Root Cause Analysis Blog

 

Friday joke

Posted: July 20th, 2018 in Jokes

Technically Speaking – Help Desk Humor

Posted: July 19th, 2018 in Technically Speaking

When warnings are obvious to you because it’s your work zone, but others are not aware of the severity of a single spark in this work zone.  Such examples are all too common and simple fixes could save injuries and even lives.  Take the time to step back and look at your workspace from an outsider perspective, you know the hazards, but would a person foreign to your workspace recognize the dangers?

Technically Speaking is a weekly series that highlights various aspects of the TapRooT® VI software and occasionally includes a little Help Desk humor.

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

The Best Incident Investigation Performance Indicator

Posted: July 18th, 2018 in Investigations, Performance Improvement, Root Cause Analysis Tips

NewImage

If an incident investigation and the corrective actions are effective, it will prevent, or significantly reduce the likelihood or consequences of, a repeat incident.

If we want to monitor the effectiveness of our incident investigation, root cause analysis, and corrective action processes, probably the best performance indicator is monitoring the rate of repeat incidents.

If an incident (or even a Causal Factor) is a repeat, it indicates that there was a problem with the previous investigation. For example:

  • Was the root cause analysis inadequate?
  • Were the corrective actions ineffective?
  • Why didn’t management or peer review catch the problem with the previous investigation?

Of course, the question that is tough to answer is … What is a repeat incident (or Causal Factor).

Judging repeat incidents takes some soul searching. The real question is, should have the previous incident investigation prevented the current incident.

Here are two examples:

  • Should the investigation and corrective actions for the Challenger Space Shuttle accident have prevented the Columbia Space Shuttle accident?
  • Should the BP Texas City fire and explosion accident investigation have prevented the BP Deepwater Horizon accident?

You be the judge.

What is the rate for your facility? Do you have 80% repeats? 10%? 0.1%?

Each repeat incident provides a learning opportunity to improve your incident investigation, root cause analysis, corrective action, and incident review processes. Are you using these opportunities to improve your system?

Join TapRooT® at Noon EST Today for Facebook Live!

Posted: July 18th, 2018 in Career Development Tips, Meet Our Staff, Performance Improvement, TapRooT, Topic of the Week, Video

 

For news you can use, join TapRooT® professionals Dave Janney and Michelle Wishoun in our Facebook Live discussion. Our topic today is: Why Is SnapChart® So Important? As always, feel free to ask questions or comment on our Facebook page during the session.

We look forward to being with you on Wednesdays! Here’s how to connect with us for today’s Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

When? Today, Wednesday, July 18

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Do your own investigation into our courses and discover what TapRooT® can do for you.

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

Technically Speaking – June Customer Satisfaction Survey Winner

Posted: July 17th, 2018 in Technical Support, Technically Speaking

Here at System Improvements, customer satisfaction is very important to us. We strive to ensure our customers’ questions are treated in a timely and efficient manner. This is so important to us that it’s actually part of our Technical Support Mission Statement:

To provide timely, courteous, and effective technical support to System Improvements staff and all TapRooT® customers, achieving customer satisfaction and process efficiency.

In order to ensure we are providing great service, we have implemented a new customer satisfaction rating system, where our customers can rate their experience with our Support Team. The feedback has been extremely valuable to us.

As a thank you to all our customers who take the time to fill out a survey, all respondents are entered into a monthly drawing to win a TapRooT® shirt. Everyone, let’s congratulate Gregg Nickel, Application Architect, from Matrix Service Company. as the winner for the month of June!

What does a bad day look like?

Posted: July 17th, 2018 in Bad day

“Home from vacation to discover installation of stairs from a Harry Potter movie in our renovations. Maybe in Hogwarts or train platform 9¾?”

Career Opportunities for Candidates with TapRooT® Skills

Posted: July 16th, 2018 in Career Development, Courses, Job Postings, TapRooT, Training

When you have the expertise of TapRooT® training on your resume, you’re communicating to others the level of your career development. Professional training and skill sets in investigation, problem-solving, and root cause analysis convey competency to the prospective employer. If you have TapRooT® training and skills, explore your professional advancement through one of these global opportunities.

