Root Cause Analysis Blog

 

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

Equipment Failure? Parachuting Accident

Posted: February 5th, 2016 in Accidents, Equipment/Equifactor®

formation

I’m going to be bringing you some examples of accidents and problems that are quickly listed as “equipment failure.” Take a look at these problems and ask yourself:

– Is this really an equipment problem?

– Have we looked deep enough into the actual reason that the equipment did not work as intended?

– Were there any safeguards that were in place that failed, or should have been in place and were not?”

Here’s an example that is just quickly labeled “equipment failure”. List the safeguards that you think should have been in place (and maybe were, maybe weren’t) to prevent the accident’s outcome.

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

Posted: February 4th, 2016 in Performance Improvement, Pictures, Root Cause Analysis Tips, TapRooT

NewImage

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

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

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

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

If you could use some help … read on!

FIRST

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

What is the wrong message?

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

For example:

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

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

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

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

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

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

WATCH OUT!

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

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

SECOND

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

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

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

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

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

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THIRD

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

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

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

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Good news:

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

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

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

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

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

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

FINALLY

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

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.

Technically Speaking – Backing up a TapRooT® Database

Posted: February 4th, 2016 in Software, Technical Support, Technically Speaking, Video Depot

This week I ‘d like to discuss the steps to backup your TapRooT® database. This is great to know should you need to move your software to a new machine and want to retain your data.

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!

Will They Really Find the Root Causes?

Posted: February 3rd, 2016 in Current Events, Investigations, Pictures

NewImage

The new littoral combat ship USS Milwaukee suffered an embarrassing breakdown while transiting to Norfolk. The Navy is doing a “root cause analysis” of the failure. See the story at:

http://dodbuzz.com/2016/02/01/navy-seeks-answers-as-2-lcss-break-down-in-a-month/

When I read these press stories I always think:

What techniques are they using and will they really find the root causes and fix them?

All too often the final answer is “No.”

What does a bad day look like?

Posted: February 3rd, 2016 in Video

They try to make this sound like a good day … but when you wreck your boat … it is never a good day.

Eagle Takes Down a Drone

Posted: February 2nd, 2016 in Video

I thought this was interesting …

Weekly Wisdom: The Opportunities Are Endless When You Have Courage

Posted: February 2nd, 2016 in Wisdom Quote

Life shrinks

“Life shrinks or expands in proportion to one’s courage.” -Anais Nin

Caption Writing Contest: Enter Today to Win!

Posted: February 1st, 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.

prize

Registration for the 2016 Global TapRooT® Summit is OPEN

Posted: January 29th, 2016 in Software, Summit, Technically Speaking

We opened up registration this week for the TapRooT® Global Summit which begins on August 3rd, 2016 in San Antonio, Texas (you can also register for the Pre-Summit Courses which will commence on August 1st).

I am sure you will hear a lot about the amazing Keynote Speakers and Best Practice Presenters in this forum over the next 6 months; but I wanted to take a moment to discuss one Keynote Speaker in particular and share a personal story.

My first day with System Improvements was May 3rd, 2006 and I immediately became a TapRooT-ite.

Wait… is that a word? TapRooT-ian? TapRooT-eer?

Err… let’s just say I immediately fell in love with TapRooT®.

It was not hard to fall in love, as May 3rd, 2006 also happened to be the first day of the TapRooT® Summit in Gatlinburg, Tennessee. Yep, you read that right. My very first day of work was at a large Global Summit.

A story we tell around the office (that always gets a few laughs) is that our President Mark Paradies referred to me as “that helpful hotel employee” the entire first day of the Summit (we had not yet met). He laughed profusely when he learned I was a new employee and NOT a hotel concierge, just helping out. (I was just glad to hear I was not described as “that UN-helpful hotel employee”.)

To describe my first day: I was simply enthralled by the spectacle.

Here was this amazing group of attendees and speakers, from all over the world, uniting out of a common interest of making their co-workers SAFE and happy with their jobs. People dedicated to SOLVING problems. What do you think this group of people is like to be around? If you guessed, ‘pretty fantastic’, you are correct.

But no memory stands out to me more than watching Michael Durant, best selling author and inspiration for the movie Black Hawk Down, give his Keynote Address.

I was just so impressed with this man, and by proxy I was so impressed with TapRooT®.

This next part is not an exaggeration. I swear.

I went home that night with his book In The Company of Heroes in tow, and I sat down and read it cover-to-cover that evening.

The book still sits prominently displayed on my bookshelf today, unscathed, despite several attacks from my dog on my collection of literature (So even my dog seems to respect Durant’s work).

In our Summit planning meetings the last few years, I have dropped Michael Durant’s name a few times as a potential Keynote Speaker, hoping he might get a return engagement. I just found out this week that he will be back at the Summit this year in San Antonio.

