Root Cause Analysis Blog

For the article in the Houston Chronicle, see:

http://www.chron.com/disp/story.mpl/business/4849376.html

This is the first post in a new weekly column written to introduce you to the individuals who make up our dynamic team of TapRooT® instructors. It was difficult for me to pick the first instructor to highlight, so I’ll tie today’s column in with today’s post about our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training in Calgary, and introduce you to one of our Canadian instructors who is also a co-instructor for the Calgary course, Michele Lindsay.

Michele is always developing new ideas that inspire and empower others, like the Innovative and Creative Solutions course she held at the 2007 TapRooT® Summit. She is the type of leader that keeps people “in the know” to give them the tools they need to go back to their facilities and create an exciting future.

Michele has been a certified Instructor for the TapRooT® System since 1998 and has consulted, investigated and taught using this tool to a long list of Companies that include: NASA, ExxonMobil, Pfizer, Exelon, First Energy, Ontario Hydro, PetroCanada, GE and Fluor. She has taught hundreds of TapRooT® courses and thousands of students throughout Canada, USA and Europe.

Michele is Principal of Performance Potential or P², a company whose vision is to help organizations and individuals access their potential. By helping clients understand their problems and come up with innovative solutions P² can help access the potential that lies within all organizations.

Michele has always been an “outside of the box” thinker, but was formally trained in Creative thinking techniques in 1994. Recognizing the challenges and limitations of improvement teams to come up with effective and innovative solutions to problems, Michele became a Certified Instructor of the Six Thinking Hats™ that includes Lateral Thinking tools by Edward De Bono. These creativity tools and techniques have helped hundreds of organizations improve existing processes and develop breakthrough ideas to move them closer to their performance potential.

Prior to opening her own consulting practice, Michele worked at Ontario Hydro, in the Corporate Heath & Safety Department. She has a B.Sc (specializing in Human Kinetics) from the University of Guelph. She currently resides north of Toronto, ON, CA with her husband and two daughters and is an avid sports enthusiast, playing basketball, hockey, baseball and golf.

Thank you, Michele, for your hard work and dedication to changing the way the world solves problems!

Our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training is scheduled in Calgary, Canada July 16-20, 2007. Calgary is the largest city in the province of Alberta, Canada with a population of around 1 million! Arrive the weekend before the course begins and enjoy the closing days of the Calgary Stampede, a 10-day event that will be held July 6 to 15, 2007. The Stampede is one of Canada’s largest annual events, and the world’s largest outdoor rodeo. Reba McEntire is scheduled to perform at the Stampede on Saturday, July 15, and event tickets purchased for the Reba McEntire concert will also admit you to Stampede Park for the day.

For more info on the City of Calgary, visit these sites:

Tourism Calgary

The City of Calgary

Discover Calgary

Hike the Calgary Rocky Mountains

The Calgary Zoo

The Calgary Tower

Downtown Calgary (The weekend starts on Thursday!)

This is your opportunity to register for a course that will teach you every skill that a Team Leader needs to collect information, analyze root causes, and develop effective corrective actions. Register online or visit our course info page for more information about upcoming training!

Sometimes it seems that our freedom is so easily obtained by most in the US today, that we forget the price that others have paid and are paying. This isn’t to suggest that the price should be higher for all. Rather, that all should stop and remember the price that others have paid to provide the freedom that we enjoy.

The other aspect of Memorial Day that we need to remember is the thanks that we owe to those who currently serve to protect our freedom. Even if they don’t have to fight for our freedom, they sacrifice with long deployments away from those they love.

So thanks to all who serve from all of us at System Improvements.