EHS&T Advisor

Service Specialist I-Pipeline/Process Svc

Associate- Senior Engineer Nuclear

Patient Safety Assistant Coordinator

PM&L Governance & Controls Mgr

Patient Safety Analyst

Lead Engineer

Service Supervisor I-Pipeline/Process

Field Operations Excellence Leader 

Patient Safety Analyst

If you are not TapRooT® trained, becoming TapRooT® trained in troubleshooting and identifying root causes of issues and incidents is the proven path to develop your skills and training. Pursue your goals through these TapRooT® courses to advance your professional development and your career.

Reno, Nevada, July 25, 2018: 2-Day TapRooT® Root Cause Analysis Training

Edmonton, Alberta, Canada, August 02, 2018: 2-Day TapRooT® Root Cause Analysis Training

Dallas, Texas, August 6, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Nashville, Tennessee, August 13, 2018: 2-Day TapRooT® Root Cause Analysis Training

Adelaide, Australia, August 21, 2018: 2-Day TapRooT® Root Cause Analysis Training

Monterrey, Mexico, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Johannesburg, South Africa, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Newcastle, Australia, September 12, 2018: 2-Day TapRooT® Root Cause Analysis Training

Calgary, Canada, September 24: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Amsterdam, Netherlands, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Manchester, United Kingdom, October 1, 2018: 2-Day TapRooT® Root Cause Analysis Training

Aberdeen, Scotland, October 8, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Dubai, UAE, October 14: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Kuala Lumpur, Malaysia, October 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Singapore, Singapore, November 15, 2018: 2-Day TapRooT® Root Cause Analysis Training

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

Monday Accidents & Lessons Learned: When One Good Turn Definitely Doesn’t Deserve Another

Posted: July 16th, 2018 in Accidents, Career Development Tips, Current Events, Great Human Factors, Human Performance

The electronic flight bag (EFB) is rapidly replacing pilots’ conventional papers in the cockpit. While the EFB has demonstrated improved capability to display aviation information—airport charts, weather, NOTAMs, performance data, flight releases, and weight and balance—NASA’s Aviation Safety and Reporting System (ASRS) has received reports that describe various kinds of EFB anomalies, such as this one:

“This B757 Captain received holding instructions during heavy traffic. While manipulating his EFB for clarification, he inadvertently contributed to an incorrect holding entry.

‘[We were] asked to hold at SHAFF intersection due to unexpected traffic saturation. While setting up the FMC and consulting the arrival chart, I expanded the view on my [tablet] to find any depicted hold along the airway at SHAFF intersection. In doing so, I inadvertently moved the actual hold depiction…out of view and [off] the screen.

‘The First Officer and I only recall holding instructions that said to hold northeast of SHAFF, 10-mile legs. I asked the First Officer if he saw any depicted hold, and he said, “No.” We don’t recall instructions to hold as depicted, so not seeing a depicted hold along the airway at SHAFF, we entered a right-hand turn. I had intended to clarify the holding side with ATC, however there was extreme radio congestion and we were very close to SHAFF, so the hold was entered in a right-hand turn.

‘After completing our first 180-degree turn, the controller informed us that the hold at SHAFF was left turns. We said that we would correct our holding side on the next turn. Before we got back to SHAFF for the next turn, we were cleared to [the airport].'”

Volpe National Transportation Systems Center, U.S. Department of Transportation, weighs in on EFBs: “While the promise of EFBs is great, government regulators, potential customers, and industry developers all agree that EFBs raise many human factors considerations that must be handled appropriately in order to realize this promise without adverse effects.”

CALLBACK is the award-winning publication and monthly safety newsletter from NASA’s Aviation Safety Reporting System (ASRS). CALLBACK shares reports, such as the one above, that reveal current issues, incidents, and episodes.

