We discussed the use of checklists in the medical industry in a previous blog entry. Yesterday, CNN’s Sanjay Gupta interviewed Dr. Peter Provonost, a medical researcher at Johns Hopkins University. He was selected in 2008 as Time Magazine’s Top 100 Most Influential People. He had a great discussion on the use of checklists in medical industry, specifically hospitals. He mentioned a statistic that there are over 30,000 preventable deaths each year in the US due to inadvertent infections that could be mitigated by the use of simple checklists. He said that consistent use of checklists in the medical industry would save more lives than any other single medical therapy currently being developed. Quite a statement! Something as cheap and as inexpensive as implementing simple checklists could save more lives than many of the more expensive therapies now under development. What do you think? With so much research indicating the benefits of checklists, why have they not yet come into widespread use?
Whenever accident get this much press, you know that lawsuits will follow. That’s a “lesson learned” that shouldn’t be forgotten. If Toyota had found the root causes of these accidents and fixed them two years ago, they wouldn’t be facing these serious lawsuits.
One more thing. How serious are these lawsuits? I saw one blog posting saying that he wouldn’t be surprised if Toyota declared bankruptcy because of the lawsuits. I don’t think that’s possible … how many suits would it take to make Toyota go bankrupt? But the fact that somebody might suggest it makes one think twice about what the final cost of this quality/safety issue will be.
An AP story published in the Houston Chronicle says that Transportation Secretary Ray LaHood said that Toyota was:
“…dragging its feet on safety concerns over its gas pedals, suggesting the automaker was ‘a little safety deaf’ to mounting evidence of problems.”
He also said that:
“… federal safety officials had to ‘wake them up’ to the seriousness of the safety issues that eventually led Toyota to recall millions of cars such as its Camry and Corolla. That included a visit to Toyota’s offices in Japan to persuade them to take action.“
The article also said:
“… the government was considering civil penalties for Toyota over its handling of the recalls…”
This kind of press couldn’t come at a worse time as Toyota struggles with this quality/safety issue and the bad press that it has generated.
How much damage to your reputation can a quality/safety issue do? Toyota is finding out the hard way.
They question Toyota’s management, organization, and cost cutting efforts.
Should Toyota release their root cause analysis for the world to see to stop the speculation in the press? Or would the official root cause analysis just raise questions about the depth and accuracy of the analysis and of the resulting corrective actions? Surely it must be done by now with approved corrective actions on the way to the dealers. No matter what, it may come out as future lawsuits (and their will be many) make their way through US courts.
The Associated Press reports that an Air Force official reported that a missile intercept test failed because “the system’s sea-based X-band radar did not perform as expected.”
The story also said:
“The statement says officials from the Missile Defense Agency that conducted the test will conduct an extensive investigation to determine the cause of the failure.“
Let’s hope they use an advanced root cause analysis tool to find the real root causes of the failure and develop effective corrective actions. They need TapRooT®!
The Associated Press reports that Toyota is stopping production for at least a day at six assembly plants and is stopping sales of eight models until accelerator sticking problems are solved.
“A new round of construction problems on U.S. Navy vessels built by Northrop Grumman Corp. have spawned yet another investigation into the nation’s largest Navy shipbuilder.
Northrop, already under fire for widespread yet unrelated welding problems that surfaced two years ago at its Newport News shipyard, now faces quality issues at its Gulf Coast yards in Avondale, La., and Pascagoula, Miss., the Navy said Thursday.
All Gulf Coast vessels built by the company over the last several years are under investigation for a host of problems, including improper welds and defective engines and lube-oil systems, the Navy said.“
Other bad press for Northrop Grumman Shipyards include:
Sounds like they need better root cause analysis and better corrective actions! Maybe it’s time they took a TapRooT® Course?
Poor quality over an extended period of time is an indicator that your problem reporting and corrective action programs aren’t working. Applying the same old corrective actions of blame, counseling employees, more training, and making procedures longer doesn’t solve quality issues. People stuck in the blame game need a systematic investigation process that finds the true root causes of problems and the solutions.
