Category: Root Cause Analysis Tips
– Required by regulators or law
– Required by company policy
– Perceived higher return on investment
However, companies often default to less developed (and therefore less accurate) analyses for lower risk, lower consequence problems. For example, almost everyone will perform a TapRooT® investigation when there is a serious injury; this is a high-consequence incident, and preventing it in the future is perceived to have the highest ROI. But what about a near miss? Or maybe someone tripped over an air line on the floor, dropping a repair part and damaging it? Most companies will either not perform any investigation, or they will default to “easy” methods (5-Why’s, etc.). Why spend any time on these “simple” incidents? Let’s just do a quick “analysis” and move on?
While I completely understand this thought process, there are some serious flaws in this thinking.
- Low ROI. While a particular incident may not have caused a large loss, this dos not mean it automatically deserves no attention. Maybe tripping over the air line only caused $800 in damage this time. But what about the other issues that have been caused by poor housekeeping in the past? What if the person had tripped and fallen over the edge of a platform? Making a quick assumption like this can allow you to miss potentially serious issues when taken together. Performing a poor analysis will lead to repeats of the problem.
- Poor results of “quick” RCA methods. Keep in mind that a quick method probably means that you did not gather any information. You are therefore performing an “analysis” without any data to analyze. If your analysis method takes 5 minutes, you have probably just wasted 5 minutes of your time. If you’re going to perform an RCA, make sure it gets to useable and consistent answers.
- TapRooT® is only for the big stuff. This thought often frustrates me. It is true that you will not perform a TapRooT® investigation in 5 minutes. However, any method that purports to give you magic answers in a few minutes is not being honest. See #2 above. However, that does NOT mean that TapRooT® must take days of your time. For simple investigations, the results of a TapRooT® investigation may be found in just an hour or so.
So, how do we use TapRooT® for lower risk or low consequence problems? This year, we have modified the TapRooT® methodology to allow you to use the steps of the process that you need to perform a great investigation on simple problems. This updated process isn’t really new; it just codifies how we’ve taught you to use TapRooT® in the past for these simpler problems. We make the process more efficient and give you the opportunity to optionally skip some of the steps.
Here is the new process flow for low to medium risk incidents:
There are some important points that I wanted to highlight about this new process flow:
- You always start with a SnapCharT®. There is no way to perform any type of analysis unless you first gather some information. Again, any other process that advocates performing an analysis on the information you received in a quick phone call is not a real analysis. The SnapCharT® ensures you have the right information to actually look for root causes.
- There is an off-ramp right at the beginning. Once you’ve gathered information in a SnapCharT®, you can then make an intelligent decision as to whether this problem has the potential to uncover significant problems. You may find, after building your SnapCharT®, that this really was an extremely low potential problem, with minimal consequences. You will then stop the analysis at that point, put simple corrective actions in place to fix what you found, and then document the problem for later trends. That’s it. While most investigations will continue on with the rest of the process, there are some issues that do not require any further analysis and don’t deserve any further resources.
- For most investigations, you will continue by identifying Causal Factors, and run those Causal Factors through the Root Cause Tree®. No different than before.
- For these simpler problems, it probably is not worth the effort of looking for generic causes. We have made this step optional. It you feel the problem has the potential to be more widespread, you can continue to look for generic issues, otherwise, go straight to corrective actions.
- Low to medium risk incidents probably do not need the resources you would normally expend writing full SMARTER corrective actions. We encourage you to write corrective actions based on the guidance in the Corrective Action Helper®, but writing fully SMARTER fixes is probably not necessary.
For more serious incidents, we would still use the full 7-Step TapRooT® Process that you are familiar with. However, for lower risk or lower consequence problems, this abbreviated process flow is much easier to use, allowing you to more quickly work through a TapRooT® investigation. Why use 5-Why’s and get poor results (as expected) just to “save time,” when you can use the simplified TapRooT® process to get MUCH better answers with less effort than before?
The 2-Day TapRooT® Root Cause Analysis Course not covers this simpler method of performing TapRooT® investigations. Attendees will still be able to perform investigations on any incident, but we stress this more efficient process flow.
Choose a course and register here!
You’ve seen it hundreds of times. Something goes wrong and management starts the witch hunt. WHO is to BLAME?
Is this the best approach to preventing future problems? NO! Not by a long shot.
We’ve written about the knee-jerk reaction to discipline someone after an accident many times. Here are a few links to some of the better articles:
- Wacky Willie
- Will Discipline Fix the CTA’s Problems?
- USS Hartford / USS New Orleans Collision & Subsequent Discipline
- Should You Discipline BEFORE an Investigation is Complete?
- What Should Managers Know About Root Cause Analysis?
- Root Cause Analysis – Do it before even thinking about discipline!
Let me sum up what we know …
Always do a complete root cause analysis BEFORE you discipline someone for an incident. You will find that most accidents are NOT a result of bad people who lack discipline. Thus, disciplining innocent victims of the systems just leads to uncooperative employees and moral issues.
In the very few cases where discipline is called for after a root cause analysis, you will have the facts to justify the discipline.
For those who need to learn about effective advanced root cause analysis techniques that help you find the real causes of problems, attend out 5-Day TapRooT® Root Cause Analysis Training. See: http://www.taproot.com/courses
My grandmother (with whom I spent many of my childhood weekends) would say to us grandkids, “You can’t see the forest for the trees!” That usually came right after something bad happened or we did something that was not considered “right” by the adults. I always wondered what that meant, I have thought about it for years and I believe from an adult perspective I finally get it… Granny Lillie, if you can hear this, “I FINALLY GET IT!” (I hear her saying, “It is about time……sheesh.”)