Circumstances can crop up anywhere at any time if proper sequence and procedures are not planned and followed. We encourage you to learn and use the TapRooT® System to find and fix problems. Attend one of our courses. We offer a basic 2-Day Course and an advanced 5-Day Course. You may also contact us about having a course at your site.

Welcome Marcus Miller!

Posted: July 13th, 2018 in Media Room, Medical/Healthcare, Meet Our Staff, Performance Improvement, Press Releases, Root Cause Analysis Tips, TapRooT® Instructor, TapRooT® Instructor Profiles

TapRooT® is growing! We are pleased to welcome Marcus Miller, Vice President of Business Development.

Marcus has hit the ground running, and you may have already read some of his informative healthcare-focused posts on the Root Cause Analysis Blog:

  • Using TapRooT® to Prevent Medicare Payment Reduction (Read post.)
  • QAPI and TapRooT®: The Bridge to Operational Excellence and Quality Care in our Nursing Homes (Read post.)
  • Joint Commission Focuses Surveys to Assess Safety Culture (Read post.)
  • Winners and Losers in Healthcare’s Shift to Value-Based Payments (Read post.)
  • Bias and Blame in Healthcare’s Culture has to Change (Read post.)

We hope you will join us in welcoming him to the TapRooT® team. To learn more about Marcus, click here.

 

 

 

 

Friday joke

Posted: July 13th, 2018 in Jokes

“Ask not for whom the photocopier jams. It jams for thee.”

TapRooT® Training Around the World: New Zealand

Posted: July 12th, 2018 in Career Development, Courses, Pictures, TapRooT® Instructor, Training

Here is a glimpse into a recent in-house 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course at Practical Solutions Group in New Zealand. In just 5 days through TapRooT® Training, these students learned to find and fix the root causes of incidents, accidents, quality problems, precursors, operational errors, hospital sentinel events, and many other types of problems.

TapRooT® Techniques within the 5-Day course included SnapCharT®, Root Cause Tree® & Corrective Action Helper®, plus additional advanced topics such as CHAP, Human Engineering, Interviewing, Safeguard Analysis, and Proactive Improvement. Upon completion of the course, the students received a certificate of completion and a 90-Day Subscription to TapRooT® VI online.

Take a course taught by one of our expert TapRooT® instructors and you will understand how to troubleshoot and identify the root cause of any issue and/or incident. We thank Narelle Wright at Practical Solutions Group for sharing these pictures of the interaction and learning during the course!

Put yourself in the picture by becoming trained in troubleshooting and identifying root causes of issues and incidents. Register today for a TapRooT® course and gain advantage, experience, and expertise from our professional instructors. Here is a listing of our upcoming 5-Day courses:

Nairobi, Kenya, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Portland, Oregon, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Dallas, Texas, August 06, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Newcastle, Australia, August 13, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Johannesburg, South Africa, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Monterrey, Mexico, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Calgary, Canada, September 24, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Aberdeen, Scotland, October 08, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Dubai, United Arab Emirates, October 14, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Knoxville, Tennessee, October 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Bogota, Colombia, October 22, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Brisbane, Australia, November 12, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

New Orleans, Louisiana, November 12, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Monterrey, Mexico, November 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Johannesburg, South Africa, November 19, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Perth, Australia, November 26, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Houston, Texas, December 3, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Amsterdam, The Netherlands, December 3, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Edmonton, Canada, December 10, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

We are global to meet your needs. If you need other times or locations, please see our full selection of courses.

If you would like for us to teach a course at your workplace, please reach out to discuss what we can do for you, or call us at 865.539.2139.

TapRooT® Around the World: Singapore

Posted: July 11th, 2018 in Career Development, Courses, Pictures, TapRooT® Instructor, Training

TapRooT® Instructor Malcolm Gresham, certified in TapRooT® instruction since 2006, was recently in Singapore teaching students the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course at Practical Solutions Group. In a course taught by one of our expert TapRooT® instructors, you will understand how to troubleshoot and identify the root cause of any issue and/or incident. We thank Narelle Wright for sharing these pictures of the interaction and learning during the course!