TapRooT® does that with proprietary, copyrighted systems and training, and patented software that comes with a money back guarantee. Nobody else stands behind their system like we do. And that’s just one of the reasons that industry leaders choose TapRooT®.
If you are interested in thorough investigation of quality problems with effective corrective actions, consider sending some of your quality professionals to a 5-Day TapRooT® Advanced Team Leader Training public course. See:
“Qwest Communications confirmed Thursday that the company experienced a long distance outage that lasted about two and a half hours.“
Wow! A two hour outage in long distance service is like a lifetime. That’s a significant quality of service issue. It would be interesting to see their root cause analysis and proposed corrective actions.
These kinds of issues (network reliability, computer reliability, service outages) can be analyzed using TapRooT® just like an equipment outage or a safety issue can be analyzed.
What we’ve found is that people make mistakes for the same kind of reasons whether they are a computer programmer, a refinery operator, or a brain surgeon. That’s why TapRooT® can be used in almost any industry and on every continent.
For more information about TapRooT®, including Success Stories from users (one from BellSouth about network reliability), see:
I received a piece of marketing material for a webinar claiming to teach “simple” root cause analysis techniques in just one hour.
The marketing material included the quote that these basic techniques:
“…are sometimes the best.“
Of course, they lost all credibility with me when they claimed to teach root cause analysis in 60 minutes on the web. But the e-mail made me think …
“What are the minimum tools needed to perform a good root cause analysis of a simple problem?“
We’ve researched this question for over 20 years and I know the answer.
First, you need to understand:
“Make the answer as simple as possible, but not simplier.” (Albert Einstein)
What is the minimum needed information to find a root cause?
1. You need to completely understand what happened before you can understand why it happened. And this understanding should NOT be made through verification of a hypothesis. Rather, the understanding should be an unbiased collection of evidence.
The tool that helps people build the story of what happened using evidence that is collected is a SnapCharT®. And example of a SnapCharT® can be found at this link:
2. Next, you need to identify all the Causal Factors. These are the problems that, if removed, would have prevented the incident or reduced its severity.
There are two techniques that are taught in TapRooT® Training to help investigators identify Causal Factors. The first is the Four Question Method and the second is Safeguards Analysis.
3. Finally, to analyze what caused the Causal Factor, you need a robust root cause analysis tool. There are many substandard tools available so … be careful. Many “experts” recommend a tool they are familiar with without doing thorough research of the tools limitations and understanding the serious shortcomings of supposedly “simple” tools. But we have dedicated our lives to understanding root cause analysis and developing a tool that does not fall into the trap of being just simple but inadequate.
The TapRooT® Root Cause Tree® have been carefully designed and tested to provide the simplest tool possible while yielding robust root cause analysis for equipment and human performance related Causal Factors. The research basis is extensive, so I won’t provide it all here. But I will provide several links so that you can start to understand it…
However, some people continue to cling to inadequate tools because they are “easy” and “sometimes the best.” (Makes one wonder when they are “sometimes the worst.”)
Usually this insistance on using easy, inadequate tools is because the person has failed to do what is needed to make real root cause analysis possible.
What did they miss? See this link to learn what is needed for efficient and effective root cause analysis:
So these tools are the required minimum set (the essential tools) for a good root cause analysis. Anything less is root cause analysis malpractice.
We’ve found that a 2-day course is needed to effectively teach these tools to experienced investigators who want to apply them both reactively and proactively and then have them be used effectively.
So, don’t be fooled into economizing into “quick/easy” methods with fast but inadequate web based training. All you will get is inadequate investigations and recurring problems.
And if this approach seems to be too hard, consider skipping investigations altogether. If you aren’t going to perform an adequate investigation then you should consider that you may be better off by performing no investigation at all.
Found this on YouTube … It’s produced from a quality auditor perspective.
Hope your corrective actions don’t sound like those.
If any of them sound familiar, perhaps you need TapRooT® Training and the Corrective Action Helper® Book that comes with the course. For more info, see:
TapRooT® is well known throughout the world as the premier incident investigation and root cause analysis system. In a perfect world, however, we would like to never have to do an investigation! The only way to get there is to have a good proactive process.
