Author Archives: Mark Paradies

Carl Dixon at the 2018 Global TapRooT® Summit Reception

Posted: February 1st, 2018 in Accidents, Current Events, Summit, TapRooT, Video

You’ve heard rock star Carl Dixon talk at previous Summits about his comeback from a near-fatal car crash. Don’t miss him playing at the 2018 Global TapRooT® Summit!

Where Do You Get Ideas To Improve Root Cause Analysis?

Posted: January 31st, 2018 in Courses, Performance Improvement, Pictures, Root Cause Analysis Tips, Summit, TapRooT, Training, Video

When I was assigned the job of figuring out how to improve investigations and root cause analysis … I knew that we were NOT finding the causes of human errors. But where would I get ideas to help make things better? The year was 1985 and there wasn’t an easy place to start …

  • no internet
  • no e-mails with upcoming courses
  • no conferences on the topic (maybe one talk at a nuclear industry conference’s breakout session)

I knew that the Institute for Nuclear Power Operations was working on a system because they had tried to hire me to help create it.

So what did I do?

  • Started looking at the human factors research.
  • Networked with the folks I knew at our corporate headquarters, INPO, the University of Illinois, INEL, EPRI, and several utilities where I knew people.
  • Started trying to create a list of causes that encompassed the human factors research that I was familiar with.

This lead to a beginning system to find root causes that, eventually, led to the development of TapRooT® Root Cause Analysis System.

It was a long road with many lessons learned.

In 1988, we started System Improvements to help people improve their root cause analysis systems. In 1990, we won a contract to help the US Nuclear Regulator Commission improve their analysis of human errors. In 1991 we started working with our first oil and chemical company (Chevron) to improve their root cause analysis as part of their efforts to improve process safety. From there our growth into all types of industries with incidents – incidents that need fixes to prevent recurrence based on the real root causes – has been … pretty dramatic.

In 1994 we held the first TapRooT® Summit (not named the Summit until sometime later). It had great speakers and 35 attendees. I cooked steaks for everyone as our closing session.

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 1996 Summit Keynote Speaker with Mark Paradies (left)

Why did we decide to have a summit to focus on root cause analysis and performance improvement? Because I thought that our clients needed it. They needed:

  • a place to learn the latest ways to improve human performance.
  • to network and share best practices they were testing and perfecting.
  • to hear about what we were doing to improve the TapRooT® System.
  • motivation to keep them at the “performance improvement grindstone.”

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Linda Under and Mark Paradies with 1997 Astronaut Keynote Speaker

Little did I know that this first conference would turn into an annual event that had hundreds of attendees who are some of the smartest people improving industrial safety, quality, patient safety, process safety, asset optimization, and operational excellence from around the world.

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Linda Unger with Summit attendee from South Korea in 1998

I would never have guessed that I would draw people from Australia, Indonesia, Malaysia, UK, Saudi Arabia, Tanzania, New Zealand, Colombia, Brazil, Canada, Mexico, South Africa, Russia, Denmark, France, and many other countries (even the USA!) to hear what we thought others needed to learn to make their performance great.

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People sharing best practices at the 2016 Global TapRooT® Summit

But it happened. And now, if someone asks:

“Where Do You Get Ideas To Improve Root Cause Analysis?”

The answer is … The Global TapRooT® Summit.

The next Summit is rapidly approaching. Where is it? It is being held in Knoxville, Tennessee, (our hometown) on February 26 – March 2.

Want to find out more about the 10 pre-Summit courses being held on February 26-27? CLICK HERE.

Want to find out more about the blockbuster talks being delivered by the Keynote Speakers? CLICK HERE.

Want to see a list of the Best Practice Presenters? CLICK HERE.

Want to see the schedules for all nine Summit Tracks? CLICK HERE.

But don’t spend too much time clicking. You need to REGISTER ASAP and get your hotel and travel plans finalized because you need to attend this Summit.

Watch this video to see what past Summit attendees have to say…

4 Signs You Need to Improve Your Investigations

Posted: January 29th, 2018 in Investigations, Performance Improvement, Summit, TapRooT

If you want to improve your root cause analysis beyond simple techniques that yield incomplete results that don’t stop problems, you are probably ready for step one … implementing the TapRooT® Root Cause Analysis System.

But many find that after they implement the TapRooT® System, they still have room to improve their investigations. Here are four signs that you’re ready for step two:

  1. Investigator Bad Habits – Before your investigators were trained to use TapRooT®, they probably had some other method they used to find “the root cause.” The bad habits they learned probably aren’t completely corrected in a single 2-Day or 5-Day TapRooT® Root Cause Analysis Course. They may have previously been trained that there was only one root cause. They might not know how to interview or collect information (facts). They may need practice drawing complete SnapCharT®s or identifying all the Causal Factors. Therefore, they may need more training or some coaching to complete the development of their skills.
  2. Insufficient Time & Resources – Even if you are a great investigator, you need time to collect evidence and complete your investigation. If you have too little time and if you don’t have adequate resources, the TapRooT® Training alone can’t make your investigations excellent.
  3. Inadequate Investigation Review – Investigators need feedback to improve their skills. Where do they get expert feedback? It could come from management if they are experts in root cause analysis. If management doesn’t understand root cause analysis, the feedback they get may not improve future results. Therefore, you should probably implement a “peer review” before management review occurs. The “peer review” will be done by one or more root cause analysis experts to identify areas for improvement BEFORE the investigation is presented to management. The best peer reviews are conducted while the investigation is being performed. Think of this as just-in-time coaching.
  4. Insufficient Practice – Even with great training to start with, people become “rusty” if they don’t practice their skills. Of course, you don’t want to have more serious incidents to get more experience for your investigators. What can you do? Three things … a) Use the TapRooT® System to investigate less serious but potentially serious incident. The new book, Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents, can show you how to do this without wasting time and effort. b) Use the TapRooT® System to prepare for, perform, and analyze the results of audits. Learn how to do this in the upcoming pre-Summit course, TapRooT® for Audits. Or get the book, TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement. c) Have a refresher course for your investigators (contact us for info by CLICKING HERE) or have them attend a pre-Summit Course and the Global TapRooT® Summit to refresh their skills.

Are you ready for step two? Would you like to learn more about improving your implementation of TapRooT® and changing the culture of your companies investigations and root cause analysis? Then get registered for the 2018 Global TapRooT® Summit.

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FIRST, Mark Paradies, President of System Improvements and TapRooT® author will be giving a keynote address titled: How Good is Your TapRooT® Implementation. Learn how to apply best practices from around the world to improve your use of TapRooT® Root Cause Analysis.

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SECOND, Jack Frost, Vice President HSE of Matrix Service Company, will be giving a Best Practice Track talk titled: Improving Safety Culture Through Measuring and Grading Investigations. In this session he will discuss using an evaluation matrix to grade your investigations and coach your investigators to better root cause analysis.

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You can download the matrix that Jack uses here: http://www.taproot.com/content/wp-content/uploads/2015/04/RateRootCauseAnalysis11414.xlsx.

Don’t be satisfied. Continually improve your root cause analysis!

Monday Accident & Lessons Learned: How Long Should a Root Cause Analysis Take?

Posted: January 29th, 2018 in Accidents, Current Events, Investigations, Pictures

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On January 25th, The Atlanta Journal-Constitution reported that Georgia Power had not identified the cause of the December 17th electrical fire that shut down power to large portions of Atlanta’s Hartsfield-Jackson Airport. The article reports that the service disruption caused massive passenger disruptions and will cost $230,000 to repair. Delta says that the disruption from the fire and an early December snow storm will cost the airlines $60 million dollars.

Obviously this incident is worth preventing and needs an effective root cause analysis. It has been over a month since the fire. The questions is … how long should a root cause analysis take? A month, three months, a year, three years?

Of course, the answer varies depending on the type of the incident but what do you think is reasonable?

Leave your comments by clicking on the Comment link below.

CSB to Investigate Fatal Well Explosion in Oklahoma

Posted: January 27th, 2018 in Accidents, Current Events, Investigations

I don’t know when the CSB became the drilling investigator but here is their press release announcing the investigation…

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CSB Will Investigate Fatal Well Explosion in Oklahoma

Washington D.C. January 25, 2018 – The U.S. Chemical Safety Board announced today that it will be moving forward with a full investigation into the fatal gas well explosion near Quinton, Oklahoma. The explosion fatally injured five workers.

Upon notification of the incident, the CSB deployed two investigators to gather additional facts  to assist the Board in making  a decision regarding the scope of the investigation. Investigators arrived on site Wednesday morning and met with the lease holder for the well and the drilling operator.  CSB investigators will continue to meet with well service providers and the well site consultant company that had employees on site at the time of the incident. Evidence preservation and collection is the initial focus of the investigation.

The CSB is an independent, non-regulatory federal agency whose mission is to drive chemical safety change through independent investigations to protect people and the environment. The agency’s board members are appointed by the President and confirmed by the Senate.

CSB investigations examine all aspects of chemical incidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems. For more information, contact public@csb.gov.

Have FUN at the 2018 Global TapRooT® Summit!

Posted: January 25th, 2018 in Current Events, Pictures, Summit, TapRooT, Video

We don’t want the 2018 Global TapRooT® Summit to be boring. We want you to meet smart industry leaders, learn amazing best practices, and have fun!

Learning while having fun is much more effective that trying to stay awake during boring presentations. That’s why we organize the Global TapRooT® Summit to have activities, Keynote Speakers, and sessions that are active and entertaining.

Plus we start with the Name Game and have an excellent Reception on Wednesday.

This year we will again have rock star Carl Dixon as our entertainment at the reception where you can network with the new friends and important contacts that you have established.

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Here’s Carl back in the day playing with April Wine …

And more classic rock from Carl and April Wine …

And just one more …

I think he is even better today. Don’t miss the 2018 Global TapRooT® Summit reception!