Put yourself in the picture by becoming trained in troubleshooting and identifying root causes of issues and incidents. Register today for a TapRooT® course and gain advantage, experience, and expertise from our professional instructors. Here are some of our upcoming 5-Day courses:

Nairobi, Kenya, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Portland, Oregon, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Dallas, Texas, August 06, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Newcastle, Australia, August 13, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Johannesburg, South Africa, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Monterrey, Mexico, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Calgary, Canada, September 24, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Aberdeen, Scotland, October 08, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Dubai, United Arab Emirates, October 14, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Knoxville, Tennessee, October 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Bogota, Colombia, October 22, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Brisbane, Australia, November 12, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

New Orleans, Louisiana, November 12, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Monterrey, Mexico, November 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Johannesburg, South Africa, November 19, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Perth, Australia, November 26, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Houston, Texas, December 3, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Amsterdam, The Netherlands, December 3, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Edmonton, Canada, December 10, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

We are global to meet your needs. If you need other times or locations, please see our full selection of courses.

If you would like for us to teach a course at your workplace, please reach out to discuss what we can do for you, or call us at 865.539.2139.

Management System

Posted: July 11th, 2018 in RCA Tip Videos, Root Causes, TapRooT

Screen Shot 2018 05 24 at 10 02 52 PM

Back in 1985, my boss suggested I (Mark Paradies) look at better ways to analyze and trend root causes. I already understood human factors (from training for my master’s degree from the University of Illinois) and equipment reliability (from my experience in the Nuclear Navy). Therefore, I had a good start on the knowledge I needed to develop a system for root cause analysis.

The very first system I developed had a category (today we would call it a Basic Cause Category) of Leadership.

When I showed the system to my boss and he saw the Leadership category, he said:

“You have to take that out.”

He explained that senior management would go nuts if we said there was a leadership issue. We argued for quite a while. I said that management would just have to accept that they, too, could improve. He explained that I had done such a good job NOT having blame categories in the system that I shouldn’t have a blame category for leadership and that’s how the company’s management would view a Leadership category.

Eventually, he convinced me that we could come up with a better name. He wanted to call it “Organizational Factors.” I said that it should be “Management.” He said that was just as bad as Leadership. He wanted to call it “Systems.” I thought that clouded the responsibility for where the changes needed to be made. Finally I suggested “Management System.” It took a while, but he finally agreed.

After several management presentations and several discussions with senior management, we finally got approval for the “Management System” category.

Little did I know that we had invented a term that would be used around the world.

The first place it spread to was INPO (Institute of Nuclear Power Operation). I had interviewed for a job there and they had tried to hire me but I had already taken another job. However, I stayed in contact with Joe Bishop who was in charge of developing the HPES (Human Performance Evaluation System) system for INPO. When they had a version of the system ready, he sent me a copy for review. I commented that they had missed the Management System causes. Sure enough, my work on Management System made it into INPO’s HPES system.

From there, the terminology spread throughout the U.S. nuclear industry and to nuclear plants around the world.

Once I started System Improvements in 1988, the terminology started spreading to other industries. Refining, chemicals, oil exploration and production, and other industries. By the early 1990s, TapRooT® was adopted by industry leaders around the world. And the terminology “Management System” went with it.

Then, I began hearing the term at professional society meetings. People started insisting that to find root causes you needed to find “management system” causes. I thought this was interesting. Where had the term “management system” come from?

I researched the term on the internet and couldn’t find any references prior to the meeting I had with my boss back in 1986. In fact, it looked like the terminology had started to be used in the mid-1990s.

I can’t prove it but I think the terminology came from that meeting with my boss, Rod Satterfield. And that is how the Management System terminology got started.