Dakota tribal wisdom says that when you discover you are riding a dead horse, the best strategy is to dismount. However, in safety management we find that many try other strategies with dead horses, including the following:

1. Buy a stronger whip and declare that “No horse is too dead to beat.”

2. Change riders.

3. Say things like, “This is the way we always have ridden this horse.”

4. Appoint a committee to study the horse.

5. Visit other sites to see how they ride dead horses.

6. Change the procedure to ride dead horses.

7. Appoint a special team to revive the dead horse.

8. Consider whether or not the rider needs more skill/knowledge to ride the dead horse.

9. Compare the state of dead horses in today’s environment.

10. Change the threshold of “dead” declaring that “This horse is not dead.”

11. Hire contractors to ride the dead horse.

12. Harness several dead horses together for increased speed.

13. Provide additional funding to increase the horse’s performance.

14. Perform a study to see if contractors can ride it cheaper.

15. Purchase a product to make dead horses run faster.

16. Declare the horse is “better, faster and cheaper” dead.

17. Form a quality circle to find uses for dead horses.

18. Revisit the performance requirements for horses.

19. Develop an incentive awards program to encourage the dead horse to perform at acceptable levels.

And if all else fails:

20. Promote the dead horse to a supervisory position.

It’s an interesting concept … The hospital makes an error - like a caretaker contaminating a needle and causing a bloodstream infection - and the government then pays the hospital more to cure the disease they created.

This process seems to reward the hospital with additional payments for making errors. It certainly doesn’t reward a hospital that spends more to stop medical errors.

An article in the May 22 edition of the Indy Star indicates that Medicare is rethinking this payment policy and may stop paying for the following conditions acquired after admissions:

1. Catheter-associated urinary tract infections.
2. Bed sores.
3. Objects left in after surgery.
4. Air embolism, or bubbles, in bloodstream from injection.
5. Patients given incompatible blood type.
6. Bloodstream staph infection.
7. Ventilator-associated pneumonia.
8. Vascular-catheter-associated infection.
9. Clostridium difficile-associated disease (gastrointestinal infections).
10. Drug-resistant staph infection.
11. Surgical site infections.
12. Wrong surgery.
13. Falls.

With Medicare being such a large payer of claims, this would certainly give hospitals a much bigger reason to improve - their profitability!

And as a taxpayer I can’t see why they have waited this long.

For the complete article, see:

http://www.indystar.com/apps/pbcs.dll/article?AID=2007705220351

ES&H Manager for support of Emergency Response work - Out of town - Kansas – 3-4 month assignment, hourly rate plus per diem.
Requires 5-10 years ES&H Project Experience – Emergency Response experience a plus.
Send resume immediately to:

Mike Agentis
President
1st Contracts Management, LLC
magentis@comcast.net
Mobile - 865-335-7367

I know I’ve posted many entries on fatigue and medical errors, but I got an e-mail from a reader and they pointed me to a web blog with an interesting personal story about fatigue in the OR.

To read it (it is long) go to:

http://medicintegrity-team.blogspot.com/

In the “Continue reading …” section below is a Press Release from the CSB that says there are “striking similarities” between the root causes discovered by the CSB’s investigation of the BP’s Texas City Refinery Explosion and the causes of the pipeline leak at BP’s Prudhoe Bay oil field as outlined in a study by Booz Allen Hamilton.

With the considerable turnover among BP’s senior management ranks, it leaves one to wonder, can BP learn from these accidents, or will the senior management turnover just lead to a new culture without any real learning from the accidents?

Some may say that the disciplinary documents released recently point to a culture of blame - not a learning culture. If after a year and a half after the tragedy at Texas City, BP executives are still looking higher and higher in the corporation for people to blame, perhaps they haven’t learned that they need to put strict systems in place rather than relying on managements’ changing priorities to manage safety at highly hazardous workplaces.

You may consider this to be a harsh evaluation, but getting beyond blame and putting effective systems in place - systems that are supported by management - is the only way to stop the kind of unwise cost cutting that lead to unsafe conditions at the BP Texas City Refinery and the BP Prudhoe Bay Oil Pipeline.
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Hmmm . . . not good advertisement for this company:

Lunch anyone?

This town is serious about keeping it under 15:

But not as serious as these folks:

Wow, I didn’t know this:

View more funny signs at www.funnysigns.com

Here’s pictures of people working hard at 4 PM in a Public TapRooT® Advanced Root Cause Analysis Team Leader Course in  Las Vegas.