What Pre-Summit Course Should I Attend?

Posted: January 23rd, 2018 in Courses, Summit, TapRooT

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That’s a tough question…

Here is more course info: http://www.taproot.com/taproot-summit/pre-summit-courses

Attending the 2018 Global TapRooT® Summit and a Pre-Summit course is a great way to learn more AND get a discount of $200 off the course.

And if you bring a team to the Summit, you can get discounts up to $600 off per person!

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CLICK HERE to REGISTER!

Interesting Article in “Stars & Strips” About Navy Court-Martials for COs Involved in Collisions

Posted: January 22nd, 2018 in Accidents, Current Events, Human Performance, Performance Improvement, Pictures

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The article starts with:

The Navy’s decision to pursue charges of negligent homicide against the former commanders of the USS Fitzgerald and USS John McCain has little precedent, according to a Navy scholar who has extensively scrutinized cases of command failure.”

See the whole article at:

https://www.stripes.com/news/navy/few-navy-commanders-face-court-martial-for-operational-failures-1.507226

The article implies that blame and shame is the normal process for COs whose ships are involved in accidents.

Isn’t it time for the US Navy to learn real advanced root cause analysis that can teach them to find and fix the causes of problems at cause collisions at sea?

Safety Fines Double in One Year in UK

Posted: January 18th, 2018 in Accidents, Current Events, Performance Improvement, TapRooT, Video

In the UK, fines related to safety doubled from 2016 to 2017. Here is a video from Safety & Health Practitioner (SHP) that provides more details…

Perhaps now is the time to invest in improved root cause analysis as part of your safety improvement efforts?

CLICK HERE for more information about TapRooT® Root Cause Analysis or CLICK HERE for information about TapRooT® Training.

CLICK HERE to see a list of public TapRooT® Courses in Europe.

CLICK HERE to contact us for information about training at your site.

Ready for a road trip? Then wrap up your travel planning for the 2018 Global TapRooT® Summit in Knoxville, Tennessee!

Posted: January 18th, 2018 in Current Events, Pictures, Summit

 


When some people think of Knoxville, Tennessee they often think of the regional attractions such as the Smoky Mountains and the area’s large, picturesque lakes. However, this city has plenty to offer without ever leaving town. Knoxville’s Urban Wilderness is just three miles from the Knoxville Convention Center where the 2018 Global TapRooT® Summit will be held. It includes 50 miles of natural surface for hikers, mountain bikers and trail runners. The city also has a rich musical heritage, which includes stars like Dolly Parton, the Everly Brothers and Roy Acuff. Popular music venues today include the historic Tennessee Theatre, Bijou Theatre, the Square Room and a host of clubs that present live music every night of the week. Dining options are numerous . . . you’ll find a heavy focus on farm-to-table fare during your visit downtown. In addition to hiking, biking, music, history and arts, the city has an exciting craft beer scene and the opportunity to relax with some of the country’s finest beers and people.

Have you taken the steps to a memorable road trip? It’s simple!

Step 1: REGISTER for the 2018 Global TapRooT® Summit.

Step 2: Do your travel planning and get a hotel booked.

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And don’t miss the activities the week of the Summit.

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Miranda Lambert is performing at Thompson-Boling Arena on Thursday, March 1, 2018.

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Tape Face, the Comedian, is performing at the Bijou Theatre on Sunday, February 25, 2018.

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Jonny Lang with Tony Lucca Solo is performing at the Bijou Theatre on Tuesday, February 27, 2018.

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Beth Hart is performing at the Bijou Theatre on Thursday, March 1, 2018.

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The Wizard of Oz national tour will be starring at The Tennessee Theatre on Friday, Saturday and Sunday, March 1, 2 and 3, 2018.

Who’s Coming to the 2018 Global TapRooT® Summit in Knoxville, TN?

Posted: January 18th, 2018 in Uncategorized

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It’s still to early to make a final attendance list but I thought people might be interested in a list of the companies who have signed people up early to attend the 2018 Global TaoRooT® Summit.

American Water
APS
Asplund
BG&E
Champion Technologies
Encana
Energy Systems Group
ExxonMobil
First Energy
Flint Hills Resources
IAP Worldwide
INEL
Lotte Chemical
Marathon Petroleum
Matrix North American Construction
Monsanto
Nalco Chemicals
Nine Energy Services
North Star Generation
Nutrien
Oceaneering
Oxy
Parker Drilling
Patten Energy
PNM Resources
PPL
Prairie State Generating
SAExploration
Saudi Aramco
SBM Offshore
Suncor
TD Williamson
Terango Gold
TransAlta
TransCanada
United Tehnologies
Vancouver Airport Authority

That’s a sample (not a complete list). The list grows every day.

If you are waiting to sign up, STOP waiting. CLICK on this LINK and register NOW!

What do people who have attended the Global TapRooT® Summit in the past have to say about it? here are just a few people sharing their experience…

Is this a good idea? … Navy to have “Article 32” hearings for COs involved in collisions at sea.