As I have worked with healthcare organizations over the past 20 years working to improve performance and improve their systems we always talked about examining failures and finding the causes. Finding the “Whys” is the step necessary for you to fix issues that existed. Those issues that underlie our systems and turn into incidents, accidents and breed adverse behaviors have to be removed following a problem so that we can prevent reoccurrence. This is preached, taught, and required by all organizations in today’s business world. But why do we wait, why do we have to fail to learn? That question has always concerned me. This is where my grandmother fits in…
When as kids we would go out, make decisions to do things that had adverse outcomes, she would always say to us “you can’t see the forest for the trees” and we would just nod our heads and say “ok” then continue on our merry way. Not only would we not learn from our mistakes but we could not see the mistakes and incidents they happened. The correlation in today’s adult world from an organizational perspective relates to making decisions without considering the consequences. The “Trees” from the statement above is the change you are going to make. If you focus on the “Trees” in front of you and do not consider the future beyond that “the Forest” you are taking unnecessary risk and possibly creating problems. Do you “get it”?
What got me thinking about this today came from an article I read which dealt with an investigation by the State’s Office of Inspector General at a Louisville, KY hospital. This along with the TJC visit which found many problems at the facility prompted concerns. The investigation was prompted by complaints by staff (that survived the downsizing) regarding health and safety issues due to the decreased staffing. After reading the article I immediately began thinking about our Proactive Flow within the TapRooT® process.
Notice that when we get to step 3 in the Proactive flow we take the observed issues or problems and ask the simple question, “What could result from this?” We would pose this question against our view of the future system. Let’s suppose that they had recognized these future conditions:
- A reduction in staffing would create a significantly higher workload for existing staff
- Hospital maintained customer/patient throughput with reduced staffing
- Using traveling nurses with little or no facility or system related training to supplement staffing levels
- Reduced staffing could cause difficulty in maintaining the Quality Control standards due to pressure based on census
We can now take this information and use that “What could result from this?” and we could have had this conclusion:
a) Training – No Training – Decided not to Train
b) Management System – Standards, Policies and Administrative Controls NI – Not Strict Enough
c) Work Direction – Preparation – Scheduling NI
d) Work Direction – Selection of Worker – Not Qualified
And there certainly could have been others. At this point you have the ability to re-evaluate the changes you are about to make and ensure that the programs put in place following this down-sizing remove these potential problems. This allows you to evaluate the “Forest” behind those “Trees” and ensure the safety of your future patients and staff while working through the “Forest.” If this one hospital had performed this analysis the outcome and where they are today could have been significantly different.
By using this thought process and by being Proactive we can all create safer systems, create a more effective and acceptable working environment, and protect those around us that depend on us… just as Granny Lillie tried to do for us kids so many years ago. Sometimes the simplest, most practical viewpoint is the best. If you have any questions about the TapRooT® process for Proactive assessments please contact me directly at firstname.lastname@example.org.
Words that I hate to hear when asked to help with an investigation: “I am surprised this incident did not happen earlier!” Rarely have I seen an incident where there is not a history of the same problems occurring. Think of it like a math equation:
X + Y (A) = The Incident
A company’s issues are just waiting for the right math equation to occur at the right time. What are some of the common factors that populate the equation above?
- Audit Findings (risk or compliance)
- Near Misses (or some cases, Near Hits)
- OSHA Non-Recordable(s)
- Defects (caught before the defect reached the customer)
- Project Delays
- Procurement Issues
- Behavior Based Safety Entries
This list of variables is infinite and dependent on the industry and service or product that your company provides. Should you be required to perform a full root cause analysis on each and every write-up or issue listed above to prevent an Incident? Not, necessarily.
Instead, I recommend that you start looking at what would be a risk to employees, customers, environment, product/service or future company success if you combined any of your issues in the same timeline or process of transactions (in TapRooT® our timeline is called a SnapCharT®). For example, take the 3 issues listed below that have a higher potential of incident occurrence when combined in the right equation.
Issue 1: Audit finding for outdated procedures found in a laboratory for testing blood samples.
Issue 2: Behavior Based Safety Write-up entered for cracked and faded face shields
Issue 3: Older Blood Analyzer has open equipment work orders for service issues.
Combining the 3 items above could cause a contaminated blood sample, exposure of contaminated blood to the lab worker or a failed test sample to the patient.
If the cautions about your future combination of known issues are not heeded then please do not acted surprised after the future Incident occurs.
Want to learn about causal factors? It’s not too late to sign up for our Advanced Causal Factor Development Course, August 1-2, 2016, San Antonio, Texas.
I was teaching a class (not in the healthcare arena) and had some interesting discussions around the use of procedures during work. First let’s recap the TapRooT® Definition of a procedure:
A procedure is a written step-by-step description of how a particular task is to be performed that is read and followed during performance of the work by the person performing the work.
A checklist is considered a procedure in our system. For this company there were two perceptions regarding procedures and their uses:
- Those are only necessary if there are people who are not knowledgable on the task.
- Those procedures always make work more difficult.
Now, I have heard these comments before from folks in the healthcare field when the work procedure is used not for a medical “procedure” but when it is used as a checklist. Many doctors and nurses don’t like having to follow a specific path towards medical treatment. And I agree because each human is different, each course of treatment is different, and every scenario is different that it is more difficult to set procedures for every medical treatment. But can tasks and scenarios benefit from the use of checklists within healthcare?