I’m always amazed at how involved people get in our courses and how hard people work learning to improve performance so that they can save lives, improve quality, prevent injuries, save jobs, and generally make the workplace  a better place.

So even though we are in a location that some might see as a distraction to learning, people in TapRooT® Courses are hard at work.

If you are interested in learning advanced root cause analysis skills to improve performance at your facility, see our upcoming course list, pick a great location, and get registered!

What are some of my favorite locations that are coming up this Summer?

2-Day

Aberdeen, Scotland

Niagara Falls, Canada

Dallas, Texas

Lake Tahoe, Nevada

3-Day Equifactor®

Aberdeen, Scotland

Dallas, Texas

Lake Tahoe, Nevada

5-Day

Charleston, South Carolina (Kiawah Island)

Gatlinburg, Tennessee

Leamington Spa, England

Calgary, Canada (during the Stampede)

Seattle, Washington

Recently received these photos … once again was amazed …

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Below is a note I received from Summit Speaker, Bill Sirois. (Bill Sirois is Senior Vice President and Chief Operating Officer of Circadian Technologies, Inc. (CTI). You may contact him through his website: www.circadian.com.) ~ Barbara

While we all know intuitively that fatigue is frequently a root cause of today’s accidents and injuries, it is still being grossly under-reported as a causative factor. This is because we are not collecting the necessary data to identify fatigue as the real culprit. Plus, it is much easier to blame “behavior” as the cause of human error. For example, the truck driver who recently crashed into the Bay City Bridge in Oakland at 4:30am was cited for speeding, rather than the more likely scenario that he simply nodded-off during the low point on the human biological scale. Moreover, his entire life’s history is being scrutinized to find just cause that he was simply a “bad apple” to begin with. Yet, the fact remains that there is a 15 times greater likelihood of an accident between 3am and 6am than at any other time of day (DOT, 1995). It has to do with our human design specifications (i.e. circadian rhythms), and most of us have known that for a long time. Just how to prove it in an industrial or transportation accident is another matter. That’s where FACTS comes in.

In the meantime, please let me know if you have any questions on the FACTS System, or if you have any incidents that you would like to have analyzed for fatigue as part of the research and development effort.

[Please click the icon below to view Bill’s Summit presentation.]

Several of weeks ago, the network that carries BlackBerry messages went down. Why? That’s a question for a good root cause analysis.

For details see these articles …

http://www.informationweek.com/news/showArticle.jhtml?articleID=199100624

http://www.canada.com/nationalpost/financialpost/story.html?id=fff9217c-651c-40c7-8aad-73586d2a953a&k=32960

What is the lesson learned? That IT folks need thorough, systematic root cause analysis as much as safety, equipment, environmental, or hospital quality improvement people do.

One common root cause analysis problem is that investigators stop with the symptoms of the failure and call these symptoms the cause. The don’t dig deep enough to find the true system root causes. They don’t know the questions to ask to get beyond the symptoms.

That’s one of the benefits of TapRooT® - it helps investigators get beyond symptoms to the fixable root causes and generic causes of accident, incidents, qiality problems, equipment failures, and even IT problems.

For more information about TapRooT® see:

http://www.taproot.com/about.php

And for a success story about improving network reliability at BellSouth, see:

http://www.taproot.com/about.php?s=9

but an interesting golf video clip, indeed:

http://bubblare.se/movie/golf_ar_fantastiskt_kul/

EH&S Inc. has 2 job openings they are trying to fill:

1) ES&H Entry Level Professional – A minimum of an Associates or Bachelors of Science Degree in Safety, Environmental, or other technical fields with 0-3 years experience implementing ES&H functions. The successful candidate will assist a manufacturing client with daily ES&H operations including management of their chemical inventory and MSDS system, work order and incidence management system, training and program implementation (hazard communication, respiratory protection, lock out / tag out), ISO 14001 procedure development and implementation, and hazardous/electronic waste disposal. The candidate should possess problem solving skills including the ability to prioritize multiple projects and adjust workload accordingly and address ES&H issues specific to the clients needs. Good interpersonal skills and proficiency in MS Office applications is a must. Project expected to last until 12/07 with the option to become a fulltime employee with the client.

