many investigators try to jump ahead and try to determine why things happened in an incident. But until you have all the facts, this is premature, and can lead to missing important data and letting the investigator’s bias drive the rest of the investigation. In the beginning of your investigation, you want to understand what happened. This is why evidence collection is so important.

Remember the old TV show Dragnet? The star of the show, Joe Friday, had a famous line:

“Just the facts, Ma’am, just the facts.”

Untitled

Once you understand the facts, you can then move to why.

You must know WHY before you can write corrective actions.

If you do not have good evidence you will miss causal factors and root causes. Your root cause analysis results are based on two things; the evidence you collected, and the guidance in the Root Cause Tree® Dictionary. If you do not have both, you do not have a strong case.

This is actually the easy part of TapRooT®, because the dictionary is all based on research.

Last but not least, you must FIX the root causes. Your corrective action has to specifically address the root causes, has to be implemented, and has to be verified.

How many times have you seen a corrective action that has nothing to do with the root cause? The Corrective Action Helper® has a check at the beginning of each section to make sure you are clear on what you are fixing. It does not matter how good something sounds, it has to directly apply to the root cause it is fixing. Otherwise it is extra work for no gain. And it likely means another investigation in the future.

And of course, it has to be implemented. Do you have a way to follow-up to make sure? And do you have a plan to judge the effectiveness?

Corrective actions are the OUTPUT of your investigation. Good investigations with weak corrective actions are a WASTE OF TIME.

Hopefully this gives you some things to think about. Thanks for visiting the blog, and if you want to learn how to do good investigations, join us at a future course.

CLICK HERE to view our upcoming course list.

The Use of the Safeguard Hierarchy in Healthcare

March 17th, 2016 by

I often wonder about the thought process that goes into corrective and preventative measures. My gut feeling is that many times we go straight to the same old ideas because they are comfortable, we have knowledge of them due to past use, or simply because they are easy. Whatever the reason, I think we need to remember as TapRooT® users we have many tools at our disposal (SMARTER, Corrective Action Helper®, and Safeguards) to aid us in building better fixes.

A friend told me a story about the death of a relative due to a Unintended Retained Foreign Object (URFO). Due to the object, he ultimately succumbed to an infection and died. So I did some digging and found an article (http://www.beckershospitalreview.com/quality/4-strategies-to-prevent-unintended-retention-of-foreign-object.html) that talked about four strategies from TJC to help reduce URFO’s and started thinking about our Safeguard Hierarchy. When evaluating corrective actions we need to think in terms of protection, protecting the Target from the Hazard.  In this case the Target is the Patient and the Hazard is the URFO.

So in line with this, let’s examine our hierarchy of Safeguards and see how it compares to our strategies:

All Safeguards Are Not Created Equal
Examining this list, I would suggest that the first 2 on the list, Remove the Hazard and Remove the Target are out at this point. You will always have a Target (patient) and with technology as it is today we cannot remove the need for tools/instruments/sponges et cetera. So we are truly working in the lower four items on the list.

With that in mind let’s look at the 4 strategies proposed by TJC:

Count process: Standardize policies for all procedures, not just those involving an open chest or abdomen. It should be the entire team’s responsibility to reconcile the count. If one member wants the count repeated, the team should comply.

Team communication in the OR: Call out when and instrument is placed in the body cavity and not promptly removed. When a policy deviation occurs, all staff should be capable and comfortable with speaking out and driving issues up the chain of command.

Tools: Items like white boards, sponge trees, radio-frequency identification technology and others should be available whenever invasive procedures are performed. Staff should be held accountable in regards to consistently utilizing these tools.

Standardize the layout: The physical space of a procedural areas should be as close to replicable as possible. While locations may vary, the equipment available should be consistent. Also, cap the number of people allowed in the procedure room. An excess of individuals in the procedural space can increase noise levels, alter visibility and ultimately distract staff.

With a simple analysis we can squarely see that these all fall within the scope of items 4-6 on the Safeguard list above with two of the recommendations falling within the scope of #4 (Standardize the layout) which deals with workspace design. The other two deal with standards and policies for both communication and the process for counting. Even one of the items (Tools) is a crossover action between standards and policies and holding folks accountable. So truly we are 1.5 actions dealing with the workspace, and 2.5 dealing with policies and procedures.

One thing that is a common thread amongst all these items is that they all depend on Human Performance to be truly effective. And although we do not want to see it or believe it, this is the weakest of all safeguards, the reliance on people. But, the fact is, our caregivers are ultimately responsible. Is it any wonder that we see the following comments regarding URFO’s?

While the frequency of URFOs dipped in 2013 after holding the No. 1 position of most frequently reported sentinel event in 2011 and 2012, the numbers trended upward in 2014 and in 2015 they emerged again as the most frequently reported sentinel event.

When we implement safeguards near the bottom of the safeguard hierarchy they will quickly raise the awareness on the issue, thus the dip in URFO’s, but over time they will not be effective (alone or in part) in truly changing the behaviors that cause these issues. We need to shift our focus to the top of the hierarchy if at all possible to truly impact performance.

If topics like this interest you, I’m leading a medical track at the 2016 Global TapRooT® Summit.  Breakout sessions include:

  • 7 Deadly Sins of Human Performance
  • TapRooT® Changes for the Medical Community
  • Human Error Causes of Quality Problems
  • Writing TapRooT® Driven Preventative & Corrective Actions Workshop
  • Anatomy of a Medical Investigation & more!

GO HERE to view or download a .pdf brochure.

Grading Your Investigations

March 10th, 2016 by

How do you grade an incident investigation? Here’s an Excel spreadsheet to use…

RateRootCauseAnalysis03082016.xlsx

How do you use the spreadsheet? Here’s a video from last year’s Summit …

Grading Your Investigation from TapRooT® Root Cause Analysis on Vimeo.

Would you like to learn this and hear about someone who has been using it to improve their company’s investigations? Go to the Grading Your Investigations Breakout Session (Wednesday – 1:30-2:30) at the 2016 Global TapRooT® Summit.

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.

Communication’s Role in Healthcare Events

March 2nd, 2016 by
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Ensure messages sent match messages heard.

Communication has always been an issue within healthcare. From the earliest days of TJC alerts and the Event RCA guidance, communication has been a focus. There are multiple communication threads between practitioners, nurses, patients and family that create many avenues for possible problems.

As an example, I will use a story told to me by a friend regarding a recent surgical procedure. I will not try to recount the actual surgery as it is not truly relevant to this discussion. I will, however,  start this story in Recovery after the person underwent surgery with no complications. During post-surgery recovery, they were provided with their formal discharge instructions from the nurse which included the following:

1) No lifting over 25 lbs for 1 week.
2) May return to work the next day.
3) Other medicine related and wound care information included.

After getting these instructions but before being discharged the surgeon came by to check on the patient and briefly discuss the procedure. During the discussion the following exchange occurred:

Patient asked the surgeon “Can I go back to work Monday?”

Surgeon asked, “What do you do?”

Patient answered, “Course setup and planning.”

