Category: Quality

My 20+ Year Relationship with 5-Why’s

December 11th, 2017 by

I first heard of 5-Why’s over 20 years ago when I got my first job in Quality. I had no experience of any kind, I got the job because I worked with the Quality Manager’s wife in another department and she told him I was a good guy. True story…but that’s how things worked back then!

When I was first exposed to the 5-Why concept, it did not really make any sense to me; I could not understand how it actually could work, as it seemed like the only thing it revealed was the obvious. So, if it is obvious, why do I need it? That is a pretty good question from someone who did not know much at the time.

I dived into Quality and got all the certifications, went to all the classes and conferences, and helped my company build an industry leading program from the ground up. A recurring concept in the study and materials I was exposed to was 5-Why. I learned the “correct” way to do it. Now I understood it, but I still never thought it was a good way to find root causes.

I transferred to another division of the company to run their safety program. I did not know how to run a safety program – I did know all the rules, as I had been auditing them for years, but I really did not know how to run the program. But I did know quality, and those concepts helped me instill an improvement mindset in the leaders which we successfully applied to safety.

The first thing I did when I took the job was to look at the safety policies and procedures, and there it was; when you have an incident, “ask Why 5 times” to get your root cause! That was the extent of the guidance. So whatever random thought was your fifth Why would be the root cause on the report! The people using it had absolutely no idea how the concept worked or how to do it. And my review of old reports validated this. Since then I have realized this is a common theme with 5-Why’s; there is a very wide variation in the way it is used. I don’t believe it works particularly well even when used correctly, but it usually isn’t in my experience.

Since retiring from my career and coming to work with TapRooT®, I’ve had literally hundreds of conversations with colleagues, clients, and potential clients about 5-Why’s. I used to be somewhat soft when criticizing 5-Why’s and just try to help people understand why TapRooT® gets better results. Recently, I’ve started to take a more militant approach. Why? Because most of the people I talk to already know that 5-Why’s does not work well, but they still use it anyway (easier/cheaper/quicker)!

So it is time to take the gloves off; let’s not dance around this any longer. To quote Mark Paradies:
“5-Why’s is Root Cause Malpractice!”

To those that are still dug in and take offense, I do apologize! I can only share my experience.

For more information, here are some previous blog articles:

What’s Wrong With Cause-and-Effect, 5-Why’s, & Fault Trees

Comparing TapRooT® to Other Root Cause Tools

What’s Fundamentally Wrong with 5-Whys?

Five Trends that Will Impact Companies in Environment, Health and Safety in 2018

November 17th, 2017 by

As we approach 2018, now is a good time to look at some external trends to gauge what is coming down the pike. At System Improvements we recently fired up the crystal balls, and spotted five trends that will impact companies:

  • Proactive Safety Culture,
  • Reporting Capability
  • Focus on Prevention
  • Work force changes
  • Increased Drug Use

Let’s look at each of these.

Proactive Safety Culture: Executives continue to get more involved, safety is seen as an improvement opportunity and something to be managed, rather than a liability driven by chance or “workers unsafe actions”. Preventive methods will be used more, like work site evaluations, audits, functional job analysis, and ergonomics training. Instead of having impossible goals like “Zero Harm”, companies will set improvement KPIs, then investigate, track and trend incidents and near misses and put corrective actions in place

Reporting Capability: User- friendly software like TapRooT® and Enablon is available for capturing data and carrying out analysis. Mobile apps and devices like wearable technology enables rapid collection and dissemination of findings. Training is readily available to make sense of the data collected and empower the front line

Focus on Prevention: Companies take active steps to prevent injuries and promote health and safety. We will see more fitness and wellness initiatives but also focus on “intangible” issues like stress, fatigue and mental health. Companies out of line will face ever- increasing Workers Comp costs

Work Force Changes: The age distribution and values of workers are changing, with millennials entering the workforce. The shortage of skilled workers will get worse, and there will be more contract and temp workers. It will be important to involve all these groups in the EHSQ efforts. There will also be more lone and unsupervised workers, which makes behavior- based safety much more difficult to implement

Increased Use of Illegal and Legalized Drugs:  Serious safety, quality and environmental risk. Executives will have to find ways to manage the opioids cycle where injuries drive prescriptions and workers under the influence of opioids get injured again… In some jurisdictions legalization of marijuana is disqualifying a large share of the worker pool from safely operating vehicles, machinery and equipment. In the Hotels & restaurant industry, research found up to 19% of workers using drugs on a regular basis, a clear risk in e.g. kitchen areas. Alcohol will continue to be an issue, not least in Mining and Construction where up to a fifth of workers are estimated to be affected.

