Root Cause Analysis Blog

 

Public TapRooT® Course in Knoxville, TN

Posted: February 11th, 2016 in Courses, Pictures

 

Take a look at a course here in our hometown, Knoxville, TN. IMG_1963

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Important! Instructor Recertification Information

Posted: February 11th, 2016 in Courses, Summit, TapRooT® Instructor, Training

2016 Global TapRooT® Summit

Are you a Certified Instructor that is NOT planning to attend the 2016 TapRooT® Summit because you don’t need to be recertified until 2017? Please keep reading for important information regarding 2017.

Did you know that the TapRooT® Summit is held every 14-16 months? If you look back at the past few Summits, they have been in April 2014, June 2015 and now August 2016. There is a strategic rotating schedule that TapRooT® uses to choose the best time for the Summit.

Due to this rotation schedule, once in a while there is a gap year. A year with no Summit. This detail requires some extra planning on our Certified Instructor’s part since each instructor is required to go through recertification every two years.

What does this rotating schedule mean for 2017? It means that 2017 will be our next gap year. To clarify, there will NOT be a TapRooT® Summit in 2017. We are aware that some of our instructors will be due for recertification in 2017 making this a potential hiccup in their future plans.

Those of you who attended our 2015 Summit might remember Mark announcing the upcoming changes here at TapRooT®. There have been significant improvements and modernization to our 2-Day course that would be beneficial for all Certified Instructors to attend and see in person. The 2016 Summit this August will provide all Certified Instructors with the new 2-Day course materials and look into the new layout. Stay tuned for more details on these improvements in a later post!

What does TapRooT® recommend? We highly recommend that each instructor look at their schedule for this year and plan to attend the 2016 Summit in San Antonio this August 1-5. You will be able to go through recertification early, to continue teaching in 2017, not need recertification until 2018, and get a first-look at the new 2-Day course. Besides, you don’t want to miss the 2016 Summit and all that we have in store for you!

If you have questions or concerns regarding your recertification, please contact Michelle Wishoun (wishoun@taproot.com) or Linda Unger (unger@taproot.com) or call our office (865) 539-2139 for assistance.

Technically Speaking – A Sneak Peek at TapRooT® VI (Q and A Edition)

Posted: February 11th, 2016 in Software, Technical Support, Technically Speaking

I recently attended a 5 Day Course (it was awesome!) so I had a chance to get feedback directly from people in the field using the TapRooT® Version 5 Software. I received lots of great questions and comments so I thought I would share some of the questions (and answers) with you. You may notice a theme here…

Q: On the SnapCharT® in Version 5, if I decide I need to change an Event to a Condition or a Condition to an Event, can I do this without having to add a new shape and delete the old one?

A: No. BUT, you can in TapRooT® VI!
With the simple click of a button, you can change an Event to a Condition or vice versa. No more adding, moving or deleting shapes just because you want to change it. Keep your text in place and simply click the “Change” button.

Q: Can I apply default colors, and fonts, sizes, etc. to my Events, Conditions and Incidents in Version 5?

A: No. BUT, you can in TapRooT® VI!
EVERY USER can assign their own custom colors, and font types, sizes, bold/italics/underline settings for EACH SnapCharT® shape. And once you indicate these preferences, they will carry over to every SnapCharT® you do.

Q: When I’m using any of the Optional Techniques in Version 5 (like Change Analysis, CHAP, Equifactor® or Safeguards Analysis) and I identify a Condition or Event that needs to be added to my SnapCharT®, can I do this without having to leave the Optional Technique, open my SnapCharT® and manually add the shape and text?

A: No. BUT, you can in TapRooT® VI!
The new and improved Optional Techniques allow you to immediately take your information and click a button that adds your Condition or Event to the SnapCharT®. It is added to a “Drop Zone” area and when you return to the SnapCharT®, your new Condition or Event is waiting there for you to drag and drop it onto the chart.

Q: When I’m using the Root Cause Tree® and I want to remember specifically which questions I answered “Yes” to, can I indicate this in the Version 5 Software or do I manually have to add a comment?