Surgeon answered without hesitation, “You should be able to go back to work and perform that job without an issue”.

End of discussion.

See any potential problems with this communication? Any conflicting information? Very interesting isn’t it? Now, if we examine the duties within “Course setup and planning”:

1) Packing boxes
2) Shipping boxes
3) Lifting boxes
4) Computer work
5) Course Documentation

We can immediately determine that this job should be restricted based on the original instructions provided by the RN in the formal discharge instructions. But as with most people the words and advice from the surgeon were the ones that were heeded. My friend went to work on the next work day and continued to lift boxes that were in fact greater in weight than what was allowed. Now, in this case there was no additional injury, there were no complications, but this showed me in a glaring way how communications could cause a problem.

Now, had my friend had a complication and was forced to go back and receive an additional surgery, would this issue have been found as part of the RCA (if one were performed)? Did the communication have a role in the event? Here is a possible causal factor:

BoxLift
Examining this causal factor, it is easy to see that the communication would play a role in this issue. When taking this through the Root Cause Tree® we would likely answer yes to the question “Did verbal communication or shift change play a role in this problem?”. This would lead us to the Communication Basic Cause Category on the back of the Root Cause Tree® where we would examine those possible Communication related causes.

So during the examination of any event whether high or low risk, it is important to consider the impact of the spoken word. Looking into all communications that are involved to ensure that the messages sent match the messages heard. And that there are no conflicting communications that can cause confusion or set the patient or family up for failure. If you would like more information on how to consistently analyze healthcare related events using TapRooT® please feel free to contact me at: skompski@taproot.com.

Learn more about Healthcare RCA at the 2016 Global TapRooT® Summit.

How Can the Summit Help Your Company and Your Career?

March 2nd, 2016 by
San Antonio, Texas

San Antonio, Texas

Should you attend the Global TapRooT® Summit in San Antonio, Texas, August 1 – 5, 2016?  How can it help your company and your career?

Ask yourself these questions:

1. Does your facility/company need to improve in any of these areas:

  • Asset Optimization
  • Human Factors
  • Investigations
  • Reducing Medical Error
  • Quality
  • Safety
  • TapRooT® Software

2. Are you a Certified TapRooT® Instructor that needs to maintain their certification?

3. Do you want to be more motivated to improve performance?

4. Would you like to get a team of people from your facility excited about performance improvement?

5. Do you need knew ideas to take your improvement program to the next level?

6. Do you need to refresh your TapRooT® knowledge?

7. Would you like to visit the world-famous San Antonio River Walk?

8. Would you like to meet a bunch of new valuable contacts that can help you improve performance at your facility and advance your career?

9. Are you interested in benchmarking your improvement efforts against other industry leaders?

10. Are you interested in best practices from other industries that can be applied to improve performance in your industry?

If you said “yes” to any of these questions, that’s how it will help your company and your career!

To register, click here.

For more information, click here.

For the Summit schedule, click here.

Root Cause Analysis Tip: 3 Tips for Drawing a Better SnapCharT®

February 26th, 2016 by

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Visualize each step of an incident with a SnapCharT®.

It’s nearly impossible to conduct a useful root cause analysis unless you actually have some data to analyze. Many systems seem to think that you can dive right into an analysis before you have a full understanding of what actually happened. During the development of the TapRooT® System, one of the first items of business was to develop an easy way to visualize the problem and document the gathered facts. Thus, SnapCharT® was born.

SnapCharT®s are pretty easy to build. With just three shapes to worry about, and a few simple rules, the SnapCharT® gets you moving in the right direction right from the get-go.

Here are a few tips to help make the SnapCharT® even easier and more useful.

1. Avoid the word “and” in your Events. Events are meant to show a single action that occurred in the course of the incident investigation. Some people have an aversion to having a bunch of Events, and therefore put several actions in each one.  For example, if I wanted to document that the driver stopped at the stop sign, looked both ways, and then pulled out into the intersection, I would not want to write this as a single Event.  This should be 3 separate (short) Events, one after the other.

The reason this is important is because we want to see if any mistakes are made during each step in the sequence of events.  If we put several actions into a single Event, we find it is easy to miss one of these mistakes.  On the other hand, with 3 separate Events, I can ask, “Did the driver make a mistake while stopping?  Did she make a mistake while looking both ways?  Did she make a mistake by pulling forward?”  Having separate Events makes it much easier to catch individual problems.

Keep in mind that, later in the investigation, you may find that there were no mistakes made in any of these Events.  When you complete your SnapCharT®, it might then make sense to combine some Events to make the final SnapCharT® easier to read.  It is OK to combine Events later on; just leave them separate during your initial data-gathering phase.

2. Leave lots of space.  Many people tend to cram all their Events close together, I suppose to conserve real estate.  Don’t worry about it; leave lots of room between your individual Events.  Spread everything out.  You’ll be adding Conditions underneath each of these Events, and you’ll almost certainly end up moving everything to make room for these Conditions anyway.  Give yourself plenty of room to work at the beginning.  If using the software, I usually only put 2 or 3 Events on each page to start out.  Later on, once you have all of your Conditions documented and grouped, you can compress everything down a bit and get rid of extra spaces.  But even then, don’t try to squeeze everything tightly together.  It can make it hard to read, even after everything is set.  And you might also find new Conditions that need to be added once you start the root cause analysis.

3. Draw your lines at the very end.  It is tempting to start drawing lines early in the process.  You want to see those arrows showing your progression from one Event to the next.  And you want to arrange your Conditions into neat groups right from the start.  Unfortunately, this can cause problems later on.  There is a good chance you’ll be adding new Events, changing the order of the Events you have, or regrouping your Conditions into Causal Factor groups.  If you have already drawn your lines, you’ll just have to delete them, make your changes, and then draw them back in.  And then probably do it again later on.

I normally don’t draw any lines between Events or Conditions until after I’ve identified my Causal Factor groups.  My SnapCharT® is probably pretty close to being complete by that point, so I’m reasonably confident that I won’t be making a lot of changes.  This can be a tough lesson for those that are REALLY detail oriented (you know who you are!), and just have to have those lines drawn in early in the process.  Resist the temptation; it’ll save you some time (and frustration!) later on.

Let me know what you think about these tips.  If you have other tips that you’ve found that make it easier and quicker to produce your SnapCharT®s, share the best practices you’ve learned in the comments below.

We hope that you will also consider coming to the 2016 Global TapRooT® Summit, San Antonio, Texas, August 1-5 to share best practices.  Click here to learn more about the Summit.

 

Can the Cause of a Surgical Error be the Same as the Cause of an Oil Spill?

February 18th, 2016 by

This article raises a very fundamental question, are industries different when it comes to the causes of accidents? And even simpler, are job functions so different that they cannot have similar issues or problems?

Before we discuss this issue I want to start with a personal story. Many years ago I was giving a talk on Root Cause Analysis to a group of Physicians for a health system in Florida (about 50 if I remember correctly). The questions and discussion from the group had worked its way around to the difference in classes (jobs) within a hospital and the types of mistakes that are made. Understanding Human Performance as I do, I made what I thought was a simple statement of fact (and I quote),

Doctors and janitors make mistakes for the same reasons.