A good way to prepare for these trends is to do effective Root Cause Analysis. The TapRooT® methodology helps companies identify root causes of incidents, and put effective corrective actions in place. The process is also used for proactive audits, where issues can be nipped in the bud. Click here for more information: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training.

KISS and Root Cause Analysis

November 1st, 2017 by

I’ve heard many “experts” claim that you need to apply the KISS principle when it comes to root cause analysis. You may hear this too and I want you to understand where these experts lead many people astray.

First, what is KISS? Keep It Simple Stupid! The acronym implies that simple solutions are better solutions. And when simple solution work (are effective) KISS is a dream come true. But remember Einstein’s quote:

Make things as simple as possible, but not simpler.

So let’s start with some of the reasons that these experts say you need to use simple techniques and debunk or demystify each one. Here’s a list of common expert advice.

  1. It’s a waste of time to use full root cause analysis on every problem.
  2. People can’t understand complex root cause analysis techniques.
  3. Learning simple techniques will get people to start thinking deeper about problems.
  4. Simple is just about as good as those fancy techniques.
  5. Managers don’t have time to do fancy root cause analysis and they already know what is wrong.
  6. You can apply those complicated techniques to just the most serious accidents.
  7. The data from the simple investigations will help you identify the more complex issues you need to solve.

I see these arguments all the time. They make me want to scream! Let me debunk each one and then you too can dismiss these “experts” the next time they try one or more of these arguments on your management team.

1. It’s a waste of time to use full root cause analysis on every problem.

I actually sort of agree with this statement. What I don’t agree with is the answer they arrive at. Their answer is that you should apply some “simple” root cause analysis technique (let’s just say 5-Whys as an example) to “solve” these problems that don’t deserve a well thought out answer.

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First, what do I have against their ideas of simple root cause analysis? If you’ve been reading this blog for a while you know what I’m going the explain, so just skip ahead. For those who don’t know what’s wrong with most “simple” root cause analysis techniques, I would suggest start reading from the top of the links below until you are convinced that most expert advice about “simple” root cause analysis is root cause analysis malpractice. If you haven’t been convinced by the end of the links … perhaps you are one of the experts I’m talking about. Here’s the list of links:

What happens when root cause analysis becomes too simple? Six problems I’ve observed. 

An Example of 5 Whys – Is this Root Cause Analysis? Let Me Know Your Thoughts…

What’s Wrong with 5-Whys??? – Complete Article 

What’s Fundamentally Wrong with 5-Whys?

Teruyuki Minoura (Toyota Exec) Talks About Problems with 5-Whys

I believe that one of the biggest root cause analysis problems that companies face is that they are performing “root cause analysis” on problems that don’t need to be analyzed.  YES – I said it. Not every problem deserves a root cause analysis.

What problems don’t need to be analyzed? Problems that aren’t going to teach you anything significant. I call these “paper cut problems.” You don’t need to investigate paper cuts.

But some people would say that you do need to investigate every loss time injury and medical treatment case. Maybe … maybe not.

You do need to investigate an incident if it could have caused an outcome that you are trying to prevent and there are worthy lessons learned. Some medical treatment cases fall into this category. They got a cut finger but they could have lost their whole arm.

Two similar examples are provided in the book: Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents. One is a sprained ankle and one is a sprained wrist. Both came from falling down. One was judged worthy of a full but simple root cause analysis using the essential features of the TapRooT® Root Cause Analysis System. One was judged not worthy of a full investigation after a simple SnapCharT® was developed. Interested in how this works? Read the book. It’s only 100 pages long and seeing how to judge if a root cause analysis is worthwhile is worth it. (And you will learn how to apply TapRooT® simply to low-to-medium risk incidents.)

Once you know how to do a real “simple” investigation with an effective technique, you won’t need to do bad root cause analysis with an ineffective technique.

2. People can’t understand complex root cause analysis techniques.

I don’t know every “complex” root cause analysis technique but I do know that this statement does NOT apply to TapRooT®. Why? Because we’ve tested it.

One “test” was at a refinery. The Operation Manager (a good guy) thought that TapRooT® was a good system but wasn’t sure that his operators would understand it. We decided to run a test. We decided to teach a basic class to all his union stewards. Then refinery management did a focus group with the shop stewards.

I was one of the instructors and from the course examples that they analyzed, I knew that they were really enjoying finding real root causes rather than placing blame.

They did the focus group (with us in another room). I could hear what was going on. The first question the facilitator asked was: “Did you understand the TapRooT® Root Cause Analysis Technique?” One of the shop stewards said …

“If I can run a Cat Cracker I can certainly understand this! After all, it’s not rocket science!”

