Category: Root Cause Analysis Tips

Equifactor® Equipment Troubleshooting Basics

May 25th, 2016 by

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Equifactor® is designed to be used to help your equipment maintenance and reliability people figure out the root causes of mechanical or electrical equipment failures.

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.

How Does Senior Leadership Affect RCA in Healthcare?

May 23rd, 2016 by
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Across industries, senior leadership has some level of impact on every process and system.

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:

Negative Impact:

  1. Unreasonable expectations for timelines in determining root causes
  2. Not providing a charter or guideline that provides the responsibilities of the team and communicates the abilities of the team/team leader
  3. Messages communicated from the Administration do not match with the “reality” of our working environment
  4. 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

Positive Impact:

  1. Our team feels like we are provided the necessary support to gather what we need to gather to understand the event
  2. Management supports our efforts to implement corrective and preventative measures following an adverse outcome
  3. 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 skompski@taproot.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!

Root Cause Analysis Tip: Use the Dictionary!

May 19th, 2016 by

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.

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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).

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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):

  1. Was an issue cause by excessive exposure of personnel to hot or cold environments (for example, heat exhaustion or numbness from the cold)?
  2. Did hurrying to get out of an excessively hot or cold environment contribute to the issue?
  3. 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

 Dublin, Ireland      June 8-9, 2016

Pittsburgh, PA   June 20-21, 2016

Hartford, CT       July 13-14, 2016

San Antonio, TX   August, 1-2, 2016

Copenhagen, Denmark September 22-23, 2016

 

2-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Training

San Antonio, TX   August 1-2, 2016

 

5-Day TapRooT® Advanced Root Cause Analysis Training

Houston, TX           June 13-17, 2016

Gatlinburg, TN          June 20-24, 2016

Niagara Falls, Canada July 11-15, 2016

Monterrey, Mexico   August 22-26, 2016

Mumbai, India   August 29 – September 2, 2016

Aberdeen, Scotland  September 19-23, 2016

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.)

Using TapRooT® for Audits

May 18th, 2016 by

pablo (96)

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

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

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

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

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

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

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

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

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

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

How Fast Can You Do A Root Cause Analysis (1 hour, 1 day, 1 week, 1 month)?

May 11th, 2016 by

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Many of us have heard the tale of “The Turtle and the Hare” and their renowned race. At the end, the turtle makes it to the finish line by pacing himself, and the rabbit expends all his energy and never finishes. When it comes to the speed of getting to the finish line of your Root Cause Analysis, this tale and many real world questions come to mind.

  1. Who is mandating the time of root cause analysis completion?
  2. What does finished really mean in relation to this set deadline?
  3. Are there stopping and rest points to reach while you race towards the finish line?
  4. 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.

  1. How complex is the incident?
  2. How recent was the incident?
  3. 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.)
  4. 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

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Does management have a different perspective on how work is being performed?

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.

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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 skompski@taproot.com.

Root Cause Analysis Tip: Save Time and Effort

May 4th, 2016 by

The Nuclear Energy Institute published a white paper titled:

Reduce Cumulative Impact From the Corrective Action Program

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:

Using the Essential TapRooT® Techniquesto Investigate Low-to-Medium Risk Incidents

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 Just published this year, this book is now the basis for our 2-Day TapRooT® Root Cause Analysis Course and starting on Thursday will be the standard book in our public 2-Day TapRooT® Courses.

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?

 That’s easy.

 

  • 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.

 

 

 

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.”

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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

book_graphic_1511

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

meteor

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

NewImage

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.

NewImage

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)

NewImage

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!

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