Posted: January 17th, 2018 in Accidents, Current Events, Investigations, Performance Improvement, Pictures

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Didn’t I just read (see this LINK) a Navy investigation that implied there were Management System causes of the two collisions in the Pacific? Didn’t the report suggest that the Navy needed to change it’s culture?

An article in USNI News says that both Commander Alfredo J. Sanchez and Commander Bryce Benson will face Article 32 hearings (the prelude to a court martial) over their role in the ships’ collisions in the Pacific.

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Will punishment make the Navy better? Will it make it easier for ship’s commanding officers to admit mistakes? And what about the crew members who are facing disciplinary hearings? Will that make the culture of the Navy change from a reactive-punitive culture to a culture where mistakes are shared and learned from BEFORE major accidents happen?

What do you think…

Here is the press release from the Navy’s Consolidated Disposal Authority (Director of Naval Reactors Adm. James F. Caldwell):

On 30 October 2017, Admiral William Moran, Vice Chief of Naval Operations, designated Admiral Frank Caldwell as the Consolidated Disposition Authority to review the accountability actions taken to date in relation to USS Fitzgerald (DDG 62) and USS John S. McCain (DDG 56) collisions and to take additional administrative or disciplinary actions as appropriate.

After careful deliberation, today Admiral Frank Caldwell announced that Uniform Code of Military Justice (UCMJ) charges are being preferred against individual service members in relation to the collisions.

USS Fitzgerald: Courts-martial proceedings/Article 32 hearings are being convened to review evidence supporting possible criminal charges against Fitzgerald members. The members’ ranks include one Commander (the Commanding Officer), two Lieutenants, and one Lieutenant Junior Grade. The charges include dereliction of duty, hazarding a vessel, and negligent homicide.

USS John S. McCain: Additionally, for John S. McCain, one court- martial proceeding/Article 32 hearing is being convened to review evidence supporting possible criminal charges against one Commander (the Commanding Officer). The charges include dereliction of duty, hazarding a vessel, and negligent homicide. Also, one charge of dereliction of duty was preferred and is pending referral to a forum for a Chief Petty Officer.

The announcement of an Article 32 hearing and referral to a court-martial is not intended to and does not reflect a determination of guilt or innocence related to any offenses. All individuals alleged to have committed misconduct are entitled to a presumption of innocence.

Additional administrative actions are being conducted for members of both crews including non-judicial punishment for four Fitzgerald and four John S. McCain crewmembers.

Information regarding further actions, if warranted, will be discussed at the appropriate time.

Why do people try to make root cause analysis so difficult?

Posted: January 17th, 2018 in Performance Improvement, Pictures, Root Cause Analysis Tips, TapRooT

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I read a comment string on LinkedIn about root cause analysis. People made the concepts and techniques so hard to understand.

First, there was an argument over what is a root cause. One person argued that there was no such thing because EVERY cause had another deeper cause. Someone else argued that there wasn’t a root cause because most incidents had multiple causes. Someone else introduced the idea of root causes, contributing causes, causal factors, and initiating events. Someone else brought up the concept of latent causes and Swiss cheese.

If that wasn’t enough disagreement, another side argument started over what was an incident, and accident, a near-miss, and a significant incident. This lead to a discussion of what needed investigation and how good an investigation was good enough.

At SI, we too had discussions about these topics 30 years ago. However, in the TapRooT® System, these arguments are settled and the terminology is either settled or irrelevant.

Perhaps it is my engineering and Nuclear Navy training that lead me away from philosophical discussions and turned me toward practical solutions to problems.

Perhaps it was my human factors training that made it easy to see why people made mistakes and what we could do to prevent them.

Perhaps it is my ability to take complex subjects and make them understandable that lead to the development of a systematic, practical, repeatable system to find the root causes of problems – the TapRooT® System.

So, if you are tired of debate and just want a system that has been proven around the world to find and fix the root causes of safety, quality, equipment, and production issues, learn about TapRooT® and save lot’s of time by avoiding needless arguments.

CLICK HERE to find out more about our 2-Day and 5-Day TapRooT® Training.

CLICK HERE to see where our upcoming public TapRooT® Training is being held.

Or CLICK HERE to contact us about having a course at your site.

Why are the SMARTEST people going to the 2018 Global TapRooT® Summit?

Posted: January 17th, 2018 in Performance Improvement, Pictures, Summit, TapRooT, Video

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About three Summits ago, I had a Summit attendee come up to me and say:

Mark, it is amazing the quality of speakers and topics you put together for the Summit.
But even more amazing is the networking. The people at this Summit are some of
the smartest people working on real life performance improvement in industry!
I just wanted to tell you thanks for making this happen.

 How do we get such high quality attendees? That’s the kind of people who use TapRooT® Root Cause Analysis to stop accidents, improve quality, reduce risk, and improve equipment reliability.

If you haven’t registered for the 2018 Global TapRooT® Summit yet, GET HOT! Visit the Summit web site and get registered TODAY!