The following article talks about the use of checklists and examined 10,700 surgical procedures. The results although only showing small decreases did show that the implementation of quality checklists dealing with Surgical Safety reduced the following:
Length of Stay from 10.4 to 9.6 days
30-day Readmission Rates from 14.6 to 14.5%
90-day Death Rates from 2.4 to 2.2%
Small numerical changes equate to large numbers in the overall scheme of healthcare. From a 2010 National Hospital Discharge Survey and the National Center for Health Statistics showing some 51.4 million inpatient surgeries performed, that means that we can reduce the number of readmissions by 51,400 patients, and the 90-day death rate means we lower the number of deaths by 102,800 patients. Now I am not sure if you agree but that is a SIGNIFICANT impact on patient care. Those are numbers that could provide pause for those who don’t think checklists can be used in healthcare!
Now going back to our two objections above, let’s now think about why procedures, when implemented and designed properly, can improve performance.
Those are only necessary if there are people who are not knowledgeable on the task.
Procedures can be built to contain a level of information that can be helpful to both experienced and non-experienced practitioners. The idea that just because you have a lot of experience that you cannot make a mistake is unacceptable today. We are fallible, we are human, so why can’t we accept help? I believe it is perception, see comment 2 above:
Those procedures always make work more difficult.
Perception is reality and if people don’t believe or understand why you implement these checklists and don’t implement them effectively then this is understandable.
Here is what checklists help you do:
- Not rely on short-term memory
- Become more consistent in an approach to a job
- Remind and caution against unsafe behaviors
- Document the way work is “expected” to be performed
These four items alone are work an additional 2-3 minutes of time it takes to address and use the checklist, don’t you think?
From the numbers above, and the possible impact on patient care the use of checklists where reasonable is a very simply and effective way to raise the level of performance of your staff and have a very positive impact on patient care. If you would like more information on this or other topics around the TapRooT® system and how it impacts human and equipment performance please feel free to contact me at email@example.com.
Sometimes, it seems like the toughest part of an investigation is figuring out how to get started. What’s the first step? Where am I headed? Who do I need to talk to? What questions should I ask?
Unfortunately, most systems kind of leave you hanging. They assume that you’re some kind of forensic and investigation expert, with years of psychological and interviewing training already under your belt. Like you’re only job at your company is to sit around and wait for a problem to occur so that you can perform an investigation!
Luckily, TapRooT® has some great tools that are designed to walk you through an investigation process. We have recently tweaked this guidance to make it even easier to quickly progress through the investigation. Some of the tools are used for every investigation; some are used only in specialized circumstances when you need additional help gathering information.
Some of these tools are required for every investigation; some are optional data-gathering tools. Let’s first take a look at the required tools.
One of the first things you need to do is get a good understanding of exactly what happened. Instead of just grabbing a big yellow legal pad and start scribbling down random thoughts, you will use the SnapCharT® to build a visual representation and timeline of what actually occurred. By putting your thoughts down on the timeline, you can more easily see not only what you already know, but also what you still need to find out. It helps you figure out what questions to ask and who to ask. Building your SnapCharT® is ALWAYS the first step in your investigation for just this reason. There is no reason to go into the interview process if you don’t already have a basic understanding of what happened and what questions you need to ask. It’s really amazing to see a group of people start building a SnapCharT®, thinking they already have a good understanding of the issues, and watch them suddenly realize that they still need to ask a few pointed questions to truly understand the problem.
Root Cause Tree®:
Most TapRooT® users know that the Root Cause Tree® is used during the root cause analysis steps in the process. However, this tool is a treasure trove of terrific questions and guidance that can be used while building your SnapCharT®. In conjunction with the Dictionary®, it contains a comprehensive list of interview questions; the same questions that a human performance expert would ask if they were performing this same investigation. You’ll need the answers to these questions once you get to the root cause analysis phase. Why not “cheat” a little bit and ask these questions right up front while building your SnapCharT®?
The tools I listed above are used during EVERY investigation. However, in certain circumstances, you may need some additional guidance and data-gathering tools to help build your SnapCharT®. Let’s look at the non-required tools.
Change Analysis: This is a great tool to use to help you ask thought-provoking questions. It is used when either something is different than it used to be, or when there is a difference between two seemingly identical circumstances. The Change Analysis tool helps you determine what would have normally made the situation operate correctly, and (this time) what allowed the problem to show up under the exact circumstances of the incident. It is actually an extremely easy tool to use, and yet it is very powerful. I find this to be my most-used optional tool. The results of this analysis are now added to your SnapCharT® for later root cause analysis.
Critical Human Action Profile (CHAP): Sometimes, you need help understanding those “dumb” mistakes. How can someone be walking down the stairs and just plain fall down? The person must just be clumsy! This is a great time to use CHAP. It allows you to do an in-depth job task analysis, understanding exactly what the person was doing at each step in the task. What tools were they using (and supposed to be using)? How did we expect them to perform the individual steps in the task? This tool forces you to drill down to a very detailed analysis of exactly what the person was doing, and also should have been doing. The differences you find will be added to your SnapCharT® to help you understand EXACTLY what was going on.
Equifactor®: If your investigation includes equipment failures, you may need some help understanding the exact cause of the failure. You can’t really progress through the root cause analysis unless you understand the physical cause of the equipment problem. For example, if a compressor has excessive vibration, and this was directly related to your incident, you really need to know exactly why the vibration was occurring. Just putting “Compressor begins vibrating” on your SnapCharT® is not very useful; you have to know what lead to the vibration. The Equifactor® equipment troubleshooting tables can give your maintenance and reliability folks some expert advice on where to start looking for the cause of the failure. These tables were developed by Heinz Bloch, so you now have the benefit of some of his expertise as you troubleshoot the failure. Once you find the problem (maybe the flexible coupling has seized), you can add this to your SnapCharT® and look at the human performance issues that were likely present in this failure.