After the blank stares turned to surprise, contempt, then anger, I am sure you know the response I received. Later, once I escaped the room and was safely on a plane home, I thought about the reaction and came to the following conclusion. People truly believe that their job is different, different from any other, more important and difficult than any other. Is this perception? Or is this reality? Let’s find out …

Now, on the surface, I believe most people would say the answer to the question “Can the Cause of a Surgical Error be the Same as the Cause of an Oil Spill?” will be a stern “No”. The widely-held belief is that the causes of these two issues have to be different. A surgical error made by a physician or nurse in a surgical suite has to be different from the errors made by a highly skilled tradesman causing an environmental release. They appear as different as night and day until you dig down deep into Human Performance and realize that both situations hinge on similar human factors. Let’s begin this search by looking at these two events along with causal factors for each:

Our Sentinel Event is: Surgery is performed on the wrong patient

Our Spill accident is: 500 gallons released environment

Here are a couple of causal factors, one for each. Looking at these two different situations do you see any similarities?

Policy Violation

Both of these causal factors, although from different industries and different situations and job types, have similar causes to them. Both deal with Management System->SPAC Not Used->Enforcement NI. Both situations show a series of behaviors that have not been addressed or fixed by supervision or management, that have happened multiple times and have become common practice. Looking at our Root Cause Tree® Dictionary, we would get a yes to the following question in the Enforcement NI Definition for both:

  1. Has failure to follow SPAC in the past gone uncorrected or unpunished?

I think that shows that both of these situations have common systemic problems that have led to similar behaviors. There may also be other root causes based on other causal factors and other conditions presented here. But there is at least one common thread above.

One more example from the same incident, here are two additional causal factors:

Labels

Again, both of these deal with misidentification of a critical part of the system, one the patient receiving surgery and one a valve in a process. Now before I get emails saying that you can’t equate a human life to a valve, I understand that point and that is not what I am doing. I am simply showing that the quality of the “label” used to ID something (no matter what it is) can impact the end result. There are also other root causes here that may be different based on the data presented, but there are similar Human Factors that apply to both.

And just to make sure you understand the label in the industrial example used, here is the font and the label used:

Valve Label Font
See any issues here????

So in the end, no matter what you do for a living, no matter how educated or experienced the person is, mistakes happen because of Human Performance based issues. The same issues affect us all no matter how different we believe our systems can be. This is exactly why our system is based on Human Performance and Equipment Performance principles and not based on industry variables and conditions. Our TapRooT® system has been proven to work in any industry equally as well. The only limitation that is put on the use of TapRooT® is the one we impose on ourselves based on our own professional bias.

If you would like to learn more about how TapRooT® can work in your industry please feel free to contact me at skompski@taproot.com or attend one of our public seminars. Our courses can be found at www.taproot.com/courses.

Using the Essential TapRooT® Techniques to Perform Apparent Cause Analysis

February 17th, 2016 by

If you are in the nuclear industry you have probably read my rant on apparent cause analysis. I said that apparent cause analysis was a curse.

The curse as been lifted!

We published a book that describes how to use TapRooT® for low-to-moderate risk incidents. And this new way of using TapRoot® is perfect for apparent cause analysis!

EssentialsBook

What’s in the book? Here’s the Table of Contents …

Chapter 1: When is a Basic Investigation Good Enough?

Chapter 2: How to Investigate a Fairly Simple Problem Using the Basic Tools of the TapRooT® Root Cause Analysis System

  • Find Out What Happened & Draw a SnapCharT®
  • Decision: Stop or More to Learn?
  • Find Causal Factors Using Safeguard Analysis
  • Find Root Causes Using the Root Cause Tree® Diagram
  • Develop Fixes Using the Corrective Action Helper Module
  • Optional Step: Find and Fix Generic Causes
  • What is Left Out of a Basic Investigation to Make it Easy?

Chapter 3: Comparing the Results of a 5-Why Investigation to a Basic TapRooT® Investigation

Appendix A: Quick Reference: How to Perform a Basic TapRooT® Investigation

WHEN CAN YOU BUY THIS NEW BOOK??? NOW!!!

See this link: 

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

New TapRooT® Essentials Book is Perfect for Low-to-Medium Risk Incident Investigations

February 10th, 2016 by

In 2008 we wrote the book TapRooT® – Changing the Way the World Solves Problems. In one book we stuffed in all the information we thought was needed for anyone from a beginner to an expert trying to improve their root cause analysis program. It was a great book – very complete.

As the years went on, I realized that everybody didn’t need everything. In fact, everything might even seem confusing to those who were just getting started. They just wanted to be able to apply the proven essential TapRooT® Techniques too investigate low-to-moderate risk incidents.

Finally I understood. For a majority of users, the big book was overkill. They wanted something simpler. Something that was easy to understand and as easy as possible to use and get consistent, high-quality results. They wanted to use TapRooT® but didn’t care about trending, investigating fatalities, advanced interviewing techniques, or optional techniques that they would not be applying.

Therefore, I spent months deciding was were the bare essentials and how they could be applied as simply as possible while still being effective. Then Linda Unger and I spent more months writing an easy to read 50 page book that explained it all. (Yes … it takes more work to write something simply.)

 

EssentialsBook

Book Contents:

Chapter 1: When is a Basic Investigation Good Enough?

Chapter 2: How to Investigate a Fairly Simple Problem Using the Basic Tools of the TapRooT® Root Cause Analysis System

  • Find Out What Happened & Draw a SnapCharT®
  • Decision: Stop or More to Learn?
  • Find Causal Factors Using Safeguard Analysis
  • Find Root Causes Using the Root Cause Tree® Diagram
  • Develop Fixes Using the Corrective Action Helper Module
  • Optional Step: Find and Fix Generic Causes
  • What is Left Out of a Basic Investigation to Make it Easy?

Chapter 3: Comparing the Results of a 5-Why Investigation to a Basic TapRooT® Investigation

Appendix A: Quick Reference: How to Perform a Basic TapRooT® Investigation

By April, the new book and philosophy will be incorporated into our 2-Day TapRooT® Root Cause Analysis Course. But you can buy the new book (that comes with the latest Dictionary, Root Cause Tree®, and TapRooT® Corrective Action Helper® Guide) from our web site NOW. See:

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

I think you will find the book invaluable because it has just what you need to get everything you need for root cause analysis of low-to-medium risk incidents in just 10% of the old book’s pages.

Eventually, we are developing another eight books and the whole set will take the place of the old 2008 TapRooT® Book. You will be able to buy the books separately or in a boxed set. Watch for us to release each of them as they are finished and the final box set when everything is complete. 

Top 3 Worst Practices in Root Cause Analysis Interviewing

February 8th, 2016 by
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Allow interviewees to set the pace of the interview by encouraging them to tell the story of what happened during the incident instead of waiting for you to ask a “yes” or “no” answer.