Don’t Miss the TapRooT® Family Reunion

Posted: January 17th, 2018 in Performance Improvement, Pictures, Summit, TapRooT

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The Global TapRooT® Summit was almost named the TapRooT® Family Reunion. Why? Because that’s the way it feels.

Friendly folks getting together to say hello and get reacquainted.

Unless you belong to a dysfunctional family, you know what I mean.

This family has a common goal. They to share best practices and learn how to achieve outstanding performance. TapRooT® Root Cause Analysis is a part of that effort. But there is so much more to learn and share at the reunion (Summit). And that’s why we sponsor the Summit and spend lavishly on speakers.

We want to provide the opportunity for our best clients to meet face to face, develop relationships, and get new ideas to make safety, quality, equipment reliability, patient and process safety, and productivity even better. And leave the Summit inspired to go back home and make performance great.

The learning that takes place is one of the reasons that we require Certified TapRooT® instructors to attend the Summit at least once every two years. We think that keeping up to date on the latest improvement ideas is that important.

So don’t miss the reunion (the Summit) and your chances to make your performance improvement efforts that much better. Register for the 2018 Global TapRooT® Summit (February 26 – March 2, Knoxville, TN) TODAY by CLICKING HERE.

Come be INSPIRED by Inky at the 2018 Global TapRooT® Summit

Posted: January 16th, 2018 in Summit, Video

Het more information HERE.

Register HERE.

Time for some advanced root cause analysis?

Posted: January 15th, 2018 in Accidents, Current Events, Human Performance, Pictures, TapRooT

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What do you think? Does someone in the Hawaii government need to attend TapRooT® Training?

Which Summit Track Should You Attend?

Posted: January 15th, 2018 in Current Events, Pictures, Summit, Video

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There is so much to new information to learn and so many best practices being shared that the hardest question you have to answer is:

“What Best Practice Track should I attend at the 2018 Global TapRooT® Summit?”

 That’s a tough question to answer. Maybe you should bring enough folks so that some attends each track?

If you have to pick just one, watch these videos and read the information at the links below to help you select the right track that will help you improve performance at your company.

Quality

http://www.taproot.com/archives/61257

Patient Safety

http://www.taproot.com/archives/61721

Human Performance

http://www.taproot.com/archives/60950

Investigator

http://www.taproot.com/archives/61241

Asset Optimization

http://www.taproot.com/archives/61327

Safety

http://www.taproot.com/archives/60790

Software

http://www.taproot.com/archives/61000

Some info about the new software …

 

TapRooT® Certified Instructor

http://www.taproot.com/archives/61023

General Discussion and Keynote Speakers

Now REGISTER! 

What Will You Learn in the Patient Safety Best Practice Track at the Summit?

Posted: January 12th, 2018 in Best Practice Presentations, Best Practice Presenters, Medical/Healthcare, Pictures, Summit

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Since 1994, System Improvements has included information about improving Patient Safety in the Summit. This year we have a whole best Practices Track dedicated to improving patient safety and a Keynote Speaker talking about a fatal sentinel event.

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Let’s start by telling you about Dr,. Carol Gunn, one of our Keynote Speakers. She is a medical doctor who was trained to use the TapRooT® Root Cause Analysis System before she became a doctor. While she was a doctor, her sister died in a hospital from “complications.” It turns out that those complications were a result of a medical error. She will tell the story of her sisters death and what can be learned when root cause analysis is used properly and what happens when sentinel events are covered up.

Now let’s look at what’s covered in the Patient Safety Best Practices Track:

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Improving Patient Safety – Gaining a Win from a Loss (Michel Lindsay): Michele will share the evolution and success of their system for managing patient safety incidents and the expanded role of the Quality of Care Committee (QCC) on its journey to a high reliability organization at Southlake Regional Health Centre. A serious incident can have devastating outcomes to patients, their families, and to the caregivers involved. Even errors that result in no or mild harm to the patient can be devastating and career changing for staff and physicians. We have created structures and supports for immediate and long term organizational learning and improvements from incidents while maintaining a culture of care. Learn how the process QCC role has assisted in removing the shame and blame from an incident and turned it into a powerful lever for caring, sharing and repairing. Michele will describe the investigation processes using illustrations and case studies to describe how patient safety, learning, performance and culture has been positively impacted by their approach. The presentation includes the input from the COO & SVP Operations, Director of Surgery, the Director of Risk, the Manager of Risk, the Manager of a Cardiac Clinical Program, a Physician and the Quality Specialist.

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Improving Sentinel Event Investigations (Ken Turnbull): Ken is one of the authors of the new book, Improving Patient safety with TapRooT® Root Cause Analysis (to be released somewhere around the time of the Summit) and will share some of the new ideas presented in the book.

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Using Wearables to Minimize Daily Human Errors (Kevin McManus): Look at how wearables are being used both now and in the future to help prevent errors and identify problems more effectively.