Did you know that TapRooT® can also be a powerful tool in your proactive/continuous improvement arsenal? Michele Lindsay and I are teaching the five day course in Niagara Falls this week, and Thursday is what I call “proactive day.”
We started the day discussing how the TapRooT® 7 Step Process can also be used for audits. After the group understood the process, we did a communication audit where the group performed an audit of 4 willing class volunteers doing a shift turnover. We then took what we learned from the audit and did a root cause analysis and applied corrective actions.
Next, we did two exercises involving an oil boiler and learned how we might use Safeguards Analysis to find problems before an incident occurred, and we identified some significant issues that should receive a good root cause analysis.
Finally, we discussed how TapRooT® fits into continuous improvement programs such as Six Sigma and Lean, and covered trending and moving from a reactive to a proactive environment.
The icing on the cake was when the group got to perform a live audit of a training exercise from the Niagara Falls Fire Department! We don’t always have a chance to do something so fun but things just were going our way this particular day. I’m pleased to report the exercise went off without a hitch and our very detailed (and tough!) auditors (the class) were not able to find any significant issues from the audit. That is surely a good day for an auditor!
Check out the pictures:
The auditors:
If you would like to learn more, attend the 5 day TapRooT® Advanced Root Cause Analysis Team Leader course. See the schedule HERE.
Join me again on the blog next Wednesday for the Root Cause Analysis Tips column, where I will share some more information on the proactive use of TapRooT®.
I recently read 11 nuclear plant trend reports. Not one had a mathematically valid way to trend. (One did come close.)
These 11 nuclear industry trend reports are not unusual … They are typical of trend reports from various industries.
This makes one ask: “Why do so many companies have trouble trending?”
Let’s look at specific problems in the 11 reports.
First, many “trend” reports showed no trends. Three of the eleven reports didn’t even have a single graph. They were just discussions of incidents and audits in a particular quarter with discussions of “trends” with no data.
Most of the reports that had graphs used simple bar and line graphs. Bar graphs with no timeline don’t really show “trends.” They are best used to look for the Pareto Principle and help to identify the biggest problems to attack first.
One report tried to use a mathematically based approach. They used a c-Chart with limits based on 3 times the square root of the mean of the data. But c-Charts require independent data with a constant area of opportunity – which is unlikely for incident data.
The most common error made in trending reports (and by management) is looking at the number of problems in one quarter and comparing them to the next quarter. If the number of problems goes down – that’s a good trend. If the number of problems goes up – that’s a bad trend. They tend to use straight-line approximations to “project the future” (as in the example below).
What’s wrong with this approach? Management starts reacting to noise rather than signals.
Some might say that there’s nothing wrong with trying to “fix things when they aren’t broke.” But they are wrong.
They don’t understand the cost of reacting to non-problems.
They don’t understand how employees get tired of the new improvement flavor of the week.
They haven’t thought about the negative cycle of blame, cover-up, and surprise that is all too common when major accidents occur.
What should people do? Where can they find out about the best practices in trending? First, they can read Chapter 5 of TapRooT® - Changing the Way the World Solves Problems. The new TapRooT® Book explains the problems with trending and the ways to implement best practices in performance measures and trending.
Would you like to go beyond reading? Then you should plan to attend this year’s Advanced Trending Techniques Course on October 5-6 in Nashville, Tennessee (just before the Summit).
What will you learn? First, you will learn why trending is needed and the basics of trending (including the proper way to apply Pareto Charts).
Second, you will learn the math behind Process Behavior Charts (the only chart you need to view trends over time). This math only requires addition, subtraction, multiplication, & division (no different¬ial equations).
Third, You will also learn special ways to use the charts to trend infrequently occurring accident data.
Finally, you will learn how to use your own trend data including how to improve the data and how to present it to management. Get more information about the course by clicking on the “Courses” button above.