Investigative interviewing is challenging because most investigators have learned how to do it on the job and do not have formal training. However, it is a very important component of evidence collection so it’s essential to know what practices to avoid.  Here are the top three worst practices in root cause analysis interviewing.

1. Not using a variety of open-ended questions. Asking too many closed-ended questions (questions that can be answered with a “yes” or “no”) will get you just that — a “yes” or “no.” Not only that, but closed-ended questions tend to be leading. Open-ended questions will help the interviewee retrieve from memory and maybe even provide information you did not know to ask. That’s not to say you should never use closed-ended questions.  Use your closed ended questions judiciously to verify something the interviewee has said or to tie up loose ends after the interviewee finishes his or her narrative.

2. Treat the interviewee with respect. When you seem uninterested in what the interviewee has to say, (i.e., you look at your phone/computer, take non-essential calls and allow other people to interrupt, sigh/show you are impatient/bored with your body language), he or she will try to make answers as brief as possible.  Interviewees will follow your lead but you really want them to set the pace – allowing them space to retrieve from memory and tell their stories as they remember them.  Set aside a time you will not be interrupted and break the ice at the beginning of the interview with a friendly tone and body language.

3. Don’t interrupt!  This goes along with #2 above but it also deserves it’s own spot because it is so important.  Even if you don’t do anything else right in the interview, don’t interrupt the interviewee while he or she is telling the story from memory. It will cause them to lose a train of thought and cause you to lose valuable information to get to the root cause.  You’ll also give out a “I already know what happened” attitude.  You don’t know the root cause until the investigation is complete, (and I hope you are nodding your head affirmatively).

What can you share about good interviewing practices?  Please leave your comments below.

And plan to attend the 2016 Global TapRooT® Summit, August 1-5, 2016 in San Antonio, Texas, where I will be teaching the 2-day Interviewing & Investigation Basics course as well as the best practice sessions, “15 Questions – Interview Topics” and “Interviewing Behaviors & Body Language” during Summit week.

Meteorite Casualty: Natural Disaster in TapRooT® Root Cause Analysis

February 8th, 2016 by

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Photo of meteor from Chelyabinsk, Russia in 2013

If confirmed, here is a link to the first recorded fatality due to a meteorite strike in modern history. This would be one of the few appropriate uses of the Natural Disaster category on the Root Cause Tree®.

When doing a root cause analysis using TapRooT®, one of the top-level paths you can follow can lead you to Natural Disaster as a possibility. We note that this doesn’t come up very often. When you go down this path, TapRooT® makes you verify that the problem was caused by a natural event that was outside of your control.

I have seen people try to select Natural Disaster because there was a rainstorm, and a leak in the roof caused damage to equipment inside the building. Using TapRooT®, this would most likely NOT meet the TapRooT® Dictionary® definition of Natural Disaster. In this case, we would want to look at why the roof leaked. There should have been multiple safeguards in place to prevent this. We might find that:

The roofing material was improperly installed.
We do not do any inspections of our roof.
We have noted minor water damage before, but did not take action.
We have deferred maintenance on the roof due to budget, etc.

Therefore, the leaky roof would not be Natural Disaster, but a Human Performance issue.

The case of the meteorite strike, however, is a different issue. There are no reasonable mitigations that an organization can put in place that would prevent injury due to a meteorite. This is just one of those times that you verify that your emergency response was appropriate (Did we call the correct people? Did medical aid arrive as expected?). If we find no issues with our response, we can conclude that this was a Natural Disaster, and there are no root causes that could have prevented or mitigated the accident.

Times are Tough … How Can TapRooT® Root Cause Analysis Help?

February 4th, 2016 by

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Many industries have dropped into a recession or a downright depression.

Oil, coal, iron ore, gas, and many other commodity prices are at near term (or all time) lows.

When the economy goes bad, the natural tendency is for companies to cut costs (and lay people off). Of course, we’ve seen this in many industries and the repercussion have been felt around the world.

Since many of our clients are in the effected industries, we think about how we could help. 

If you could use some help … read on!

FIRST

I think the first way we can help is to remind TapRooT® Users and management at companies that use TapRooT® that in hard times, it is easy for employees to hear they wrong message.

What is the wrong message?

Workers and supervisors think that because of the tough economic times, they need to cut corners to save money. Therefore, they shortcut safety requirements.

For example:

  • A mechanic might save time by not locking out a piece of equipment while making an adjustment. 
  • An operator might take shortcuts when using a procedure to save time. 
  • Pre-job hazard analyses or pre-job brief might be skipped to save time.
  • Facility management might cut operating staff or maintenance personnel below the level needed to operate and maintain a facility safely.
  • Supervisors may have to use excessive overtime to make up for short staffing after layoffs.
  • Maintenance may be delayed way past the point of being safe because funds weren’t available.

These changes might seem OK at first. When shortcuts are taken and no immediate problems are seen, the decision to take the shortcut seems justified. This starts a culture shift. More shortcuts are deemed acceptable. 

In facilities that have multiple Safeguards (often true in the oil, mining, and other industries that ascribe to process safety management), the failure of a single Safeguard or even multiple Safeguards may go unnoticed because there is still one Safeguard left that is preventing a disaster. But every Safeguard has weaknesses and when the final Safeguard fails … BOOM!

This phenomenon of shortcuts becoming normal has a PhD term … Normalization of Deviation

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The result of normalization of deviation? Usually a major accident that causes extensive damage, kills multiple people, and ruins a company’s reputation.

So, the first thing that we at System Improvements can do to help you through tough times is to say …

WATCH OUT!

This could be happening to your operators, your mechanics, or your local management and supervision. 

When times are bad you MUST double up on safety audits and management walk arounds to make sure that supervisors and workers know that bad times are not the time to take shortcuts. Certain costs can’t be cut. There are requirements that can’t be eliminated because times are tough and the economy is bad. 

SECOND

When times are tough you need the very BEST performance just to get by.

When times are tough, you need to make sure that your incident investigation programs and trending are catching problems and keeping performance at the highest levels to assure that major accidents don’t happen.

Your incident investigation system and your audit programs should produce KPI’s (key performance indicators) that help management see if the problems mentioned above are happening (or are being prevented).

If you aren’t positive if your systems are working 100%, give us a call (865-539-2139) and we would be happy to discuss your concerns and provide ideas to get your site back on the right track. For industries that are in tough times, we will even provide a free assessment to help you decide if you need to request additional resources before something bad happens. 

Believe me, you don’t want a major accident to be your wake up call that your cost cutting gone too far.

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THIRD

How would you like to save time and effort and still have effective root cause analysis of small problems (to prevent big problems from happening)? 

For years I’ve had users request “TapRooT®-Lite” for less severe incidents and near-misses. I’ve tried to help people by explaining what needed to be done but we didn’t have explicit instructions.

Last summer I started working on a new book about using TapRooT® to find the root causes of low-to-medium risk incidents. And the book is now finished and back from the printers.

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Good news:

  • The book is only 50 pages long.
  • It makes using TapRooT® easy.
  • It provides the tools needed to produce excellent quality investigations with the minimum effort.
  • It will become the basis for our 2-Day TapRooT® Root Cause Analysis Course.