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Deep Dive Into the Procedures Basic Cause Category (Ralph Brickey): Procedures (checlists) are almost a new concept being used to improve patient safety. Learn from the TapRooT® procedures best practices including: Learn: the philosophy and practice of using procedures; different types of procedures and how they are addressed in the TapRooT® Root Cause Dictionary and the Root Cause Tree®; and two human performance tools to aid in proper procedure use

Influencing Change (Jonathon Kennedy): Change is what improving performance is all about. What is the best way to influence change? Hear what Jonathan Kennedy has to say.

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Top 7 Secrets of a Great Investigation Interview (Barb Carr): Take your interviewing skills to the next level and collect better quality and quantity of information from your investigative interviews by harnessing the power of the seven secrets.
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TapRooT® Users Share Best Practices (Linda Unger): Share best practices about root cause analysis, investigations, and performance improvement with industry leaders from around the world.

Performance Improvement Gap Analysis (Linda Unger): Evaluate where you are and where you want to go and how you will apply what you have learned at the Summit to improve performance at your facility. The goal of this session is to go back to work with a plan to improve patient safety.

That an impressive list of breakout sessions.

So are you really interested in improving patient safety? Then you should attend the 2018 Global TapRoot® Summit. Register HERE!

Why does your site need someone (or a team) at the 2018 Global TapRooT® Summit?

Posted: January 10th, 2018 in Current Events, Performance Improvement, Pictures, Summit, TapRooT, Video

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Since there are so many high-quality conferences and events put on each year, you really need to think about which ones you should go to. If you haven’t signed up for the 2018 Global TapRooT® Summit yet, here are four top reasons to attend.

REASONS TO ATTEND THE SUMMIT

1. SAVE MONEY

You can’t afford a major accident, a fatality, a serious quality defect, a sentinel event or an unexpected equipment failure.

The TapRooT® Summit is a unique gathering of people intent on improving performance. They share ideas across companies, disciplines, and continents. The sharing of new ideas and best practices will help you develop ideas to stop accidents, fatalities, quality issues, sentinel events, and equipment failures.

What you may not have thought of is how much money this could save your company. Do you know the costs of human errors that occurred at your site? What were your workman’s comp costs? How much does unexpected downtime and lost production cost your site? What were the costs of legal issues due to mistakes and the resulting lawsuits? You will be far ahead financially if you stop just ONE major issue.

2. GET A PROMOTION

What will happen to your career is you are seen as an essential problem solver that leads the sites improvement efforts?

But where will you get the skills and ideas to lead improvement at your site? That’s easy. Attend the 2018 Global TapRooT® Summit.

When we plan the Summit we take the lessons we learn from teaching root cause analysis around the world and build sessions that we know will help solve frequently occurring issues that we have observed at courses. You will be surprised how many people face issues similar to the ones that you face and how there are people who have figured out how to improve performance and stop those problems. Don’t reinvent the wheel. Attend the Summit and learn from the success of others.

3. GET FIRED UP!

Improving performance requires constant attention. Working hard to constantly improve performance can wear you down. Where do you get the motivation to continually challenge the status quo? Attend the TapRooT® Summit!

Most people we talk to before the Summit say that they are attending to learn new skills and get new ideas and best practices to help their site improve performance. And after the Summit they agree that they learned valuable information well worth the time and expense of attended. But they are surprised that they got an unexpected benefit that was even more valuable. They left the Summit FIRED UP to go back to work and make things happen.

Why is motivation so valuable? Because an unmotivated person is unlikely to have the stamina to see an improvement effort through to completion. They get started but they don’t get things done.

We understand motivation and making improvements happen and that’s why we know that motivation is important. That’s why we build in events to motivate you throughout the Summit. Attend the 2018 Global TapRooT® Summit and go back to work CHARGED UP to make improvement happen.

4. HAVE FUN

What? How can fun be an important reason to attend the TapRooT® Summit? We have learned that people learn more, retain more, and bring more and better ideas back to work from the Summit if they have fun learning and sharing.

After all, who says that work and learning have to be dull and boring? We have discovered how to make the Summit an activity that you will find valuable and ENJOYABLE every time you attend.

ONE MORE IDEA…

Have you ever noticed how an effective team accomplishes much more than a single motivated individual?

That’s why we recommend that a site truly interested in achieving excellence send an improvement team to the TapRooT® Summit.

A team can spread out across the various sessions (there are tracks with various topics to pick from). Someone might attend the Safety Track while someone else attends the Quality Track, while someone else attends the Human Factors Track, while someone else attends the Asset Optimization Track. See the schedules for the various tracks by CLICKING HERE.

GUARANTEE

We know that you will find the 2018 Global TapRooT® Summit a valuable experience. We know that you will have a great return on your investment of time and money. And we provide you with this guarantee:

Attend the Summit and go back to work and use what you’ve learned. If you don’t get at least 10 times the return on your investment, simply return the Summit materials and we’ll refund the entire Summit fee.

So don’t wait. REGISTER TODAY!

Want to see what people who attend the Summit have to say after they attend? Here’s a video I made a few years ago and it sure is a blast from the past that still applies today…

Sorry, we won’t be having golf at this Summit (the first week in March in Tennessee just doesn’t work) but we will have a great reception and a lot of sharing.