2) ES&H Technician – A minimum of an Associates Degree and 1-3 years experience conducting lead, asbestos, environmental and industrial hygiene assessments. Current EPA accredited asbestos and lead inspector licenses, construction related or DOE experience a plus. Must be willing to travel and have flexible work schedule. Great opportunity to gain experience in numerous work environments and develop professionally.

Interested parties contact:
Brandon Viars, M.S.
Senior ES&H Professional
ES&H, Inc.
10732 Dutchtown Road
Knoxville, TN 37932
865.803.3215 (cell)
865.671.2374 (office)
865.675.6220 (fax)
www.eshinc.com

Next week I’m teaching a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course in Las Vegas. The course is full.

Today, four instructors are teaching two 2-Day Incident Investigation and Root Cause Analysis Courses in Calgary. Both are full.

The 5-Day Course in Houston this week? Full.

Last week we had a 2-Day Course in Portland. Full.

The two courses we had in San Antonio prior to the Summit? Full.

On June 20-21, we have a 2-Day Course in Edmonton. It has 19 people signed up already and it will be full. We don’t have room to schedule an additional class (or instructors), so if you wait until the last minute to register, you will probably be out of luck (and have to wait for the next course in November or travel somewhere else to get the training).

Why are TapRooT® Courses is so popular? I think it is because TapRooT® is so effective finding the root causes of problems and developing effective corrective actions. That’s why our public courses - which have been significantly increased this year (the number of courses was doubled this year in Canada and Australia and increased 20% in the US and Europe) - are often nearly full or are full and have a waiting lists.

Don’t be left out and miss your chance to learn great performance improvement technology. Think of the performance improvement opportunities you will miss while you are waiting for training. If you have a particular course that you are planning to attend … sign up NOW!

For course dates and details see:

http://www.taproot.com/courses.php

Here are a few more ideas shared at the TapRooT® User Best Practices session (with Linda Unger, Michele Lindsay and Jade Washmon):

“If an incident appears to be easy to resolve, immediately assign one person to investigate. If the assigned person finds the incident is more complicated, then form a team.”

“Follow through with corrective actions. We developed a system with e-mail notification. Three individuals are assigned to follow-up to make sure corrective action is implemented.”

“Corrective Actions Team: take your corrective actions back to management before the final report is complete.”

“Review process for each investigation. Use a TapRooT® quality checklist - making sure leadership is trained in TapRooT® so when management reviews the checklist, they know what they are looking for.”

“Be efficient with utilization of investigative teams. Establish a goal of the investigation that is thorough, efficient and objective. Cover all bases on data collection: 1) Go see the equipment/facility involved (example, walk to the pothole, check visability); 2) Collect all paper for the incident (example: reports, records); 3) Meet all people involved (conduct interviews); 4) Review recordings (request security videos). Last but not least, recognize your team’s work!”

Jim Whiting discussed different risk analysis methods used to estimate hazards in his Summit talk, “Using Risk Analysis as a Pre-Job Evaluation/Pre-Job Briefing Tool” (as well as how to choose the most effective risk control option!). Click below to download a copy of Jim’s papers:

All safeguards are not created equal.

In Jim Whiting’s Summit talk, he showed attendees how to identify and strengthen safeguards for proactive improvement. For more information about using safeguard analysis, download Jim’s presentation below:

After writing hundreds of reports, Mike Rodriguez shared an experienced based presentation at the Summit, “Writing the Report - Do’s and Don’ts.” Take this opportunity to download a copy of his handout below to keep as a handy report writing reference:

Single User, Multi-User, Corporate Multi-User — choices, choices — how do you weigh your options? Ed Skompski’s presentation at the Summit helped attendees make an informed decision. But if you missed Ed’s presentation at the Summit, “Comparing Individual User, Workgroup, and Enterprise TapRooT® Software - Which is Best for Your Company?” — you can view his papers below:

Six Sigma methodology focus is implementation of a measured-based strategy that focuses on process improvement and variation reduction through the application of Six Sigma improvement project. But any process improvement in healthcare demands knowledge of how its systems affect patient care. Harry Wetz and David Davis presented “Six Sigma/Lean Healthcare” at the Summit. To view their papers, see the icon below:

Six Sigma Quality

Kaizen Event Summary - Medication Administration

System Improvements has been working since the mid-90’s to help healthcare facilities perform better root cause analysis and adopt advanced strategies to stop human error. Continuing that work, David Davis, Tommy Garnett and Ed Skompski presented and facilitated ideas for “Healthcare Best and Worst Practices for Root Cause Analysis” at the TapRooT® Summit. Below is David and Tommy’s handout for the presentation:

If you are at a healthcare facility and need to learn advanced root cause analysis or would like to learn best practices to stop medical errors, see our course info and our upcoming announcements about the 2008 TapRooT® Summit on this blog.

Summit attendees who signed up for the “Stopping Medical Error” track learned best practices in infection control. David Davis and Dr. Will Sawyer presented “Stopping Nosocomial Infections” at the TapRooT® Summit. If you missed this excellent presentation about infection-control, click below to view David’s papers:

Lessons from History . . . Modern Day Techniques . . . Marco Flores presented all in his Summit presentation, “Becoming Creative - Techniques from Great Thinkers.” Find out the techniques used by great thinkers to drive their creativity by viewing Marco’s handout:

After a major flooding incident at a mine in Canada, Cameco published a report on their root cause analysis of the accident. The Regina Leader-Post published an article about the report and the reaction of some financial analysts that I thought was quite interesting.

First, the article said:

“The root-cause report into that flood concluded neither Cameco nor its contractor had identified risk scenarios, nor did they have necessary controls in place to prevent the flooding of the shaft.”

Later in the article it provided some quotes from analysts. One analyst was quoted as follows:

“William Vogel, an analyst with Harbor View Growth Equity Management in Connecticut, said Cameco appeared to have a ‘lax’ corporate culture. He said he would have expected the company would ‘have fired a lot of people,’ considering that lives were at stake in the mine. ‘I don’t think you have a standards problem. I think you have a people problem,’ Vogel said.”

What can you learn from this article?

Some people just aren’t happy until heads roll (discipline is taken by firing people).

This brings up the whole issue of the basis of performance improvement.

Do we BLAME incidents on people and fire them to improve performance OR do we find the system problems and fix them to ensure improved performance?

It seems that the analyst is in the blame camp. Without performing an investigation, he knew the answer … fire a lot of people!

Where does your corporate performance improvement philosophy fall? Is it oriented toward blame or system improvements? And what approach will yield the best long term results? This could be a major lesson learned!

Click on the continue link below for more pictures…
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For the rest of the pictures at the party, click on the continue link below…
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Yes - I had the exclusive fashion statement in western wear at the TapRooT® Summit Party - TapRooT® Jeans. The proof is below.

We were surprised when John Wayne crashed the Summit Party. But several attendees and staff members took the opportunity to have their pictures taken with him.

Several companies brought large groups and had a company meeting in conjunction with the TapRooT® Summit. Here are pictures of the groups:

If you would like to have a group of 10 or more attend the 2008 Summit, please contact Benna Dortch at 865-539-2139 (or use the contact us link above).

One of our Keynote Speakers was Judge Andrew Napolitano from Fox News. Here’s some pictures taken with the Judge (click on them to make them bigger).

In your company, is retraining the employee the frequent answer to Corrective and Preventive Actions (CAPA)? Are CAPAs often viewed as an afterthought to conducting Root Cause Analysis (RCA)?

Summit attendees learned what the FDA expects from the Biological Pharmaceutical (Bio Pharma) industry in the area of CAPAs. In Lisa Smith’s Summit presentation, an example of an adequate CAPA versus a robust CAPA was discussed and the benefits of each was compared.