When can you get the book? NOW! Our IT guys have a NEW LINK to the new book on our store.

By April, we should have our 2-Day TapRooT® Course modified and everything should be interlinked with our new TapRooT® Version VI Software.

In hard economic times, getting a boost in productivity and effectiveness in a mission critical activity (like root cause analysis) is a great helping hand for our clients.

The new book is the first of eight new books that we will be publishing this year. Watch for our new releases and take advantage of the latest improvements in root cause analysis to help your facility improve safety, quality, and efficiency even when your industry is in tough economic times. For more information on the first of the new books, see:

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

FINALLY

If you need help, give us a call. (865-539-2139)

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Are you having a backlog of investigations because of staff cuts? We can get you someone to help perform investigations on a short term basis.

Need to get people trained to investigate low-to-medium risk incidents effectively (and quickly)? We can quote a new 2-Day TapRooT® Root Cause Analysis Course t to be held at your site.

Need a job because of downsizing at your company? Watch the postings at the Root Cause Analysis Blog. We pass along job notices that require TapRooT® Root Cause Analysis skills.

This isn’t the first time that commodity prices have plummeted. Do you remember the bad times in the oil patch back in 1998? We helped our clients then and we stand by to help you today! We can’t afford to stop improvement efforts! Nobody wants to see people die to maintain a profit margin or a stock’s price. Let’s keep things going and avoid major accidents while we wait for the next economic boom.

3 Tips for Quality Root Cause Analysis

January 27th, 2016 by

“You get what you ask for,” ever hear that phrase? Well, it is a good lead into root cause tip #1.

#1 Know why you are doing the root cause analysis but DON’T let the reason drive the root cause process and findings itself.

The quality of a root cause analysis report, or in many cases the amount of information contained in the report, is driven by the requirement for the root cause analysis itself.

    1. Government Agency Requirement
    2. Regulatory Finding Requirement
    3. Internal Company CEO/CFO Requirement
    4. Internal Company Policy Requirement
    5. Supervision Request but no policy requirement

Which one of the requirements above most likely requires a more extensive root cause analysis report, written in a very specific way? Most of us, by experience, would focus on items A-C. Besides the extensive amount of time it takes to produce the regulatory report, how could the report requirement become a driver for poor root cause analysis?

  • Report writing drives the actual evidence collection.
  • Terminology required in the report forces people to prioritize one problem over another, and in some cases ignore important information because it does not have a place in the report.
  • Information is not included or addressed because the report is going to an outside organization.

If A-C root cause analysis requirements could lead to biased or incomplete root cause analyses because of the extensive regulatory requirements, then D-E should be better right? Well, not so fast.

  • Less oversight of the root cause analysis report (if there is one) could result in less validated evidence or a list of corrective actions with limited support to substantiate them.
  • There is often a higher variability of how the root cause analysis is performed depending on who is performing it and where they are performing it.

So how do you counter the problems of standardization verses non-standardization issues in root cause analysis? The easiest method is to use a guided investigation process and not drive the process itself. Once the root cause analysis is complete, then and only then focus on writing the report.

Below is a list of 7 points with a link to read more if needed that can help reduce bias and variability. 7 Secrets of Root Cause Analysis

  1. Your root cause analysis is only as good as the info you collect.
  2. Your knowledge (or lack of it) can get in the way of a good root cause analysis.
  3. You have to understand what happened before you can understand why it happened.
  4. Interviews are NOT about asking questions.
  5. You can’t solve all human performance problems with discipline, training, and procedures.
  6. Often, people can’t see effective corrective actions even if they can find the root causes.
  7. All investigations do NOT need to be created equal (but some investigation steps can’t be skipped).

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#2 Establish ownership of the root cause analysis being facilitated BEFORE you go forward.

This is just plain project management advice. If the team and process owner of the issue being analyzed believe that you as the root cause facilitator own the root cause analysis, guess what… You Do! It’s your evidence, your root causes, your corrective actions and your accountability of success or failure. It is easier to pass the buck so to be speak and can also hamper the support that the facilitator needs to ensure an effective investigation.

In most cases the root cause analysis facilitator is just that, the facilitator of information. Keep it that way and establish ownership up front.

#3 As a team, define what finished means for the root cause analysis and if there is a turnover of the root cause analysis, ensure that ownership is maintained by the appropriate people.

Often the root cause analysis facilitators in my courses tell me that once the analysis portion is done at their company, the report is handed off to their supervision to make the actual corrective actions. Not optimal in itself, and should include a validation step handled by the root cause facilitator to ensure that the corrective actions match up to the original findings. The point, however, is that whatever “finished “ is, and wherever a true handoff of information must occur, it needs to be established up front along with the ownership discussed in tip #2.

In TapRooT® Root Cause Analysis, the following would be great investigation steps to focus on with your team and peers when discussing what finished means, hear more about these steps here.

  1. After Creating Summer SnapCharT® – Is the SnapCharT® thorough enough or do we need more interviews & data?
  2. After Defining Causal Factors – Are they at the right end of the cause-and-effect chain? Was a Safeguards Analysis conducted? Were all the failed safeguards identified as causal factors?
  3. After RCA and Generic Cause Analysis – Did they use their tools (Root Cause Tree®, Root Cause Tree® Dictionary, etc.)? Did they find good root causes? Did they find generic causes? Did they have evidence for each root cause?
  4. After Developing Corrective Actions – Use corrective action helper to determine effectiveness of corrective actions.

These 3 root cause tips were designed to reduce the barriers to good quality root cause analysis. Comment below if you have additional tips that you would like to pay forward.

Root Cause Tips – What Should You Investigate?

January 13th, 2016 by
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What if you have more than you can possibly investigate?

Hello and welcome to this week’s root cause analysis tips column.

One of the questions I am asked often is “what should we investigate?”

The answer is it really depends on your company, your numbers, and your resources. I have some ideas, and these apply to anything, but I will use safety as an example.

First of all, your company may have a policy on what has to be investigated; for example, all lost time injuries or all recordable injuries. So you already know you are required to do those. But what if something is not required?

What I say is investigate as much as possible based on your numbers and your resources. If you work at a site that has 10 injuries a year but only 2 are recordable, if you have the resources to do all 10, I certainly would. It is likely the only difference between the 2 and the other 8 is……LUCK.

What if you have more than you can possibly investigate? Then you should do a really good job at categorization, and do investigations on the TRENDS. In other words, I would rather have you do one really good investigation on a trend than dozens of sub-standard investigations. You will use less resources but get better results.

How do you do an investigation on a trend? It is really very simple – instead of mapping out an incident with a SnapCharT®, you map out the process. You can leave the circle for the incident off the chart or you can make the circle the trend itself. The events timeline is simply the way the process flows from start to finish, and this is very easy to do if you understand the process. If you need help from the process owner, an SME, or employee, you can do that too. For conditions, you add everything you know about the process, as well as any data (evidence) available from the reports or other sources. You mark significant issues (the equivalent of causal factors) for things that you know have gone wrong in the past. You can take it a step further any also mark as significant issues things that COULD go wrong (think of this as potential causal factors). You then do your root cause analysis and corrective actions. This is not hard, it is just a different way of thinking.