The TapRooT® System is more than just the Root Cause Tree® that everyone is familiar with. The additional tools provided by the system can give you the guidance you need to get started and progress through your investigations. If you need some help getting started, the TapRooT® tools will get you going! Learn more in our 2-day TapRooT® Incident Investigation and Root Cause Analysis Course.
Today’s article is meant to create a discussion. We all know that Electronic Medical Records (EMR) are taking the place of written orders in healthcare (providing their own set of issues), so where does the written word fall on the Root Cause Tree®?
The cartoon below illustrates the issue we are discussing:
So thinking about written communication, if we have a Causal Factor dealing with a nurse or physician did something wrong due to a misunderstanding of a written communication…where would we go under the “Human Performance Difficulty” section?
One question that would most likely be a yes is the second question under the Team Performance Section: Did failure to agree about the who/what/when/where of performing the job play a role in this problem?. This leads us to Training, Communications, and Work Direction but does that really match?
For this week please provide your insight into where you believe this issue would fit. Thank you for reading and for providing your insight! I will write about our results in next week’s article! Have a great week……
(P.S. Don’t forget to sign up for my Medical track at the 2016 Global TapRooT® Summit, San Antonio, August 3-5, 2016.)
I must be crazy, I teach TapRooT® Root Cause Analysis and say it’s not about the root causes? Yes, it is true. Root Cause Analysis is really about fixing, prevention and improved ability to recover from a problem.
Yes, an objective root cause process is a must, for hints read the 7 Secrets of Root Cause Analysis. However the reason behind the need for and the end intent of the root cause analysis is just as important. Lets start with a new idea for many doing root cause analyses today, “improved ability to recover from a problem.”
Sometimes the first action to correct a problem on the spot was like pouring water on an oil fire. Didn’t cause the fire but sure did not help the situation, and in some cases it really made the problem. Many problem solvers just look for the root causes that caused a problem and not what also made it worse.
Here are just a few examples of actions or lack of actions that made the initial problem grow larger in extent if not worse at the end of the day:
- Flint River Lead Exposure Delayed Response
- Firestone Tire Delayed Recall
- 1947 Explosion Caused by Incorrect Response to Initial Fire
- A case closer to this article writer’s life when the wrong medicine was given for heart failure of loved one: Root Cause Analysis Tip: Patient’s heart stopped twice in the Emergency Room… what was missed?
So why do I say “improved ability to recover from a problem” is a new concept for many doing root cause analyses today? Simple, many start and stay with “why did the problem occur.” Read more on how to improve the use of the more simple “why” tools if you have to use them: A Look at 3 Popular Quick Idea Based Root Cause Analysis Techniques: 5-Whys, Fishbone Diagrams and Brainstorming.
The easiest way to improve the ability to respond to a problem is to map out a timeline for actions that occurred before the problem occurred, and the immediate responses to control or correct the problem. If the response made things worse, then perform a root cause analysis on that problem as well.
The last topic is prevention. The intent of a root cause analysis is not just to find the one “rootiest cause” or even a multitude of root causes. The intent is to find the problems and root causes that caused the problem and the problems that failed to catch/stop the problem AND THEN Eliminate or Mitigate those root causes so that future problems can be prevented or at the minimum, have the probability of the problems occurrence reduced.
So many times when I review Sentinel Event (SE) analyses for companies, I struggle to find the link between a Root Cause and the data on the SnapCharT®. But at the same time, the Corrective Action provided for that cause makes sense to reduce the likelihood of recurrence. This is perplexing as I did not want to say that the analysis was done poorly or was not correct simply because the outcome would probably be a positive one. Then it hit me, many people when going through the Root Cause Tree® were focusing more on the outcome desired than what the data told them.
Our ultimate goal is to fix a problem, reduce risk, and keep our patients, patients’ families and staff safe. To do so we have to present a very coherent, logical argument back to our administration regarding our analysis and findings. I represent this with the following diagram:
The issue that prompted this article relates to how people go through the Root Cause Tree®. As the user gets down to the Root Cause level I begin hearing people making declarations, “We could fix this issue by labeling the medication better” and with that statement the team puts a positive checkmark by Labels NI. What is wrong with this statement and action? Nothing upon first glance if it is true that a better label could prevent recurrence.
Digging deeper, these types of thought processes are actually working in reverse of what we teach. We teach to look at the data on the SnapCharT®, read the definitions to determine if the data supports selecting Labels NI. Based on our teachings we should hear statements such as, “Do I have an evidence (on my SnapCharT®) that tells me that the labeling present at the time of the event contributed to this Causal Factor (and thereby to the Incident)?” Notice that one quote is a question and one is a statement and therein lies a key difference. As we work through the analysis we should be questioning our data versus the definitions and items in the Root Cause Tree® not stating how we could fix the issue. Once we have the Root Cause, we can then work on a Corrective Action to fix the Root Cause.
In conclusion if we choose the Corrective Action first followed by a cause that justifies that action, the investigative team has created a break in that “Specific Relationship” from top to bottom. That break is between the Causal Factor/Root Causes and the data collected on our SnapCharT®. Without data on the SnapCharT® to support the Root Causes you present to your management team, you put your analysis in question. Without belief in the analysis management will be less likely to provide you the resources you need to fix issues and improve performance.
If you would like more information on this or any topic relating to the use of TapRooT® in Healthcare feel free to contact me directly at firstname.lastname@example.org or at (865) 539-2139.