Attendees learned about:

• FDA requirements

• Criteria for effective CAPAs

• The difference between adequate versus robust CAPAs

• The concept of mistake-proofed CAPAs

• The importance of using cross-functional improvement teams to solve nagging problems systemically

• The importance of assessing the post-implementation effectiveness of CAPAs

Click the link below to download a copy of Lisa’s presentation.

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SMARTER is an acronym that stands for:

Specific

Measurable

Accountable

Reasonable

Timely

Effective

Reviewed

Each corrective action should be reviewed for each of the letters in SMARTER. Sanjay Ghandi and Steve Swarthout presented how to accomplish this using the SMARTER Matrix at the TapRooT® Summit.

Click below for a copy of Sanjay’s handout for this presentation.

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This Summit session drew upon current nuclear industry initiatives to highlight recognized best practices in conducting incident investigations. The industry initiatives include an IEEE Recommended Practice on incident investigations, Corrective Action Program Owners Group working conference objectives, and industry experience. Our presenter, Kay Gallogly, provided current industry thinking on practices that are ready to implement as well as pit falls to avoid in managing an effective incident investigation process.

Click the link below to download a copy of Kay’s presentation.

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Troubleshooting mechanical equipment can take many forms. There are many methods being used, with varying degrees of success.

What makes your ace troubleshooter so good?

How can we make our entire troubleshooting team that productive?

Ken Reed showed us how to build a successful troubleshooting strategy in his Summit presentation, “Developing an Equipment Troubleshooting Strategy.”

Click the link below to view Ken’s presentation.

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How many times have you had an equipment failure occur, only to have the operators tell you:

Oh, yeah, it never has worked right.

Many would say this is a nuisance issue, sometimes costing a little extra for repeat repairs, but not worth a full investigation. At the Summit, Ken Reed presented how implementation of this philosophy is a roll of the dice, sometimes resulting in disastrous consequences.

Click below to receive a download of Ken’s handout at this presentation.

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Try to build a nuclear power plant in someone’s back yard, and you’ll witness how communities come together to fight something they perceive as extremely dangerous. And yet, at the submarine base in Groton, CT, there may be as many as 18 nuclear reactors within a quarter mile of each other, in various stages of operation and maintenance. Why is there no public outcry over this “dangerous” situation? Admiral Rickover has put in place a program that has endured over 30 years. In his Summit presentation, “Rickover’s Legacy - Safety & Equipment Reliability,” Ken Reed told us what made Admiral Rickover’s program endure, while the civilian program has, until quite recently, languished.

Click below for a download of Ken’s presentation.

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Equipment troubleshooting is an art. It requires logic, focus, and system expertise to successfully conduct equipment fault analysis and repair. Troubleshooting electrical and electronic devices takes this one step further. Ken Reed’s presentation at the Summit, “7 Step Method for Electronic Troubleshooting,” reviewed troubleshooting strategies that can be employed when faced with electronic equipment failures. Click the link below to download a copy of Ken’s presentation.

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For the complete story see:

http://www.chron.com/disp/story.mpl/business/4774310.html

To read the internal BP report see:

http://partners.ibctv.com/Bonse%20Main%20Report.pdf

The article starts out saying:

“An internal BP investigation, detailed for the first time Thursday, recommended that four executives be fired for management shortcomings in a “culture of risk taking” leading up to the 2005 explosion that killed 15 people at BP’s Texas City refinery.

The two-part report of the “management accountability” probe also chastised John Manzoni, the London-based company’s chief executive of refining and marketing, but didn’t call for his termination.

The plant blast investigation, led by BP group vice president Wilhelm Bonse-Geuking, was finished in February but remained under wraps until Thursday, after a Texas appeals court upheld a state district judge’s order that it be made public. BP fought to prevent public identification of the men recommended for firing.”

For the complete article, see the link above.

Looking for a low cost way to improve morale at your facility? Click on the link below for an easy 3-step method that can be implemented immediately using materials you already have! ~ Barbara