Just a few more thoughts about what to investigate; basically, anything that is causing you pain. Process delays, customer complaints, downtime, etc. can all be investigated. But by all means, make sure it is worth your time and that there is really something to learn from it. Please don’t investigate paper cuts!

I hope my ideas give you some food for thought. Keep pushing the boulder up the hill and improving your business. Thanks for visiting the blog.

Sign up to receive tips like these in your inbox every Tuesday. Email Barb at editor@taproot.com and ask her to subscribe you to the TapRooT® Friends & Experts eNewsletter – a great resource for refreshing your TapRooT® skills and career development.

 

How Can TapRooT® Help Prevent Falls and Maintain a Fall Prevention Program?

January 7th, 2016 by

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While reading Sentinel Event Alert 55 (SEA-55) from TJC issued September 28, 2015 on Fall Prevention, it occurred to me that TapRooT® can be used to aid in finding the root causes of the fall. Even more importantly, TapRooT® can be used to aid in maintaining your fall prevention program to ensure long-term success. The TJC lists the following common contributing factors (in TapRooT® these would be called “Causal Factors“):

  • Inadequate assessments
  • Communication Failures
  • Lack of adherence to protocols and safety practices
  • Inadequate staff orientation, supervision, staffing levels and skill mix
  • Deficiencies in the physical environment
  • Lack of Leadership

While these are good guidelines for what to look for and what data to gather, to us these do not represent root causes. These 6 items almost match up with most of the 7 Basic Categories on the back of our Root Cause Tree®. So as TapRooT® investigators, know you have to dig a bit deeper to find the true causes and define those at the Root Cause level not at the causal or contributing level.

All this being said, the more important reason I wanted to write this article is to highlight the use of your TapRooT® tools by using them for Proactive measures. How to examine and improve your fall management program and maintain continued success. Too many times we don’t think about the power of observation and the idea of raising awareness through communication. Each of these can be highlighted through the Proactive Process Flow below:

ProactiveFlow

In SEA-55, two of the actions suggested by TJC were to 1) Lead an effort to raise awareness of the need to prevent falls resulting in injury and 2) Use a standardized, validated tool to identify risk factors for falls. These two items can benefit from the TapRooT® tools directly.

Starting with step 1 above in the Proactive Flow, use the SnapCharT® tool to outline the steps in patient assessment, highlight the steps that can or will affect the fall prevention portion of patient care, then use this flow as the basis for an observation program. By getting out and observing actual performance in the field you can do two things, show your concern for patient safety (and falls in this case) and gather actual performance data. These observations can be performed both in a scheduled and/or random fashion and can be done in any setting (ambulatory, non-ambulatory, clinic et cetera).

During the observation, document findings on the SnapCharT® and identify potential “Significant Issues” as they apply to fall prevention. This data can then be either evaluated using the Root Cause Tree® to define the areas of need for that single observation, or the data can be combined with other fall prevention observation data for use in an aggregate analysis or common cause analysis. With the aggregate analysis data from multiple observations can be combined, and “Significant Issues” can be identified based on multiple observations before an analysis using the Root Cause Tree® is performed. This could give you an overall bigger picture view of your processes.

Once the RCA is performed (in either situation), Steps 5-7 can be simply followed to produce some recommended actions to be implemented and measured using Corrective Action Helper® and SMARTER. And the beauty of this Proactive process is that you have not waited for a fall to learn.  You and your organization are preventing future issues before they manifest thus showing your patients and staff that you truly care about their safety.

If you would like to learn more about using your TapRooT® tools proactively you can contact me at Skompski@taproot.com for more information or you can attend any of our public seminars, 2-day or 5-day to learn more on both the reactive and proactive use of the TapRooT® tools!

Investigative Interviewing: How to Decrease the Chance of an Inconsistent Statement

December 31st, 2015 by

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Not every inconsistent statement is meant to deceive.

 

A new investigator may believe that if an interviewee is telling the truth, he will be consistent in his recollection of an event every single time. However, not every inconsistent statement made by an interviewee is made to intentionally deceive.

In fact, most interviewees want to be helpful. Further, an inconsistent statement may be as accurate or even more accurate than consistent claims. That is, an account repeated three times with perfect consistency may be more of a red flag to dig deeper.

The two most important things to think about when evaluating inconsistencies are the passage of time between the incident and its recollection, and the significance of the event to the interviewee. Passage of time makes memory a bit foggy, and items stored in memory that become foggy the quickest are things that we don’t deem significant, like what we ate for lunch last Wednesday.

There are three ways to decrease the possibility of innocent inconsistent statements during the interviewing process.

  1. Encourage the interviewee to report events that come to mind that are not related or are trivial. In this way, you discourage an interviewee trying to please you by forcing the pieces to fit. They do not know about all the evidence that has been collected, and may believe that something is not related when it truly is.
  2. Tell the interviewee, explicitly, not to try to make-up anything he or she is unsure of simply to prove an answer. If they don’t know, simply request they say, “I don’t know.” This will help them relax.
  3. Do not give feedback after any statement like “good” or “right.” This will only encourage the interviewee to give more statements that you think are “good” or “right”– and may even influence them to believe that some things occurred that really didn’t.

We have plans to go over many more details on how to conduct a good interview at the 2016 Global TapRooT® Summit, August 1 – 5 in San Antonio, Texas.  Save the date and look for updates here.

Why Healthcare Root Cause Analyses Fail

December 16th, 2015 by

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For many years now the TJC and other governing bodies have required root cause analysis (RCA) on Sentinel events as well as analyses on near misses with high potential. To remain accredited, organizations have put together teams to perform analyses to find the causes and to recommend, implement and track corrective actions. Throughout this time of focus and effort there continue to be repeat sentinel events. So the question that arises is, why are these RCA’s failing?

This question may appear very complex but the root of the problem is actually very simple. From reading many Event reports and examining how many organizations perform these analyses two things stand out to me:

  • Many analyses stop at too high a level due to a lack of information and do not reach true root causes. They stop at what we define as a Causal of Contributing factor.
  • Many corrective actions don’t address the root cause due to the limited analysis or because the corrective actions created are not specific to changing a particular behavior or system.

What truly makes this even simpler is the fact that these two issues are interrelated. If you don’t thoroughly gather the correct information and identify the true root causes the corrective actions may not be focused enough to fix the problem. We will then fall into the trap of implement general or employee focused corrective actions that don’t address system problems. This can result in wasted time and resources and can have a very negative impact on the people involved in the event.

Here you see an example where the investigator stopped gathering data at a Causal or Contributing Factor.

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In this example there was a mistake made by the nurse when retrieving a medication for a particular patient. With no additional information gathered, the investigator is forced to stop at this level. No more analysis can be performed without many assumptions and opinions being used. In this case, when the team moves to corrective actions, how do you fix someone retrieving the wrong medication? Well, without any additional information, we counsel the employee to be more careful, we punish the nurse for making the wrong choice, and/or we retrain everyone to make sure there is an overall understanding of this issue. None of these truly change the system and address the causes of the issue (as you will see below).