If you would like to learn more about the Management System, all you need to do is read about it in the TapRooT® Root Cause Tree® Dictionary. You will receive a copy of the dictionary and will learn how to use it in any of our TapRooT® 2-Day or 5-Day Courses.

Cancel your lunch plans! Join TapRooT® today at noon EST!

Posted: July 11th, 2018 in Career Development Tips, evidence collection, Investigations, Presentations, RCA Tip Videos, Root Cause Analysis Tips, TapRooT, TapRooT® Instructor, Topic of the Week, Video

Join TapRooT® professionals Benna Dortch and Ken Reed today at noon EST for TapRooT®’s Facebook Live discussion.

We look forward to being with you on Wednesdays! Here’s how to connect with us for today’s Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

When? Today, Wednesday, July 11

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Recently, on TapRooT®’s Facebook Live, we learned that only through effective listening will you learn to pick up on the “right” questions to ask in your investigations. TapRooT® Instructor Barb Carr gave us a beginning point:”The first question is the only one you need to know going in: ‘Tell me, from start to finish, what you observed the day of the incident.’” Barb also advises that the next step is to “sit back, listen, and identify which follow-up questions need to be asked.”

Since our listening skills develop with practice, everyone can use help becoming better investigators. Use the video and Vimeo below, featuring TapRooT® professionals Benna Dortch and Barb Carr, to review your skills:


Do your own investigation into our courses and discover what TapRooT® can do for you.

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

Join TapRooT® for Facebook Live Wednesday at noon EST

Posted: July 10th, 2018 in Career Development Tips, TapRooT, Topic of the Week, Video

Make plans now to join TapRooT® professionals Benna Dortch and Ken Reed tomorrow for our Facebook Live discussion.

We look forward to being with you on Wednesdays! Here’s how to connect with us for tomorrow’s Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

When? Wednesday, July 11

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

TapRooT® Around the World: Onsite Course, Ensign Energy, Neuquén, Argentina

Posted: July 10th, 2018 in Career Development, Courses, Meet Our Staff, Pictures, TapRooT® Instructor, Training

TapRooT® Instructor Piedad Colmenares sent us some “course captures” of the recent 2-Day TapRooT® Root Cause Analysis Training class she taught in Neuquén, in chilly Argentine Patagonia, onsite at Ensign Energy.

Piedad says, “Despite the intense cold of winter, it was a very special course. We shared experiences, and it was also very pleasant to experience the excitement of the World Cup. It was very exciting to receive the gift they gave me: a shirt of the Argentine soccer team, autographed by all the students.” Piedad gives a shout-out of thanks to all the participants of the Ensign Energy onsite course.

In a TapRooT® course, you will grasp how to troubleshoot and identify the root cause of any issue and/or incident, learning from one of our expert instructors. Many thanks to Piedad for sharing these pictures of action and insights into the interactive learning during the course!

Put yourself in the picture by becoming trained in troubleshooting and identifying root causes of issues and incidents. Register today for a TapRooT® course and gain advantage, experience, and expertise from our professional instructors. Here are a few of our upcoming courses:

Brisbane, Australia, July 16, 2018: 2-Day TapRooT® Root Cause Analysis Training

Portland, Oregon, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Nairobi, Kenya, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Auckland, New Zealand, July 16, 2018: 2-Day TapRooT® Root Cause Analysis Training

Milwaukee, Wisconsin, July 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Perth, Australia, July 19, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, July 25, 2018: 2-Day Root Cause Analysis Training

Reno, Nevada, July 25, 2018: 2-Day Root Cause Analysis Training

Bogota, Colombia, July 25, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

Bogota, Colombia, July 27, 2018: 1-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis Course

Sao Paulo, Brazil, August 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Johannesburg, South Africa, August 13, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Adelaide, Australia, August 21, 2018: 2-Day TapRooT® Root Cause Analysis Training

Newcastle, Australia, September 12, 2018: 2-Day TapRooT® Root Cause Analysis Training

Manchester, United Kingdom, October 1, 2018: 2-Day TapRooT® Root Cause Analysis Training

We are global to meet your needs. If you need other times or locations, please see our full selection of courses.