A patient suffering from pregnancy induced high blood pressure walks into an Acute Care Clinic 5 Day’s after giving birth with the following symptoms (1):
* Fatigue and weakness
* Rapid heartbeat
* Shortness of breath (dyspnea) when you exert yourself or when you lie down
* Reduced ability to exercise
* Persistent cough or wheezing with white or pink blood-tinged phlegm
* Swelling (edema) in your legs, ankles and feet
* Lack of appetite and nausea
* Difficulty concentrating or decreased alertness
The patient is sent home after a lung x-ray and with medicine to slow her heart rate down. Six hours later she is admitted to the Emergency Room by ambulance with the following symptoms (1):
* Fatigue and weakness
* Irregular heartbeat
* Shortness of breath (dyspnea)
* Persistent cough or wheezing with white or pink blood-tinged phlegm
* Swelling (edema) in your legs, ankles and feet
* Lack of appetite and nausea
* Difficulty concentrating or decreased alertness
The patient is dropped off at the front desk to answer questions because she is able to sit up and speak. Finally the patient is paralyzed in order to be examined and the staff realize that she is having Congestive Heart Failure.
Two heart stops later, admission to the ICU and after fiver years, my wife, Babette, is doing okay… still gets tired but she did not need a new heart nor did she receive brain damage from lack of oxygen.
So what does this have to do with Root Cause Analysis and what I teach today…..
There must have been something “Different” with this patient… There must have been a recent “Change” in how to diagnose Congestive Heart Failure….
We have talked about performing a Change Analysis before on this site and we teach this in our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader and Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis courses…. but what if you do not find a recent Change or Difference, how could you have prevented this from happening?
While the initial thought may have been these were abnormal symptoms (A Difference)…. the symptoms listed above are pulled directly from a well known medical clinic (1). Staff are trained to look for these issues and no Change was made recently in their processes.
So could you have proactively prevented my wife’s missed diagnosis and the findings listed below?
“Multivariable analysis showed that patients who presented to the emergency department with acute cardiac ischemia were more likely not to be hospitalized if they were women less than 55 years old.”(2) So is AGE enough of a a patient difference to understand what went wrong on January 5th, 2004?
The only major difference between an audit finding and investigation finding is timing and the severity of the outcome! In all our TaprRooT® training courses proactive auditing is covered…. but what is the difference between a great audit and just watching someone work to see what policies and procedures they broke?
Go Out and Look (GOAL) and perform a robust audit. Knowing what you know now, what would you look for when auditing an examination of a patient in an Acute Clinic or the Emergency Room? Where would you start? What would you look for?
What critical Near Cause Categories could occur during this process in the timeline from Acute care clinic > ambulance > ER front desk ER > ICU (just to mention a few)…
Misunderstood Verbal Communication?
Turnover Needs Improvement?
No Communication or Not Timely?
Within each of these TapRooT® Near Cause Categories are Root Causes. So what would a Good Near Cause Category and Root Cause Best Practice look like…. the opposite of our definitions. By looking for these best practices during an Audit, you will find problems in you current unchanged process before it is too late.
So while performing an audit what is better and why… a surprise no notice audit or and a scheduled audit with plenty of notice…… I would love to see guests to the weblog and our TapRooT® students answer the above question.
After all The only major difference between an audit finding and investigation finding is timing and the severity of the outcome! Why wait! Join us and other leaders in the industry in an upcoming TapRooT® training course to learn more about effective proactive auditing. (more…)
Just yesterday, I blogged about the continuing saga of the Georgia Peanut plant - yesterday the issue was whether management could potentially be prosecuted. Today, the company filed for Bankruptcy…..how long will it be before they go under for good? http://news.yahoo.com/s/ap/20090213/ap_on_bi_ge/salmonella_outbreak_bankruptcy
The cost of poor quality can vary, but it can even put a company out of business. TapRooT® can help you avoid these problems. Right now, the press and fear mongers are trying to convince everyone that there is no money for anything. I say this is the perfect time to raise the bar and differentiate your business from the shortsighted competition. Simply put, investing in quality is investing in the customer - if you think you cannot afford to, I say you cannot afford not to. Just my opinion.
See you at a TapRooT® course in the near future - together, let’s improve the business community, one firm at a time.
Brainstorming is often successfully used to develop new ideas, increase employee moral and unfortunately… even to attempt to find Root Causes for problems. Lets start with the basics. Who should be sitting at the brainstorming table? When should brainstorming be used and more importantly when should it NOT be used? If you solve problems what can you use that has been successful?