If the investigator gathers much more information on the issue there is at least a chance to more thoroughly examine the issue using your RCA tools and dig deeper to a root cause level.

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Having this additional data available allows the investigator to dig deeper into the issue to identify the underlying system root causes that contribute to this mistake by the nurse. This changes the focus to the organizational systems and not solely on the individual. Knowing that it has become common practice during high census to not follow the second check rule (or 5 Rights) and there have been no negative consequences consistently provided by management for this issue we would be able to identify system related causes such as Management System ->SPAC Not Used ->Enforcement NI (from the Root Cause Tree®) and other causes. By getting to this level of analysis and understanding the system cause(s), we can now build corrective actions to address specific system issues. By addressing the specific causes and in this case changing the rules or terms around times with a higher than normal census, the requirements for following and consequences for not following this policy we are changing the systems in the organization. By changing the systems we can enact long lasting positive change in the organization and build sustained success and change the behaviors of our employees.

Learn more about TapRooT® here or contact us to find out how TapRooT® is the answer to succeeding in your healthcare root cause analyses.

Can You Use One Root Cause Analysis Tool for Quality, Safety, Production, IT, Cost, and Maintenance Issues?

December 2nd, 2015 by

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Break the barriers! Look for a root cause analysis process that can tie Quality, Safety, Production, IT, Cost, and Maintenance Department issues together to help solve problems as one.

What a silly question with such a simple answer, “Yes, of course you can use one root cause analysis tool for Quality, Safety, Production, IT, Cost, and Maintenance Issues!” Soooo, why don’t we? I can hear all the functional division leaders from each corner of your company yelling, “Nooo, you can’t!”

The disagreement of which root cause analysis tools are used by who actually starts with the creation of internal company functional silos. Companies that run smoothly almost transparently as one unit realize that Quality, Safety, Production, IT, Cost, and Maintenance Departments impact each other, either positively or negatively, and should use similar tools during root cause analysis to enhance root cause analysis communication between departments. Unfortunately, this unison is not often common. Let’s break it down a little.

IT (Information Technology) – often focuses on rapid root cause diagnosis and analysis.

Quality – tends to focus on the 8 Basic Quality Tools and Lean Activities with different variations in the sequence of root cause analysis.

Safety – focuses on root cause analysis tied to hazard and risk to reduce Health, Safety and Environment Issues.

Production – is probably the closest tied to quality and cost reduction issues, whereas safety is more often viewed as cost aversion. The problem solving tools utilized here are often tied to the Quality and Cost root cause analysis tools to ensure production is met and the company makes money.

Maintenance – is focused on operational efficiencies and cost to run and maintain the equipment. Often tied to Quality and Production root cause analysis tools but more tied to equipment specifics.

Cost – everybody needs to know where the money goes and if we have enough to keep the business alive. Financial knower’s in the company get tasked by many of the departments listed above, some departments more than others. Their root cause analysis tools are more tied to transactional processes.

Now that the different company functions listed above are established, what often happens next is that the department leaders search for root cause analysis tools created just for their types of problems and the silo walls between departments get even bigger. Why? Simple, the specific function tools often only look for issues and causes tied to their specific issues. So what’s wrong with that you ask?

Input – Process – Output across your Company’s Work Processes

What each functional department changes or produces impacts another department either upstream or downstream from that department. Root cause analysis tools that are too functionally specific tend to not explore or encourage multi-department discussions during root cause analysis. If the tools don’t talk your language, they do not apply to you or in some cases, the company does not think you need to be trained in the other tools.

Case in point, as a lean six sigma black belt in a previous company, I spent my last year in manufacturing mentoring our safety department in quality tools. No one from safety had ever attended our quality training that we taught internally, even though we taught classes every month. Operations and Maintenance employees attended the training because they were more tied to the return on investment company costs.

Break the silo department barriers, look for a root cause analysis process that can tie Quality, Safety, Production, IT, Cost, and Maintenance Department issues together to help solve problems as one.

For over 28 years, System Improvements has prided itself in having a standard root cause analysis process called TapRooT®. No matter what the problem being analyzed they all start with Defining the Worst Consequence that Occurred, Identifying What Happened and How It Happened and then Why. We also teach and include Corrective Actions that are global industry best practices.

Don’t fret, because we don’t recommend that you throw away your other data collection and analysis tools, instead we recommend that you use the TapRooT® Root Cause Analysis Method as the standard communication and investigation tool for the root cause process to enhance and consolidate current programs for one company vision. After all, everything has a timeline of events or a sequence of transactions, start your problem solving with a proven root cause analysis process that starts there first and then helps guide employees through multiple types of problems to help you understand Human Performance

Safeguard Analysis for Finding Causal Factors

November 25th, 2015 by

 

A Causal Factor is nothing more than a mistake or an equipment failure that, if corrected, could have prevented the incident from happening.

Once you’ve gathered all the information you need for a TapRooT® investigation, you’re ready to start with the actual root cause analysis. However, it would be cumbersome to analyze the whole incident at once (like most systems expect you to do). Therefore, we break our investigation information into logical groups of information, called Causal Factor groups. So the first step here is to find Causal Factors.

Remember, a Causal Factor is nothing more than a mistake or an equipment failure that, if corrected, could have prevented the incident from happening (or at least made it less severe).  So we’re looking for these mistakes or failures on our SnapCharT®.  They often pop right off the page at you, but sometimes you need to look a little harder.  One way to make Causal Factor identification easier is to think of these mistakes as failed or inappropriately applied Safeguards.  Therefore, we can use a Safeguard Analysis to identify our Causal Factors.

There are just a few steps required to do this:

First, identify your Hazards, your Targets, and any Safeguards that were there, or should have been there.

Now, look for:

- an error that allowed a Hazard that shouldn’t have been there, or was larger than it should have been;

- an error that allowed a Safeguard to be missing;

- an error that allowed a Safeguard to fail;

- an error that allowed the Target to get too close to a Hazard; or

- an error that allowed the Incident to become worse after it occurred.

These errors are most likely your Causal Factors.

Let’s look at an example.  It’s actually not a full Incident, but a VERY near miss.  This video is a little scary!

Train Pedestrian Incident from TapRooT® Root Cause Analysis on Vimeo.

Let’s say we’ve collected all of our evidence, and the following SnapCharT is what we’ve found.  NOTE:  THIS IS NOT A REAL INVESTIGATION!  I’m sure there is a LOT more info that I would normally gather, but let’s use this as an example on how to find Causal Factors.  We’ll assume this is all the information we need here.