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

Bias and Blame in Healthcare’s Culture Has To Change

Posted: July 10th, 2018 in Uncategorized

 

Taking the blame out of root cause analysis is critical.  See this article for more information on a physician in the UK who was charged with manslaughter when the system failed her and her patient. Click here.  The physician wasn’t at fault.  She didn’t intentionally make an error.  The system and processes need analyzed and improved so mistakes aren’t made again.  It actually does harm to put a physician in jail because of  process or system errors.  It takes the focus off of the real problems.  It diverts time and resources from where they are truly needed.  It incentives physicians to cover up errors which could be analyzed for lessons learned resulting in better outcomes.  Physician burn out and suicide rates are at an all time high because of the pressure physicians are under. Click here for more info.  They are held accountable and blamed for bad outcomes when something goes wrong.  The responsibility and burden on physicians must be tremendous.  Until Healthcare catches up to other industries that do train their teams on how to conduct unbiased root cause analysis as part of their continuous quality improvement process, the culture will be hard pressed to change.

 

To find more information on TapRooT’s® comprehensive quality improvement process, please contact me at marcus.miller@taproot.com.

What does a bad day look like?

Posted: July 10th, 2018 in Bad day

“Well, look at it this way: At least the driveway will be super fun when it snows! We’ll never get our car in and out without denting the front or back, but our sledding game is going to be the bomb.”

Acquire TapRooT® in Atlanta

Posted: July 9th, 2018 in Career Development, Courses, Local Attractions, Training

TapRooT® Training in Atlanta, Georgia, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

 

Exposure to the 2-Day TapRooT® Root Cause Analysis Training course in Atlanta will expand your professional knowledge. In two days, learn the TapRooT® Essentials to find and fix the root causes of incidents, accidents, quality problems, precursors, operational errors, hospital sentinel events, and other types of problems. Essential Techniques include: SnapCharT®, Root Cause Tree® & Corrective Action Helper®. A TapRooT® course is a career booster and can be a professional game changer for you. You’ll be amazed at how much you learn that you can immediately apply!

While in Atlanta, you will want to get out and about. Below, to route you on the road to Atlanta, we’ve included highlights of this Southern city. Be sure to discover even more gems to explore on our Atlanta Pinterest board.

Experience Atlanta

Atlanta has grown from a railway town to a Southern icon due to its cultural community, as well as for its position as a financial and commercial center. The bustling city maintains its identity as a crucial hub for transportation. Atlanta—with incredible charm, generally mild-weathered climate, and attractions such as the Georgia Aquarium, the College Football Hall of Fame, and Piedmont Park—has drawn in celebrity chefs, media magnates, and a diverse population.

Take a walk along the BeltLine, a 22-mile loop connecting parks and trails and encircling major areas of the city. See how many pieces of public art you can spot as you walk.

With 75 acres of fresh outdoor nature experiences and the world of adventure inside, Fernbank Museum of Natural History opens your eyes to a hands-on, wild side, sensory discovery.

Go for a mini-hike up Stone Mountain.

Stroll through Ponce City Market, set in a historic Sears, Roebuck & Co. building, and discover Skyline Park on the rooftop, dine and drink at City Winery, get an epic coffee at Spiller Park.

At the High Museum, explore contemporary and historical art, exhibitions, and architecture.

In downtown Atlanta, Centennial Olympic Park is where you’ll find the Georgia Aquarium.

Martin Luther King Jr. National Historic Park: Visit the park, including the home of Martin Luther King Jr. Be moved by his story in this park dedicated to the African-American leader’s life and heritage.

Atlanta Botanical Garden offers an urban oasis of more than 30 acres, adjacent to Piedmont Park in Midtown.

Taste Atlanta

 

Fork first, into a scrumptious Southern fare at Atlanta Breakfast Club. Among the temptations are fried chicken with waffles, pancakes, omelets, French toast, and, of course, grits.