Many years ago when I was in the Navy, I was writing an application to become an Assistant Professor at the University of Illinois. My boss was reviewing what I wrote and we got into a long discussion over whether a problem we had had was an event or an incident. A couple of years later, while I was doing my Master’s Degree research, I got into a very similar discussion over whether a significant problem at a nuclear plant was an accident or an incident.
OK, let’s look at the dictionary definitions… (from the Merriam-Webster on-line Dictionary)
- an unforeseen and unplanned event or circumstance
- lack of intention or necessity : chance <met by accident rather than by design>
- an unfortunate event resulting especially from carelessness or ignorance
- an unexpected and medically important bodily event especially when injurious <a cerebrovascular accident>
- an unexpected happening causing loss or injury which is not due to any fault or misconduct on the part of the person injured but for which legal relief may be sought
- used euphemistically to refer to an involuntary act or instance of urination or defecation
- a nonessential property or quality of an entity or circumstance <the accident of nationality>
- something dependent on or subordinate to something else of greater or principal importance
- an occurrence of an action or situation that is a separate unit of experience : happening
- an accompanying minor occurrence or condition : concomitant
- an action likely to lead to grave consequences especially in diplomatic matters <a serious border incident>
- outcomeb : the final outcome or determination of a legal actionc :
- a postulated outcome, condition, or eventuality <in the event that I am not there, call the house>
- something that happens : occurrence
- a noteworthy happeningc : a social occasion or activity
- an adverse or damaging medical occurrence <a heart attack or other cardiac event>
- any of the contests in a program of sports
- the fundamental entity of observed physical reality represented by a point designated by three coordinates of place and one of time in the space-time continuum postulated by the theory of relativity
- a subset of the possible outcomes of an experiment
So let’s make this simple …
In safety terminology, an EVENT is something that happens.
An INCIDENT is a minor accident.
An ACCIDENT is something that has serious human consequences (injury or fatality).
Thus we probably talk about:
- lost time accidents
- near-miss incidents
- events that led to a near-miss
In the TapRooT® System, an Event is an action step in the sequence of events on the SnapCharT®. The Incident is the worst thing that happened in the SnapCharT® sequence of events. Thus, and Incident is a special kind of Event. Plus, if the SnapCharT® is describing a serious injury, the Incident describes the Accident. Thus an Event could be an Incident that describes an Accident!
Do you define these terms at your facility?
If so, please add your definitions as a comment here.
Welcome to this week’s root cause analysis tips. This week I would like to talk about root cause analysis on trends.
One of the most common discussions I have with people involves what to do with the things you do not have time to investigate. Many companies use some sort of ranking or risk matrix to determine at what point something is important enough to warrant an investigation. I have some thoughts on this…
First of all, sometimes people try to investigate everything and end up doing poor investigations on everything; that does not help anybody. One consideration on where to draw the line is related to your current numbers. For example, if you work in a plant that has a few incidents per year, if you have the resources to investigate, I say do it. But if you are looking at large numbers at a corporate level, you may not have the resources – and you have to decide where to draw the line.
So what about the minor incidents you have that don’t get investigated – what to do with them? Well, it goes beyond minor incidents, you have other things that can be trended, rootcaused (is that a word?), and corrected. It is actually quite easy to investigate a trend, the hard part is actually collecting the data. I call this getting things in the “right bucket.” Here are some examples of information you might collect (or should):
• Minor incidents
• Near Misses
• Audit Findings
• BBS Observations
If you do a good job of collecting data, you can then trend the information. Your trends should reveal what processes are causing you pain. You then investigate the PROCESS, rather than an incident. For example, let’s say you had some near misses, some audit findings, and some BBS observations related to your lockout/tagout process that revealed issues. You may have not had a major incident yet, but you have warning signs. You can’t (or don’t have time to) go back and do full blown investigations on each data point, so you map out the process with a SnapCharT®, adding everything you know about the process as conditions, and based on that information, you identify your known failures and potential failures as Significant Issues (the equivalent to Causal Factors) in TapRooT®. Then off to the Root Cause Tree® and corrective actions. You’ve done ONE investigation on potentially dozens (or hundreds) of issues. This is more effective and much easier than doing multiple bad investigations.
Investigation of trends is a very important consideration in Audit Programs. Again, do you have time to investigate every finding? Maybe not. Here is an example:
A corporate auditor for a big box store has 100 compliance questions on a checklist and 100 locations that were audited using this checklist in the past year. That is a fair amount of data. The auditor can use this data to develop a list of top findings and then analyze the biggest issues.
The data for the yearly compliance is presented on a Pareto Chart below.
The top two categories are related to a similar topic: required signage. The audits have revealed both missing signs and outdated signs. Let’s look at these issues together on a SnapCharT®. Significant Issues are marked with a triangle:
Next, you take the Significant Issues through the Root Cause Tree®, and apply corrective actions. One investigation on dozens of findings.
I hate to use clichés, but WORK SMARTER NOT HARDER!
Want to learn more? I have a couple of opportunities that might interest you:
If you already collect good information and have good trending in place, consider attending the new TapRooT® for Audits Course on August 1-2.
If you are not there yet and want to learn how to collect data and trend, consider the Advanced Trending Techniques Course, also on August 1-2.
Thanks for taking the time to read the blog, and happy investigating/auditing.
I thought I’d take the opportunity to take us back to the basics for a moment. I’d like to describe how the Equifactor® Equipment Troubleshooting module of TapRooT® is designed to be used.
What is Equifactor®?
When performing a root cause analysis using TapRooT®, it is critical that you gather the right information for the problem at hand. This can be safety information, environmental procedures, policies and work instructions for a particular task, etc. It is usually pretty obvious what types of data you need for the type of investigation you’re performing.