Why Should I get the New TapRooT® Books?

Posted: January 9th, 2018 in Courses, Performance Improvement, Root Cause Analysis Tips, TapRooT

When someone calls me for help with an investigation, I often ask them what color TapRooT® Book they have. Sometimes they want to know..

What difference does it make what color my book is?

The answer is that it let’s me know how long ago they took TapRooT® Training and what version of the TapRooT® System they are using.  It is always sad to see people struggling with an issue we solved by improving TapRoot® and they just don’t know about the improvement.

Over the almost three decades that we have been developing TapRooT®, we have made major improvements. If you are still using the system that came in three-ring binders, you are back in the 1996 version of the system.

You might think that NOBODY would be using that outdated a version of the system but someone sent me a review of TapRooT® that they read and … sure enough … the review was of the 1996 book. So to people still using the three-ring binders: Update your documentation to the newest version and you will be shocked.

If you have the green book, you are working from the 2000 revision. You are working from a system from the same millennia. Update to the new version and you will jump ahead 16 years.

If you have the thick black book, you are working from the 2008 version. You too will be pleasantly surprised by what we have learned in the last eight years and how we have improved the usefulness of the TapRooT® Books.

And what is the latest version? These books are also black but there are  smaller and there are eight of them (currently book five and eight are still in production).

What do these books look like and how are they an improvement over the older 2008 book?

BOOKS 3 & 4

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Above is the Investigation book set. It includes:

These are the books that cover using TapRooT® to find the root causes of everything from small/minor incidents to major accidents.

How are they an improvement over the older 2008 TapRooT® Book? Well … we took everything we have learned in the last eight years and used it to improve our documentation. And the first things we learned is … LESS IS MORE. That’s why we broke the books up into separate topics. You can just read what is applicable to what you are doing. But how specifically is the investigation set improved over the old book?

  • The set includes the latest Root Cause Tree® and Dictionary that make the system even better with improved definitions in the Dictionary and an new category (language) in the Communication Basic Cause Category.
  • The Essentials Book is a an easy read (only 100 pages long). It guides you through a new 5 step process that makes TapRooT® easy to use for simple investigations. This improves your simple investigations while saving time.
  • The Major Investigations Book explains the whole TapRooT® System and includes the traditional 7-Step Investigation Process. The book includes improved TapRooT® Techniques, detailed examples of each technique, and even better ideas to help you identify your Causal Factors before you start analyzing their root causes.
  • The set also references the latest TapRooT® Software (Version VI).

The ideas we have for improving low-to-medium risk investigations alone are worth buying the new set.

Book 3: Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents, is included in the 2-Day TapRooT® Root Cause Analysis Training. The 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training include Book 4: Using TapRooT® Root Cause Analysis for Major Investigations, and Book 3.

But that’s just two (Books 3 & 4) of the new books. What else is there and what new information is in the other six books? Read on…

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BOOK 1

Until Book 1: TapRooT® Root Cause Analysis Leadership Lessons was written, we really didn’t have a book that explained the concepts of TapRooT® Root Cause Analysis to management. Now we have produced a concept book that is just 70 pages long (think of it as a bedtime story for management). When management asks what they need to know about TapRooT®, Book 1 is the place to start.

Of course, we would like leaders to learn much more about a tool that should be in their leadership tool kit but Book 1 is a starting point to get management to understand the basis for TapRooT® and how it will help them improve safety, quality, productivity, and environmental compliance.

To learn more about this book, CLICK HERE, or order your copy at: http://www.taproot.com/store/TapRooT-R-Philosophy.html.

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BOOK 2

Book 2: TapRooT® Root Cause Analysis Implementation, is for those in charge of an improvement program. It explains how TapRooT® can be used to improve an already existing program or part of a completely new improvement effort.

Making this a separate book (89 pages long) helps the right people get the right information to make their improvement program much more effective.

What’s in the book?

  • The “Just Do It!” method of getting started.
  • How to add TapRooT® Root Cause analysis to an existing 6 Sigma, Lean, 8-D, Process Safety, Behavior-Based Safety, or other improvement initiative.
  • Building a best-in-class improvement initiative.
  • A checklist to evaluate your improvement efforts.

If you are serious about improvement and in charge of a program to make improvement happen … this book is for you. Order it HERE.

Book 5

This book is close enough to finished that I can explain what you will find in it when it comes out. If you are interested in equipment troubleshooting and root cause analysis, this is the book for you.

Book 5: Using Equifactor® Troubleshooting Tools and TapRooT® Root Cause Analysis to Improve Equipment Reliability, explains how to use TapRooT® and Equifactor® to solve equipment problems. The new book explains the techniques and includes a paper version of the equipment troubleshooting tables from the TapRooT® VI Software all in one book. That makes this a much handier reference.

We expect this book to be available in the 1st half of 2018. Watch our newsletter for more information.

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Book 6

Book 6: TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement, explains how to build TapRooT® root cause analysis into your audits and proactive improvement efforts. It’s only 57 pages long and is a great compliment to books 3 and 4.