Make plans to stop at Ponce City Market and get your culinary senses sharpened in Central Food Hall.

Duck into Ria’s Bluebird for a delicious weekend brunch in the downtown heart of Atlanta. The buttermilk pancakes are ranked the world’s best by the New York Times.

Cool off with a crazy-good, flavor-filled treat from the closest King of Pops.

Bite into a Sublime Doughnut to see what all the hubbub is about.

With up to 15 trucks at a time, your options are wide open at Atlanta Food Truck Park.

If you happen to be in East Atlanta or on the West side, savor a slider at Delia’s Chicken Sausage Stand.

Go to Hankook Taqueria near the Georgia Tech campus and settle into some tong dak tacos and sesame fries.

Tuck into some Belgian Fries at Belgian Beer Bar, located in Little 5 Points.

The overstuffed burrito, rice and beans, quesadillas, and more from El Myr are something to look forward to.

Atlanta is all about the food halls. In the middle of Inman Park, you’ll find Watchman’s Seafood & Spirits featuring fresh Gulf of Mexico fare in Krog Street Market.

Register here for our Atlanta 2-Day TapRooT® Root Cause Analysis Training course.

TapRooT® is global to meet your needs. If you need other times or locations, please see our full selection of courses.

If you would like for us to teach a course at your workplace, please reach out to discuss what we can do for you, or call us at 865.539.2139.

Winners and Losers in Healthcare’s Shift to Value-Based Payments

Posted: July 9th, 2018 in Investigations, Medical/Healthcare, Performance Improvement, Quality, Root Causes, TapRooT, Uncategorized

 

Image result for scale budget

The 2010 Affordable Care Act (ACA) was established to shift payment away from the volume of services provided toward the quality of those services. The ACA directed the Department of Health and Human Services to create a budget neutral payment model. CMS (Centers for Medicare & Medicaid Services) published an ACA fact sheet in 2015 that can be found here.

What does budget neutral mean in this case? A very smart healthcare executive explained it to me.  She said that budget neutral means you will have losers and you will have winners. The Department of Heath and Human Services had to put a payment model in place that takes money away from the losers and gives it to the winners so Medicare doesn’t see an increase in costs but still incentivizes providers to focus on quality. If you don’t have positive outcomes, money will be taken away and given to the providers that do show positive outcomes (the winners). So the difference between winners and losers is the quality of their outcomes. TapRooT® should be the quality improvement process healthcare organizations use to ensure they are on the winning side by improving quality and safety which also protects their revenue and margins. To find out more how your organization can improve your outcomes and protect your reimbursement, please contact me at marcus.miller@taproot.com.

Career Opportunities for Candidates with TapRooT® Skills

Posted: July 9th, 2018 in Career Development, Courses, Job Postings, TapRooT, Training

When you have the expertise of TapRooT® training on your resume, you’re communicating to others the level of your career development. Professional training and skill sets in investigation, problem-solving, and root cause analysis convey competency to the prospective employer. If you have TapRooT® training and skills, explore your professional advancement through one of these global opportunities.

HSE Manager

Chemical Manufacturing

Field Operations Excellence Leader 

Patient Safety Analyst 

Senior Process Engineer

Associate- Senior Engineer Nuclear

Patient Safety Assistant Coordinator

Patient Safety Analyst

Patient Safety Assistant Coordinator

Lead Engineer

If you are not TapRooT® trained, becoming TapRooT® trained in troubleshooting and identifying root causes of issues and incidents is the proven path to develop your skills and training. Pursue your goals through these TapRooT® courses to advance your professional development.