A: No. BUT, you can in TapRooT® VI!
How many times have you gone back to an Investigation and wondered, “Why exactly did I decide to choose this Root Cause?” Wonder no more! TapRooT® VI still has the capability of saving Root Cause Tree® Analysis Comments, but it also allows you to select “Yes” or “No” to any question from the Root Cause Tree® Dictionary with the click of a button.

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CLICK THE ABOVE IMAGE TO VIEW A LARGER COPY IN A NEW WINDOW

Thanks to all the users for great questions and comments. These are just a few of the exciting new features that were discussed so STAY TUNED for more Sneak Peeks at TapRooT® VI.

Technically Speaking is a weekly series that highlights various aspects of our Version 5 software, introduces you to the upcoming TapRooT® VI release and occasionally includes a little Help Desk humor.

Remember, just because it’s technical, doesn’t mean it has to be complicated!

Mark Paradies has 24,000 Direct LinkedIn Connections

Posted: February 10th, 2016 in Current Events, Pictures

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If you are interested in advanced root cause analysis, join my network. Send me an invitation to connect at:

http://www.linkedin.com/in/markparadies

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

Posted: February 10th, 2016 in Investigations, Performance Improvement, Pictures, Root Cause Analysis Tips, TapRooT

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. 

What does a bad day look like?

Posted: February 10th, 2016 in Accidents, Video

Have you had a snow near-miss this year?

Weekly Wisdom: Stop Waiting, Go For It.

Posted: February 9th, 2016 in Wisdom Quote

Anne Frank

“How wonderful it is that nobody need wait a single moment before starting to improve the world.” -Anne Frank

Top 3 Worst Practices in Root Cause Analysis Interviewing

Posted: February 8th, 2016 in Root Cause Analysis Tips
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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.

Caption Writing Contest: Enter Today to Win!

Posted: February 8th, 2016 in Contest

How would you caption this image-

via GIPHY

Miss your chance to enter in our last caption contest in November? Want to give it another shot to try and win this time around? Here’s your chance! Unleash your clever side and write a caption for this image in 5 words or less. Here’s how to enter:

1. Create your caption in five words or less. All captions with more than five words will be disqualified.

2. Type your caption in the comments section of this post by February 29th.

3. If you haven’t already, subscribe to the TapRooT® Friends & Experts e-newsletter to find out if you won.
(Email the Editor at editor@taproot.com with subject “Subscribe to Win”)

Our in-house instructors will vote on the most clever caption, and the winner will be announced via our e-newsletter and a blog post on March 1st.

Prize! The winner will receive this globe tape dispenser to thank you for joining TapRooT® in changing the way the world solves problems.

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TapRooT® Public Courses in Canada

Posted: February 8th, 2016 in Courses

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Calgary, Canada

Upcoming TapRooT® Public Courses

Montreal | 5-Day | March 7, 2016

Calgary | 2-Day | April 7, 2016

St. John’s | 5-Day | April 25, 2016

For more information regarding our public courses around the world, click here.

REGISTER FOR THE 2016 TapRooT® Summit NOW. 

Monday Accident & Lessons Learned: Was “Paying Attention” the Root Cause?

Posted: February 8th, 2016 in Accidents, Human Performance, Video

Watch this video and see what you think …

Meteorite Casualty: Natural Disaster in TapRooT® Root Cause Analysis

Posted: February 8th, 2016 in Accidents, Root Cause Analysis Tips

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Photo of meteor from Chelyabinsk, Russia in 2013

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

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

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

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

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

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

Equipment Failure: Blackout for 46,000 Residents

Posted: February 8th, 2016 in Equipment/Equifactor®

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Here’s another example of generic “equipment failure.” Not a lot of details, but I’m pretty sure the substation was not designed to fail. We should look at not just the equipment, but what additional safeguards are in place to prevent a single-point failure from blacking out a large section of a city.
Again, we don’t have details yet, but the label of “equipment failure” should make you think about digging a little deeper.