Picture1 Picture2

Now, we can identify the Hazards, Targets, and Safeguards:

Hazard Safeguard Target
Moving Train Fence Pedestrians
Pedestrians (they could have stayed off the tracks)

Using the error questions above, we can see that:

- An error allowed the Hazard to be too large (the train was speeding)

- An error allowed the Targets to get too close to the Hazard (the Pedestrians decided to go through the fence, putting them almost in contact with the Hazard)

These 2 errors are our Causal Factors, and would be identified like this:

Picture3 Picture4

We can now move on to our root cause analysis to understand the human performance factors that lead to this nearly tragic Incident.

Causal Factors are an important tool that allow TapRooT® to quickly and accurately identify root causes to Incidents.  Using Safeguard Analysis can make finding Causal Factors much simpler.

Sign up to receive tips like these in your inbox every Tuesday. Email Barb at editor@taproot.com and ask her to subscribe you to the TapRooT® Friends & Experts eNewsletter – a great resource for refreshing your TapRooT® skills and career development.

Are you doing “spare time” root cause analysis?

November 19th, 2015 by

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Don’t get caught in these scenarios – make root cause analysis an integral part of your improvement program.

 Do these scenarios look familiar to you?

Here’s scenario #1:

An incident occurs.

The supervisor performs a 5-Whys analysis, or maybe just does a few interviews with a few employees out on the plant floor. The supervisor collects just enough information to fill out the company report, or to satisfy his manager because this is a task done in his spare time. Once someone or something is found to pin the cause on, the supervisor thinks of a solution, (typically an employee gets disciplined or a piece of equipment gets fixed), and the root cause analysis is complete.

The downside to doing root cause analysis in your spare time like this is you’ll probably see repeat incidents. You’ll miss root causes or not get to the root. So, instead of saving time doing the investigation in your spare time, you have created more work.  Plus, you are working within your own knowledge.  You may be very experienced, but a bias (and we all have them) can cause you to overlook important information.  Also, morale will be affected because employees do not want to live under the fear of punishment if they make a mistake. And let’s not forget when near misses and small problems aren’t solved, chances are a major incident is building on the horizon.  Don’t let your facility be the next headline!

Here’s scenario #2:

An incident occurs.

The supervisor performs a TapRooT® investigation in his or her spare time. Her company does not have a blame culture– hooray! She only had time to attend one day of a 2-day TapRooT® course, but the former supervisor showed her the basics. The supervisor uses the Root Cause Tree® as a “pick list,” (without using a Root Cause Tree® Dictionary to dig deeper – she is not even aware there is a dictionary), until one root cause and a couple of causal factors are found.  Sigh of relief. Corrective actions to the root cause are implemented.  Check! This root cause analysis is complete!

The downside to this TapRooT® “spare time” root cause analysis is similar to scenario #1 in that you will probably experience repeat incidents because you’ll miss root causes that won’t be fixed, and there was not sufficient training on the TapRooT® tools.  You may progress beyond your own knowledge in identifying root causes using the Root Cause Tree® and that’s a plus, but you may not be casting a wide enough net by using all of the tools in the TapRooT® system.  Take shortcuts and don’t use all the tools available to you, and you will lose the power of TapRooT® to effectively guide you in your root cause analysis to find and fix incidents.

Don’t be that supervisor!

To get the full benefit of TapRooT®, join us at a course to receive all of these tools and understand how to use them:

SnapChart® – a visual technique for collecting and organizing information to understand what happened.
Root Cause Tree® – a way to see beyond your current knowledge (with additional help from the Root Cause Tree® Dictionary)
Corrective Action Helper® – a tool to help you think “outside the box” to develop effective corrective actions.
Safeguard Analysis – identify and confirm causal factors

This is how you find all the root causes and fix them once and for all.  Smaller problems are also found before they turn into major disasters.  It’s a win for everyone!

Are you doing spare time root cause analysis?  There is still time to join us for a course in 2015 and make 2016 a different story.

Learn more here:
2-Day TapRooT® Incident Investigation and Root Cause Analysis Course
or
5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Peer Feedback to Improve Root Cause Analysis

November 11th, 2015 by

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What value does the peer get from giving feedback about a root cause analysis?

All Root Cause Analyses started have an initial goal…

Reduce, Mitigate or Eliminate a Problem!

As TapRooT® trained root cause analysis investigators soon learn, there is usually more than one Causal Factor that caused the Incident being investigated, and each Causal Factor has more than one Root Cause. If this sounds foreign to you as an investigator, check out our TapRooT® Root Cause method here. So if problems do not occur in isolation, why should the investigator work in isolation? Thus, the topic of today, “Peer Feedback to Improve Root Cause Analysis.”

Previously we discussed real–time peer review during the investigation TapRooT® Process and reviewing a completed TapRooT® looking for the “Good, Bad and the Ugly” with a spreadsheet audit included.

Root Cause Analysis Video Tip: Conduct Real-Time Peer Reviews
http://www.taproot.com/archives/45875

The Good, The Bad & The Ugly
http://www.taproot.com/archives/11045

So what’s next? Are peers created equal? What value can a peer add? What value does the peer get from giving feedback about a root cause analysis? Let’s see….

Peers are not created equal! This is a good thing. Below is a short list of peers to get feedback on your root cause analysis progression and the value that they add.

1. Coach/Mentor: This is a person who is competent and formally trained in the root cause process that you are using. They are not teaching you the process but guiding you through your use of it after you were formally trained. They have been in the trenches and dealt with the big investigations, These process champions can easily get you back on the right track and show unique techniques.

Too many companies get large numbers of employees trained in a process and then let them run free without future guidance or root cause analysis feedback. This is why our TapRooT® Instructors are available for process questions after training is complete. This is also why we encourage key company employees to attend our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training to help mentor those that have taken our 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course.

2. Equal: This is the person who has attended the same root cause analysis training that you have and has the same level of competence. They may also have the same industry technical experiences that you have.

The value of the feedback from this person is to keep each other grounded in the process you are using and to help validate that the evidence received is substantiated. It is very easy sometimes to start pushing any root cause process into one’s biased direction once the energy gets flowing. The trained TapRooT® investigator and peer will remind you to slow down and let the TapRooT® process guide you to the root causes.

3. Novice: There are two types of novices to get feedback from, one that is not trained in the TapRooT® process and one that is not familiar with the investigation or process being investigated.

There is a natural tendency that the more you know about the process you are investigating, the less that you put down on paper. After all, everyone knows how that thing works or what happened. Why do I need to write it down? Simple… “What does not get written down does not get investigated!” As the novice asks you more questions to understand the root cause analysis that you are performing, the more you explain and the more you write down.

4. Formal Auditor: The formal auditor usually audits the root cause analyses after they are completed and the corrective actions have been implemented. There is less communication and engagement between you and the auditor, which is very different than the first peers listed above.

The value of this feedback is that it is designed to look for consistency and standardization across multiple root cause analyses. The auditor may find investigations that need to be recalibrated but may also find new and better ways of doing an investigation based on other’s unique techniques. We also encourage auditors to have taken our 2-Day Advanced Trending Techniques Course, to help look for trends.

The final plus for this feedback activity…..

“Everyone learns something and recalibrates their Root Cause Analysis Techniques and we all help meet the goal of Reduce, Mitigate or Eliminate a Problem!”

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