Book your flight tomorrow. This guy is great, and my dog tends to agree.

I really believe this is going to be a great Summit, and we will not have another Summit until 2018.

(cough) There might also be this new software called TapRooT® VI that will be prominently featured at the Summit. I might have heard some good things about it.

And maybe, just maybe, you will leave a TapRooT-er, or a TapRooT-ist?

Dan Verlinde is a Partner and Director of Information Technology and Software Development for System Improvements, Inc.

His dog has been un-employed since birth, but his hobbies include eating any paperback on the bottom three shelves.

Photo Contest Winner!

Posted: January 29th, 2016 in Contest

Where in the

That’s a wrap on the December/January photo contest! Thank you to everyone who sent in pictures and showed us “Where In the World Is TapRooT®?”. After much deliberation, we decided on the Top 3 Winners.

The Grand Prize Winner of their choice of TapRooT® gear is…*drum roll*… Randall O.!

The Runners Up are …*drum roll*…Toney M. & Quincy H.!

 

Congratulations Randall, Toney & Quincy! 

We will be launching a new contest for February soon. Check the blog or e-Newsletter for updates and enter to win. You could be our next winner!

Friday Joke for Nukes …

Posted: January 29th, 2016 in Jokes, Pictures

Screen Shot 2015 02 20 at 8 41 57 AM

Public TapRooT® Course in Johannesburg, South Africa

Posted: January 28th, 2016 in Courses, Local Attractions

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Where in the world will TapRooT® be in February? Johannesburg! February 29-March 4, 2016, TapRooT® will be hosting a 5-Day Advanced Root Cause Analysis Team Leader Training Public Course. Are you coming?

There are quite a few things about Johannesburg that many people don’t know. It is said to be the world’s largest city not located directly on a water source, however, it is located on mineral rich land where the city’s source of gold and diamonds come from. It is also known as Africa’s economic powerhouse due to it being the largest economy of any metropolitan area in Sub-Saharan Africa. Not only that, it’s rich history with Apartheid and Nelson Mandela are what really make the country of South Africa an historical landmark. Visit Joburg and see what all this massive city has to offer, including our TapRooT® 5-Day course.

Food:

Mugg & Bean Cafe: This delicious little cafe offers a little of everything from barbeque and quesadillas to cupcakes and soups.

The GrillHouse Rosebank: Enjoy a fabulous steak dinner in a warm atmosphere with live music here at The GrillHouse.

SalvationCafe: If you love gourmet flavors and branching out from the everyday menu, check out this quaint cafe.

Attractions:

Gold Reef City: Fun on every corner! Theme parks, dining, theaters, etc await you as you stroll through and take it all in.

Apartheid Museum: History museums are always an educational, impacting experience for anyone!

Peacemakers Museum: What an inspirational and interesting exhibit full of the history of all Nobel Peace Laureates. You’re sure to learn something new and leave encouraged by all the incredible men and women all across the globe.

 

Ready to register? Click Here.

Interested in other TapRooT® Public Courses? Click Here.

Wish to inquire about a TapRooT® Onsite Course? Click Here.

REGISTER FOR THE 2016 TapRooT® Summit TODAY!

TapRooT® Public Courses in Oceania & Asia

Posted: January 28th, 2016 in Courses

Singapore_CBD_skyline_from_Esplanade_at_dusk

Singapore, Singapore

Upcoming TapRooT® Public Courses:

Queensland Australia:  Gladstone, 2-Day, March 2, 2016 | Weipa, 2-Day, March 8, 2016 | Brisbane, 5-Day, March 14, 2016
Western Australia: Perth, 2-Day, March 10, 2016 | Perth, 5-Day, April 18, 1016
South Australia:  Canberra, 2-Day, February 29, 2016Sydney, 2-Day, March 21, 2016 | Adelaide, 2-Day, April 5, 2016 | Newcastle, 2-Day, April 27, 2016
Victoria Australia: Melbourne, 2-Day, April 12, 2016
North Australia:
New Zealand: Auckland, 2-Day, March 7, 2016
Asia: Singapore, Singapore, 2-Day, March 21, 2016 | Mumbai, 5-Day, April 25, 2016

Want a course in your region? Inquire about an Onsite Course here.

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

REGISTER FOR THE 2016 TapRooT® Summit NOW.

Technically Speaking – Helpdesk Humor

Posted: January 28th, 2016 in Software, Technical Support, Technically Speaking

incorrect

Sometimes we end up with poor corrective actions… but every now and then we create the perfect solution.
TapRooT® can help create perfect Corrective Actions and Safeguards to prevent accidents before they happen!

 

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!

3 Tips for Quality Root Cause Analysis

Posted: January 27th, 2016 in Root Cause Analysis Tips

“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).

stop
#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.

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