What Does a Generic Cause Look Like in Healthcare?

Posted: February 5th, 2016 in Medical/Healthcare

I have been teaching RCA now for almost 20 years and have found that Generic Cause is many times the simplest yet most confusing step in our RCA process. The first 4 steps from Getting Started (reporting) through Root Cause Analysis (Root Cause Tree®) move very efficiently. But transitioning from “Specific” root causes linked to Causal Factors to “Generic” causes that tie multiple events together seems to trip up many professionals.

7-step Investigation Flow
I found an interesting article that can be found HERE, that provides a very good example of a generic cause.

What is a Generic Cause?

First let me start with a quick discussion of our philosophy on Generic Cause. Step 5 in the process flow above addresses this issue prior to developing your Corrective Actions. We need to first understand the “Specific” root causes from Step 4, and the “Generic” causes before we begin developing Corrective Actions so both can be addressed.

The definition of a “Generic” cause in our system is as follows:

The Systemic problem that allows a root cause to exist, across multiple incidents or sites or systems.

This is a bigger picture issue that is allowing the same root causes to exist across multiple events. So that being said, let’s dig into the article above to provide a description of a “Generic” issue.

The Duodenoscope Example

The article discusses a particular type of duodenoscope produced by one manufacturer used across the healthcare industry. This particular scope had been linked to multiple cases where infection had been spread to patients. So similar infections, when investigated by individual hospitals, provided data showing that this particular type of scope was involved. Breaking down that statement, we have the following:

  1. Same brand and model duodenoscope
  2. Used in multiple facilities over a term of 5 years
  3. Multiple instances of infection transmission following use of this scope

Are you seeing the pattern in this list? Something is similar in all these instances… the scope itself. Now, from the article (which does not provide any RCA data), I can only speculate on the Root Causes for this “spread of infection” as it relates to the scope… from the Corrective Actions taken by the manufacturer it looks as if there could be any of the following issues:

. . . A. Equipment Difficulty->Design->Specs NI
. . . B. Equipment Difficulty->Preventative/Predictive Maintenance-> PM NI-> PM for Equip NI
. . . . . .1. If you assume the cleaning procedures and recommendations to be Preventative Maintenance
…………..on the scope
. . . C. Human Performance->Procedures->Wrong->Facts Wrong
. . . . . .1. If here you assume the cleaning instructions are procedures and they did adequately provide
…………..information on cleaning the scope.

Any of these could relate back to the Corrective Actions which include the recall, a redesign of the scope as well as changes to the cleaning requirements.

Finding Generic Causes in Your Organization

Now looking at these causes, and the list of items that meet the definition of a Generic cause, I have to ask everyone reading this article:

How would you as an organization know that you are having Generic problems?

The answer to that question will probably vary from organization to organization but there is probably one key element. That key element is consistent Classification of events, consistent Root Cause Analysis, linking your Causal Factors (on the Causal Factor Editor) to specific Equipment types and Departments, and effective trending and data analysis. Without a clear, well defined classification schema for all investigations or incidents within a healthcare facility/system it would be nearly impossible to trend your RCA data and determine where similar causes and events are happening.

Once you get a standard Classification list together, and consistently classify your events, you can now perform a couple of different Trending functions (from the TapRooT® Software v5.3) to determine Generic Causes:

  1. Search your data using our Root Cause Distribution Report by filtering Classification and over a date range to see all causes produced. If you find a particular root cause across those RCA’s you may have a generic cause.
  2. Run a Pareto Chart using Equipment as your X-axis and Counts as your Y-axis on the chart to look at counts. See if one piece of equipment is linked to 70-80% of your causes… this might give you a clue to a Generic Issue
  3. Run a Process Behavior Chart looking at a Specific Classification, and run an “Instant Rate” chart or an “Interval Chart”. These would cue you in on if your rate of failure is increasing or if your time between occurrences is decreasing respectively and may provide some insight into your overall Equipment or program health.

If you have any questions about Generic Cause or any additional Trending functions please feel free to contact me at skompski@taproot.com

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