Sometimes, additional TapRooT® data-gathering tools are required for specific types of problems. Equifactor® is one of those tools. It is designed to be used to help your equipment maintenance and reliability people figure out the root causes of mechanical or electrical equipment failures.
Why use Equifactor®?
During your investigation, you may find that one of your problems relates to an equipment malfunction. For example, you might find that a compressor is vibrating above expectation. You can put this fact into your SnapCharT®, but now what? What do you do with this piece of information? To get past this point in the SnapCharT®, you really need the answer from your troubleshooting team: “Why is the compressor vibrating?” Unfortunately, if you knew that, you wouldn’t need to put the question on your SnapCharT® in the first place! You need to know the physical cause of the vibration in order to progress to a more detailed SnapCharT® with Causal Factors.
Equifactor® in detail
This is where Equifactor® comes in. To help your equipment experts figure out the physical cause of the vibration, they will probably rely on their experience and local manuals for troubleshooting advice. They’ll look at the possible causes they are familiar with, and hopefully find the problem. However, we can’t rely on hope. What happens when they check the items they are familiar with, and the problem is not found? This is when they can turn to the Equifactor® troubleshooting tables for help. The tables give a comprehensive list of possible causes of compressor vibration. Your experts can review these tables to identify all the possible causes that apply to your compressor, and then use that list of possible causes to devise a detailed troubleshooting plan to identify the issue. Theses tables give your maintenance team some great guidance on things to look at during their troubleshooting. These items are quite often things that they have never seen before, and therefore did not think to look for.
Equifactor® – a TapRooT® Tool
Once your team finds the physical cause of the compressor vibration (for example, maybe the wrong coupling bolts were used, throwing off the balance of the machine), we’re not done. Equifactor® is NOT a separate, independent tool. It is designed to be used as a data-gathering tool for your TapRooT® investigation. Therefore, the problem that was found (wrong coupling bolts) is now added to the original SnapCharT®, and we can now move forward with our normal TapRooT® investigation. I’m pretty sure the bolts didn’t magically install themselves; a human was involved. We can now discover the human performance issues that lead the mechanics to use the wrong bolts. We continue adding information to our SnapCharT®, until we can run all of the Causal Factors (one of which will probably be, “Mechanics assembled the coupling using the wrong bolts”) through the Root Cause Tree®. We can now apply effective corrective actions to the problem. Instead of blaming the mechanic (“Counselled the mechanic on the importance of using the authorized repair parts during coupling assembly”), we can now target our corrective actions at the reason the mechanic used the wrong bolts (correct bolts not available, common use of “parts bins” to repair equipment, wrong part number on repair order, etc.).
Equifactor® is a terrific tool to assist your maintenance and reliability folks in finding the physical cause of a machinery problem. It is a tool to assist you in performing your TapRooT® investigation when an equipment problem is part of that investigation. Learn to use these tables to save you time and effort when troubleshooting your equipment issues.
LEARN MORE about Equifactor®.
CONTACT US about a course.
I attended the Ohio Association of Healthcare Quality (OAHQ) Conference in Columbus last week and gave a talk on this subject. In any industry there is always some level of impact that senior leadership has on every process and system. From their expectations for the staff through their desire for the organization and business, these expectations become the guidelines within which we work.
When I talk to healthcare professionals I always hear the positive and the negative (usually in reverse order), and it is very rare that anyone is only on one side or the other. There is usually a mix. Some of the things I hear about are as follows:
- Unreasonable expectations for timelines in determining root causes
- Not providing a charter or guideline that provides the responsibilities of the team and communicates the abilities of the team/team leader
- Messages communicated from the Administration do not match with the “reality” of our working environment
- Corrective Actions that are recommended are not always implemented or followed and are substituted with managements own ideas that are not in alignment with the findings
- Our team feels like we are provided the necessary support to gather what we need to gather to understand the event
- Management supports our efforts to implement corrective and preventative measures following an adverse outcome
- The organization is very much a proactive group who truly want and desire to make our systems the best they can be
Now, looking at this list, we truly see how these issues are polar in ways. Different organizations have the opposite opinions from their counterparts. This is to be expected as each organization is different.
Looking at these comments and thinking towards TapRooT® and our Root Cause Tree®/Dictionary, where would these issues (if found to be causal factors) show up in the analysis? Well there is one primary area where I believe these truly match:
Management System – How Policies and the Actions of the Management System Impact the System
Of course this is not the only area that could show up as every investigation is different but these most certainly could have impact. And in addition to that, when investigating events you have to look at the outcomes (not root causes necessarily) from previous similar events. This portion of the analysis will gather data that could lead you to multiple root causes:
Management System->Corrective Actions->Corrective Action NI or Trending NI: If it is found that previous corrective actions were never implemented, or were not as effective as they could be you might be led to and those decisions were directly related to management decisions to change alter or not follow-up to see if the actions worked.
Management System->SPAC Not Used->Enforcement and/or Accountability: When examining events, if it is found that due to a lack of support from senior leadership to uphold investigative charters or uphold the level of responsibility given to the investigative team, then this could most certainly be a Management System issue.
These are just a few examples of how past performance can impact the events you investigate today. My recommendation is to always talk to people in your Management System to understand their expectation and compare that expectation to the actual messages received and heard throughout the organization. Then compare those messages to what happened during the event analysis to assess the actual impact. You might be surprised at what you uncover.
If you would like to know more about the TapRooT® process and our investigative philosophy please contact me directly at email@example.com or attend one of our training courses held worldwide www.taproot.com/courses and learn how TapRooT can help you improve performance. Thank you for reading!
TapRooT® Users have more than a root cause analysis tool. They have an investigation and root cause analysis system.