It describes the 7-step process for using TapRoot® in an audit and how to build TapRooT® techniques into your proactive improvement efforts.

When you order the book HERE, you will also get the latest:

  • TapRooT® Root Cause Tree®
  • TapRooT® Root Cause Tree® Dictionary
  • TapRooT® Corrective Action Helper® Guide

What’ new about book 6? It is the latest information about using TapRooT® to audit performance. It can be used for safety or quality audits. It’s a very fast read.

This book is included in the course materials for the pre-Summit TapRooT® for Audits Course.

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Book 7

Book 7: TapRooT® Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills, is all about information collection. We’ve never had a book specifically about this topic. In the past you had to find some of the information provided here buried in the steps of the old 2008 TapRooT® Book.

But this book is more than just a rehash of the information about interviewing and evidence collection. In  addition to information about planning your evidence collection, emergency response and scene management, and the TapRooT® investigation process, it includes:

  • The 3 P’s and an R of evidence collection. (People, Paper, Physical, and Recordings)
  • The TapRooT® 12-Step Interview Process (Cognitive Interviewing)
  • Decoding non verbal behavior
  • Building your investigation kit
  • An initial observation form
  • An interview preparation form
  • An evidence log
  • How to use Change Analysis and CHAP as part of an interview/evidence collection process

That’s a lot to pack into a 93 page book! Buy this book by CLICKING HERE.

Book 8

This book is also still in production but is also expected in the first half of 2018. Book 8: TapRooT® Performance Measures and Trending for Safety, Quality, and Business Management, explains the state-of-the-art in performance measurement and trending.

If you have ever wondered how you can prove that you have improved or if a “negative” trend is actually significant, this is the book for you.

In addition, the book explains what management should know about trends. This information can keep them from being misled by false trends and how to use trends to manage improvement initiative.

The math involved isn’t complicated, but it is beyond some of the common “trending” graphs that you may be using now.

This book is included in the pre-Summit Advanced Trending Techniques Course. Watch our newsletter for more information on when the book will be available.

KEEP UP TO DATE! If you don’t have the latest TapRooT® Books that apply to your work, order them today!

4 Steps to Playing like a Champion in 2018

Posted: January 8th, 2018 in Career Development, Summit


Ever wonder what your life would feel like if you had the knowledge to live life at the top of your game? Champions know how to compete, but they are not born that way. Every champion has to first learn how to qualify for the game before they even get a chance to compete for the win.

So, how do you qualify to play?

First

Begin today by forming a mental picture of where you want to be. If you can form a strong mental picture and rehearse it, your brain will find a way to get you there. Write it down.  Read it daily.

Second

Expect setbacks and move past them. Let them be lessons learned that propel you forward not anchors that weigh you down. A champion is an ordinary individual who persists through obstacles. Are expectations causing you stress? Don’t put the high expectations of others in a negative light.  Expectations are really support… a belief that you can accomplish a goal.

Third

Stay focused on your mental picture of success and support yourself with positive affirmations. If you are not telling yourself that you are capable of success every single day, there is no way you are going to experience it. If you are waiting for someone else to believe in you, they are probably waiting for you to believe in yourself. Stay positive.

Fourth

Strive for improvement. You will experience wins practicing these steps but regardless of your achievements, operate under the goal of self-improvement. So, practice these steps to qualify to play, and then join us at the 2018 Global TapRooT® Summit to continue improving! Boaz Rauchwerger is our special keynote speaker on Wednesday, February 28 at 12:30 p.m., presenting “Play Like a Champion Every Day.” After his keynote, he will be presenting “Improve People Skills and Become More Productive” in a best practice session from 1:30 pm to 2:30 pm on the Alternative Sessions Track.

Boaz Rauchwerger is Speaker of the Year for Vistage International, the world’s largest organization of CEO’s. He is the founder and president of Boaz Power Corp., a Los Angeles-based high performance consulting firm. He is also an internationally-known professional business speaker for major corporations such as American Airlines, Xerox, and Toyota.

Previously, Boaz was a newspaper publisher, owned his own advertising agency and has produced corporate films as well as a network television show. He is the author of “How to Create Exceptional Outcomes – Become the CEO of a Very Successful Life.” Boaz holds a degree in journalism, public relations and advertising from the University of Tulsa.

Join us for his game-changing presentations and live your life like a champion in 2018!

Register today!

Learn more.

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Success Stories

If you are a TapRooT® User, you may think that the TapRooT® Root Cause Analysis System exists to help people find root causes. But there is more to it than that. TapRooT® exists to: Save lives Prevent injuries Improve product/service quality Improve equipment reliability Make work easier and more productive Stop sentinel events Stop the …

Better Initial Information Collection Submitted by: Bill Missal, Senior Aviation Safety Inspector Company: FAA, Alaska Challenge Field investigators that, unfortunately, may not be trained in the use of TapRooT® collect initial information and then send it to trained investigators to analyze the root causes of aviation accidents using TapRooT®. The untrained field investigators may not …

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