Portland, Oregon, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Auckland, New Zealand, July 16, 2018: 2-Day TapRooT® Root Cause Analysis Training

Milwaukee, Wisconsin, July 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Dallas, Texas, August 6, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Adelaide, Australia, August 21, 2018: 2-Day TapRooT® Root Cause Analysis Training

Monterrey, Mexico, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Newcastle, Australia, September 12, 2018: 2-Day TapRooT® Root Cause Analysis Training

Calgary, Canada, September 24: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Amsterdam, Netherlands, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Manchester, United Kingdom, October 1, 2018: 2-Day TapRooT® Root Cause Analysis Training

Dubai, UAE, October 14: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Kuala Lumpur, Malaysia, October 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

Monday Accident & Lessons Learned: Fatal Accident While Unloading a Truck

Posted: July 9th, 2018 in Accidents, Current Events, Pictures, Video

WKBW TV reported that two employees were killed when a stack of Corian counter tops that weighed 800 pounds per slab (11 slabs total) fell on them. The accident occurred at 1:30 a.m. and the employees were pronounced dead at the scene.

The company issued a statement that said:

“We’re saddened to report that a tragic accident occurred this morning at our facility in Lockport, NY that resulted in the death of two of our colleagues. We’re working with our safety team and local law enforcement to understand the circumstances under which this tragedy occurred. Our deepest sympathies are with their families and our Lockport team members.”

OSHA will be conducting an investigation of the deaths. OSHA has investigated two other serious injuries at XPO facilities elsewhere in New York state.

What was the Hazard in this accident?

The heavy, high-piled load.

Who were the targets?

The two employees.

What were the Safeguards?

From the newspaper articles, we don’t know.

We also don’t know any of the reasons for the Safeguard’s failure.

The root cause analysis will have to determine the Safeguards, why they failed, and if they were sufficient. (Do we need additional Safeguards?)

In the TapRooT® System, a SnapCharT® would be used to collect and organize the information about what happened.

Then the failed Safeguards would be identified.

Next, the failed Safeguards (Causal Factors) would be analyzed to find their root causes using the Root Cause Tree® Diagram.

Once the root causes for all the Safeguards were found, the team would start developing corrective actions.

The Safeguards would be reviewed to see if after they were strengthened, if they would be adequate. If they would not be adequate, either additional Safeguards would be developed or the process could be modified to reduce or remove the hazard. For example, stack the counter tops no more that 16 inches high.

To improve the Safeguards that failed, you would address each of the root causes by developing SMARTER corrective actions using the Corrective Action Helper® Module of TapRooT® Software.

What is a SMARTER corrective action?

Specific

Measurable

Accountable

Reasonable

Timely

Effective

Reviewed

To learn more about the TapRooT® System, SnapCharT®, Safeguard Analysis, Causal Factors, the Root Cause Tree® Diagram, the Corrective Action Helper® Module, the TapRooT® Software, and SMARTER, attend one of our 2-Day or 5-Day TapRooT® Courses. Here is a list of the dates and locations of the courses being held around the world:

http://www.taproot.com/store/Courses

Friday Joke

Posted: July 6th, 2018 in Jokes

“Okay—who put my lunch through the mass spectrometer…?”

Connect with Us

Filter News

Search News

Authors

Angie ComerAngie Comer

Software

Anne RobertsAnne Roberts

Marketing

Barb CarrBarb Carr

Editorial Director

Chris ValleeChris Vallee

Human Factors

Dan VerlindeDan Verlinde

VP, Software

Dave JanneyDave Janney

Safety & Quality

Garrett BoydGarrett Boyd

Technical Support

Ken ReedKen Reed

VP, Equifactor®

Linda UngerLinda Unger

Co-Founder

Mark ParadiesMark Paradies

Creator of TapRooT®

Michelle WishounMichelle Wishoun

Licensing Paralegal

Per OhstromPer Ohstrom

VP, Sales

Shaun BakerShaun Baker

Technical Support

Steve RaycraftSteve Raycraft

Technical Support

Wayne BrownWayne Brown

Technical Support

Success Stories

I know that accidents happen, but I always try and learn from them and absolutely aim…

ARKEMA

Reporting of ergonomic illnesses increased by up to 40% in…

Ciba Vision, a Novartis Company
Contact Us