The TapRooT® System does more than root cause analysis. It helps you investigate the problem, collect and organize the information about what happened. Identify all the Causal Factors and then find their root causes. Finally, it helps you develop effective fixes.
But even that isn’t all that the TapRooT® System does. It helps companies TREND their problem data to spot areas needing improvement and measure performance.
One key to all this “functionality” is the systematic processes built into the TapRooT® System. One of those systematic processes is the Root Cause Tree® and Dictionary.
The Root Cause Tree® Dictionary is a detailed set of questions that helps you consistently identify root causes using the evidence you collected and organized on your SnapCharT®.
For each node on the TapRooT® Root Cause Tree® Diagram, there is a set of questions that define that node. If you get a yes for any of those questions, it indicates that you should continue down that path to see if there is an applicable root cause. Atr the root cause level, you answer the questions to see if you have the evidence you need to identify a problem that needs fixing (needs improvement).
For example, to determine if the root cause “hot/cold” under the Work Environment Near Root Cause under the Human Engineering Basic Cause Category is a root cause, you would answer the questions (shown in the Dictionary above):
- Was an issue cause by excessive exposure of personnel to hot or cold environments (for example, heat exhaustion or numbness from the cold)?
- Did hurrying to get out of an excessively hot or cold environment contribute to the issue?
- Did workers have trouble feeling items because gloves were worn to protect them from cold or hot temperatures?
If you get a “Yes” then you have a problem to solve.
How do you solve it? You use Safeguards Analysis and the Corrective Action Helper® Guide. Attend one of our TapRooT® Root Cause Analysis Courses to learn all the secrets of the advanced TapRooT® Root Cause Analysis System.
The TapRooT® Root Cause Tree® Dictionary provides a common root cause analysis language for your investigators. The Dictionary helps the investigators consistently find root causes using their investigation evidence, This makes for consistent root cause analysis identification and the ability to trend the results.
The expert systems built into the Root Cause Tree® Diagram and Dictionary expand the number of root causes that investigators look for and helps investigators identify root causes that they previously would have overlooked. This helps companies more quickly improve performance by solving human performance issues that previously would NOT have been identified and, therefore, would not have been fixed.
Are you using a tool or a system?
If you need the most advanced root cause analysis system, attend one of our public TapRooT® Courses. Here are a few that are coming up in the next six months:
2-Day TapRooT® Root Cause Analysis Training
2-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Training
5-Day TapRooT® Advanced Root Cause Analysis Training
For the complete list of current courses held around the world, see: http://www.taproot.com/store/Courses/.
To hold a course at your site, contact us by CLICKING HERE.
(Note: Copyrighted material shown above is used by permission of System Improvements.)
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.”
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
- Who is mandating the time of root cause analysis completion?
- What does finished really mean in relation to this set deadline?
- Are there stopping and rest points to reach while you race towards the finish line?
- Does racing to the finish line ensure a good root cause analysis with effective corrective actions or does it just mean you won’t be yelled out for missing the deadline mandate instead?
Who is mandating the time of root cause analysis completion?
Is the deadline an internal company or an external client/agency requirement? If it is an external requirement, you really need to evaluate questions 2 and 3 to ensure that you are utilizing your time and resources optimally during the root cause analysis process. If the deadline mandate is an internal company rule, stop and evaluate the timeline requirement for the following criteria:
A. Do you separate Triage Response to the Incident from the actual Root Cause Analysis Investigation of the Incident?
If you stabilize the incident environment first, this will allow you more time to effectively manage your investigation. The risk to further injury and damage is reduced.
B. Do you check that your prescribed corrective actions are not driving what information you collect and analyze during the Root Cause Analysis?
Often investigators drive what they think happened and how they want to fix the problems. This can reduce the time to complete the investigation but like the Hare in the race, you never made it to the true Root Cause Analysis Finish Line.
What does finished really mean in relation to this set deadline?
Are there stopping and rest points to reach while you race towards the finish line?
These two questions can help you define the timeline for investigation completion for your own company’s internal rule; however, it is also mandatory that you understand the client’s/agency’s definitions for the criteria listed above.
For example, a contract company was required to have an incident which occurred on a client’s property investigated analyzed and corrected within 30 days from the incident’s occurrence. There was also a review process where the client would review the incident and reject it for additional clarifications or changes.
The contract company sent the finished investigation with completed correction actions on day 30. The client was frustrated because there was no time per their set deadline to send back the incident for changes. Problem is that the contract company met the mandate as written, no rules were broken.
Investigated, analyzed and corrected are great stopping points to send in information for review. The other question to ask is whether the investigation is finished once the corrective actions are created, implemented or reviewed?
The client in the above example changed their process to have turn in points for review for each phase of the Root Cause Analysis Investigation to ensure that the full 30-day completion date was met with quality investigations and effective corrective actions being completed.
Does racing to the finish line ensure a good root cause analysis with effective corrective actions or does it just mean you won’t be yelled out for missing the deadline mandate?
Now we get to the race itself: 1 hour, 1 day, 1 week, 1 month. Can a good root cause analysis get completed with good corrective actions within each of the times above? Yes, but it depends.
- How complex is the incident?
- How recent was the incident?
- Does your company have a process to collect evidence and written statements immediately, no matter what the degree or level of incident? (Information is often lost because of a delay to define and incident had a major incident.)
- Are your trained TapRooT® Root Cause Investigators available when needed and onsite? (Note that anyone at any level of the company can be trained to perform a Root Cause Analysis)
If your company follows all the key points listed, you are on the way to reaching the finish line to ensure a good root cause analysis with effective corrective actions and not it just meeting the deadline mandate. As far as the Turtle and the Hare? I’ll assign the Hare to triage and stabilize the environment and then assign my Turtle to investigate in an effective pace.