So let’s start with roll call… say present if here:
Human Engineering Expert?
Procedure Expert?
Quality Control Expert?
Communication Expert?
Management Systems Expert?
Work Direction Expert?
Training Expert?
What… someone is missing? Who? Why would this matter you may ask? Let’s take a missing Training Expert. When is the last time a new training idea was suggested, developed and THEN handed off to the Training department to run with? Have you seen new training ideas getting stopped in their tracks because no one understood the process… after your brainstorming team invested all that time? After all, time is money. Why do we at System Improvements, Inc. think these are the right experts? Just take a look at our TapRooT® success stories and their companies’ return on investment and reduction of incidents.
One caution from experience, once you get the experts in the room you must also have a facilitator present to help the team keep the same perspective and reference. Try this if you don’t think so: ask everyone in a team to close their eyes and point North… which way do we go? TapRooT® has a way to solve arguments and to keep people on track, use our Root Cause Dictionary & Laminated Root Cause Tree. These tools will standardize your points of reference in your problem solving session.
When should brainstorming be used… Now that seems like it might be a tough question to answer, but it’s not. Use it when you first need to develop possible venture ideas, develop new ways to work a process or to communicate what others may have successfully done. Sometimes brainstorming can be used to develop corrective actions on GOOD problem Root Causes. System Improvements, Inc. has also developed a Corrective Action Helper® to use with our SMARTER technique. This guide includes best practice examples from multiple industries and includes references to allow you to dig even deeper.
When should brainstorming NOT be used… DO NOT use it to solve problems or to find Root Causes for problems. Why not you may ask? Brainstorming requires you to ASSUME that you know why a problem existed. Think about it, how many brainstorming sessions have you been in where you were called in as group for a company crisis… did it go a little like this:
“We are here today to solve the XYZ crisis. Write down your ideas on yellow stickies as to what the problem could be. We will affinitize these ideas and vote as a group on what the problem is and put a team on it to fix it.”
Whoa… how can you solve a problem when you don’t have the facts nor do you know the sequence of events of the problem you are attempting to solve? It CAN NOT be done from behind a table and you must GO OUT AND LOOK (GOAL)? If you are using brainstorming and other similar tools to solve your major issues and the problems continue to repeat or even get worse, then it is time to CHANGE. Look at our TapRooT® success stories and then talk to us at System Improvements, Inc. to see when the next Public class starts.
The report in the New England Journal of Medicine says that if all hospitals adopted the checklist, they could save tens of thousands of lives and $20 billion ANNUALLY.
This same article appeared in the January 15 edition of USA TODAY. This article goes on to state that:
- Surgeons are good at making sure they do most of the things most of the time, but not very good at doing all of the things all of the time. - An operation’s success depends far more on teamwork and communications skills than on an individual surgeon’s skill. - The checklist takes about 2 minutes to complete. - It is modeled on checklists used on the aviation industry. - The checklist has nothing to do with high tech solutions, instead focusing on basic safety measures.
It is almost frustrating to read an article like this. TapRooT® has been teaching these exact principles for 20 years, and now the World Health Organization funds a study that repeats exactly what our TapRooT® investigators would find if they had conducted their own investigation. In fact, after reading the article, I’d swear the author had just attended a TapRooT® course. You can scan through this article and attach the TapRooT® root causes directly to his individual statements.
Luckily, I’m more of an optimist. This study proves that we can make a difference and save lives right now. Even the most basic TapRooT® investigations have the opportunity to fnd and correct these types of relatively simple mistakes. All we have to do is DO IT!
As someone who worked for airlines for 27 years (the last 10 in safety and compliance) before joining System Improvements, I can attest to the professionalism of all the employees, from mechanics to pilots to operational folks and beyond. Safety is ingrained in the culture of this industry; after all, the smallest problem can be devastating. Congratulations to all the airline employees, suppliers, manufacturers, and air traffic controllers for getting it right over and over, day after day.
On the other side of the coin, medical mistakes have been blamed for thousands of deaths per year in the US. The same best practices for human performance used by the airlines and countless other industries can be used to reduce this alarming problem.