Learn more about conducting quality investigations with effective corrective actions at the 2016 Global TapRooT® Summit, August 3-5 in San Antonio, Texas.
Can a Difference in Opinions from the Top to the Bottom of a Healthcare Organization Impede Performance?May 9th, 2016 by Barb Phillips
I love reading about current events to stimulate the mind and to be in tune with what is happening in the world. Sometimes you simply stumble across an article and it immediately hits home and speaks to you. This article spoke to me and resonated with many questions I am asked during our Root Cause Analysis courses.
When we begin discussing the “Management System” category on our Root Cause Tree®, and get to the “Oversight/Employee Relations” Near Root Cause, I always get a lot of what I will call “Automated” nods. So, I always lead into the discussion talking about how when investigating we need to get a gauge on the messages being sent from the top, and the beliefs at the bottom. In so doing, we end up measuring both sides of a conversation. And many times the messages are the same, with the normal personal spin. But sometimes you come across data that suggests otherwise.
The article discusses the issues with changing EHR systems and impact on care. The discussion has perceptions from different groups within the polling group and there is a startling disjoint from the top down to the organization. See the following two statements:
Nursing staff reported being highly affected by the EHR replacement, but had virtually no say in the replacement decision, according to the survey. While 90 percent of nurses said EHR replacements reduced their ability to effectively provide hands-on care, 96 percent of nurses said they were not included in EHR replacement planning.
However, just 5 percent of hospital leaders said the EHR replacement process had a negative impact on care, which Mr. Brown said suggests executives are reticent to address the issues. ‘In our experience polling, most executives will not admit they were oversold or that their IT decisions had adverse bearing on patient care,’ Mr. Brown said. ‘On the other hand, workflow changes and productivity issues may have added to the disappointment nurses felt after being left out of replacement EHR product evaluations.’
If I were investigating an incident at one of these hospitals and was interviewing both Administrators and Nurses around a Sentinel Event, this would raise some very large concerns in the organization. Why is there such a large chasm in beliefs here and what kind of impact could this have on performance. In our system this would likely lead us to the Management System->Oversight/Employee Relations->Employee Communications Root Cause. With Management having such a different perspective on how work is being performed, we might answer yes to the following question from our Root Cause Tree® Dictionary:
Did management’s employee communications program fail to communicate management’s concerns for quality workmanship, safety, and the environment?
When a message that is sent from the top of the organization does not support the actual work performance of the organization, employees would certainly believe that the top tier does not show the correct level of commitment to being a high performance organization.
If you would like more information on how TapRooT® can help your hospital or health system become more efficient and provide safer patient care please attend one of our TapRooT® training courses or contact me directly at firstname.lastname@example.org.
The Nuclear Energy Institute published a white paper titled:
To summarize what is said, the nuclear industry went overboard putting everything including the kitchen sink into their Corrective Action Program, made things too complex, and tried to fix things that should never have been investigated.
How far overboard did they go? Well, in some cases if you were late to training, a condition report was filed.
For many years we’ve been preaching to our nuclear industry clients to TARGET root cause analysis to actual incidents that could cause real safety or process safety consequences worth stopping. We actually recommend expanding the number of real root cause analyses performed while simplifying the way that root cause analyses were conducted.
Also, we recommended STOPPING wasting time performing worthless apparent cause analyses and generating time wasting corrective actions for problems that really didn’t deserve a fix. They should just be categorized and trended (see out Trending Course if you need to learn more about real trending).
We also wrote a whole new book to help simplify the root cause analysis of low-to-medium risk incidents. It is titled:
Those who have read the book say that it makes TapRooT® MUCH EASIER for simple investigations. It keeps the advantages of the complete TapRooT® System without the complexity needed for major investigations.
What’s in the new 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
The TapRooT® Process for simple incidents is just 5 steps and is covered in 50 pages in the book.
If you are looking for a robust techniques that is usable on your simple incidents and for major investigations, LOOK NO FURTHER. The TapRooT® System is the answer.
If you are in the nuclear industry, use TapRooT® to simplify the investigations of low-to-moderate risk incidents.
If you are in some other industry, TapRooT® will help you achieve great results investigating both minor incidents and major accidents with techniques that will help you no matter what level of complexity your investigation requires.
One more question that you might have for us ,,,
How does TapRooT® stay one (or more) steps ahead of the industry?
- We work across almost every industry in every continent around the world.
- We spend time thinking about all the problems (opportunities for improvement) that we see.
- We work with some really smart TapRooT® Users around the world that are part of our TapRooT® Advisory Board.
- We organize and attend the annual Global TapRooT® Summit and collect best practices from around the world.
We then put all this knowledge to work to find ways to keep TapRooT® and our clients at the leading edge of root cause analysis and performance improvement excellence. We work hard, think hard, and each year keep making the TapRooT® Root Cause Analysis System better and easier to use.
If you want to reduce the cumulative impact of your corrective action program, get the latest TapRooT® Book and attend our new 2-Day TapRooT® Root Cause Analysis Course. You will be glad to get great results while saving time and effort.
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
- Cash, donation
- Some kind of gift or recognition
- 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.”
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:
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 email@example.com to subscribe today!
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.”
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.
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:
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.
How do you grade an incident investigation? Here’s an Excel spreadsheet to use…
How do you use the spreadsheet? Here’s a video from last year’s Summit …
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.
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.
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:
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: firstname.lastname@example.org.
Learn more about Healthcare RCA at the 2016 Global TapRooT® Summit.