The Joint Commission http://www.jointcommission.org/AboutUs/ is working to address these issues, but the data clearly shows there is a long way to go. In the meantime, at least you can feel good about getting on an airplane, as long as you don’t eat the food!
Healthcare Professionals - take a stand and fight against these preventable errors! Attend a TapRooT® course in 2009 - here is the schedule:
“Workplace deaths in North Carolina rose in 2008 after three years of declines, and officials worry that the nation’s sagging economy is partly to blame.”
“Labor observers worry that companies could be cutting corners on safety, making their workplaces more dangerous. Labor Department spokeswoman Dolores Quesenberry said training and safety measures are often among the first things cut from budgets.”
I don’t know if the rise in deaths in this state is tied to the economy or not; however, I have seen and heard about safety measures being cut during trying times. As safety professionals, it is our job to stand up for the employees and to rise up against the bean-counters (unless they cut us first of course!)
Don’t get caught in this trap! Today’s economy requires that a business runs smoothly; cutting back on things like safety, environment, and quality is not the answer. Take a stand - attend a TapRooT® course in 2009, be proactive, solve problems, and SAVE the company money. Show management how your efforts contribute to the bottom-line. Here is the schedule: http://www.taproot.com/courses.php
So that’s it - 2008 is in the history books and we are ready to start a new chapter. Of course the first thing people always think about is resolutions, and this usually involves some type of bad habit! For me, it is a diet (how original)!
Besides those personal resolutions, what about our business lives? Should we make a resolution for work as well? I say yes, and here is a good example:
“My resolution for 2009 is to improve organizational performance (reduce fatalities, injuries, medical mistakes, production problems, equipment downtime, environmental spills, customer complaints, cost overruns, property damage, etc. etc.)”
That’s a great resolution, but how does one get there? Why not start with a TapRooT® course in early 2009?
When equipment fails, the equipment itself becomes a convenient target to affix blame; however, a good investigation will many times find that human performance problems led to the failure. TapRooT® (and the Equifactor® module) will help you pinpoint these problems; why not enroll you and your staff in a course for 2009? See the schedule for a three day course (or a 1 day Equifactor® if you have already had the two day or five day TapRooT® course) athttp://www.taproot.com/courses.php?d=3
“The investigation found that the lease operator had not performed the required annual cathodic protection (CP) inspection nor submitted the results of the inspection to the MMS and had allowed the CP of the pipeline to fall below standards of both MMS and National Association of Corrosion Engineers (NACE). The failure to maintain adequate CP led directly to the pipeline corrosion, which caused the pipeline holes, and resulted in the pollution event.”
Not a good PR situation for someone hosting the Olympics. Nevertheless, I’m glad there were no serious injuries.
AOL News Last Updated: Wednesday, 17 December 2008, 06:50 GMT
More than 50 people were rescued from about 30 gondolas after a tower supporting the lift cables partially collapsed at Canada’s Whistler ski resort.
Police said there were no serious injuries at the resort in British Columbia, which is to host the alpine events of the 2010 winter Olympic games.
A resort statement said structural failure appeared to have caused the collapse.
Skier Graeme Bell said he was in a car that hit the ground, breaking the windows and allowing occupants to scramble out. Mr Bell said one man had a bloody head.
Another gondola hit a bus shelter, while two more were left dangling.
A crane was brought in to support the leaning tower and fire crews worked quickly to evacuate three cars that were the most in danger.
It took more than three hours to evacuate the 53 people stranded in about 30 gondolas.
Thirteen people were sent to the Whistler Health Care Centre, but all were released by late last night, health officials said.
The resort said in a press release that the gondola section where the incident took place is approximately 30ft above the ground.
“We are very thankful that no one was seriously injured in this incident,” the release said.
“The failures can be attributed to inadequate piping support, poor welding, material selection and insufficient quality assurance. They ended up putting in additional pipe support, going in and taking out in some cases whole sections of pipes and joints. I can’t tell you the blow-by-blow, what they did or repairs. I can tell you that’s in general what they did.”
She also said the the Navy team that made the repairs was “… just returning from Bahrain so we don’t have the root-cause analysis complete yet.”
I’ll translate this from Navy terminology … They haven’t decided who to blame yet.