And that’s one of the great parts about TapRooT®. We’ve added expert systems for analysis of equipment and human performance problems, but we’ve kept the system understandable and made it easy to use. Making it seem like it isn’t rocket science (even though there is a whole bunch of science embedded in it) is the secret sauce of TapRooT®.

3. Learning simple techniques will get people to start thinking deeper about problems.

Learning to count is required before you learn calculus BUT counting over and over again does not teach you calculus.

If you don’t understand the causes of human performance problems, you won’t find the causes of the problems by asking why. And I don’t care how many times you ask why … it still won’t work.

For years we did a basic poll at the start of our 5-Day TapRooT® Advanced Root Cause Analysis Courses. We asked:

“How many of you have had any formal training in human factors or the causes of human error?”

Only about 2% of the attendees had ANY training on the causes of human error. But almost everybody that attended our training said that they had previously been assigned to find the causes of human errors. I wonder how well that went? (I can tell you from the student feedback, they said that they really DID NOT address the real root causes in their previous investigations.)

So, NO. Learning simple techniques DOES NOT get people to “think deeper” about problems.

4. Simple is just about as good as those fancy techniques.

NO WAY.

First, I’ve never seen a good example of 5-Whys. I’ve seen hundreds of bad examples that 5-Why experts thought were good examples. One “good example” that I remember was published in Quality Progress, the magazine from the American Society for Quality (ASQ). I couldn’t stand it. I had to write a reply. When I sent the letter to the editor, they asked me to write a whole article … so I did. To see the example and my article that was published in Quality Progress, see page 32 of the link below:

Under Scrutiny: A Critical Look at Root Cause Analysis.

Simple is not “almost as good” as real root cause analysis (TapRooT®). If you would like another example, see Chapter 3: Comparing the Results of a 5-Why Investigation to a Basic TapRooT® Investigation in the book, Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents.

That’s it – Case Closed. Those “simple” techniques are NOT just about as good as TapRooT® Root Cause Analysis.

5. Managers don’t have time to do fancy root cause analysis and they already know what is wrong.

Once again, I’m reminding of a saying:

Why is there never enough time to do it right,
but there is always enough time to do it over? 

How many times have I seen managers misdiagnose problems because they didn’t find the root causes and then have bigger accidents because they didn’t fix the near-misses and small accidents?

The percentage of managers trained in the causes of human error is very similar to the statistics I previously provided (2%). This means that managers need an effective root cause analysis technique … just like investigators need an effective technique. That’s why the standard corrective actions they use don’t solve the problems and we have accidents that happen over and over again.

So if you don’t have time, don’t worry. You will make time to do it over and over again.

That reminds me of a quote from a plant manager I knew…

“If we investigated every incident, we’d do nothing but investigate incidents!”

6. You can apply those complicated techniques to just the most serious accidents.

I’ve seen companies saving their “best” root cause analysis for their big accidents. Here are the two problems I see with that.

FIRST, they have the big accidents BECAUSE they didn’t solve the precursor incidents. Why? because they didn’t do good root cause analysis on the precursor incidents. Thus, applying poor root cause analysis to the lessor incidents CAUSES the big accidents.

SECOND, their investigators don’t get practice using their “best” root cause analysis techniques because the “most serious” incidents are infrequent. Therefore, their investigators get rusty or they never really develop the skills they need by using the techniques on smaller incidents that could give them practice.

The key here is to learn to use TapRooT® Root Cause Analysis to investigate smaller problems. And that’s why we wrote a book about using TapRooT® for simple incidents: Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents.

Don’t wait for big accidents to find and fix the causes of your biggest risks. Find and fix them when they give you warnings (the precursor incidents).

7. The data from the simple investigations will help you identify the more complex issues you need to solve.

Why do people think that analyzing lots of bad data will yield good results? I think it is the misconception about mathematics. A good formula doesn’t provide knowledge from bad data.

If you don’t really know how to analyze data, you should attend our pre-Summit course:

Advanced Trending Techniques

As W. Edwards Deming said:

“Without data, you’re just another person with an opinion.”

And if you know much about Deming, you know that he was very interested in the accuracy of the data.

If you aren’t finding the real root causes, data about your BAD ANALYSIS only tells you what you were doing wrong. You now have data about what was NOT the causes of your problems. Go analyze that!

So data from BAD simple investigations DOES NOT help you solve your more complex issues. All it does is mislead your management.

THAT’S IT. All the bad advice debunked. Now, what do you need to do?

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1. Read the book:

TapRooT® Root Cause Analysis Leadership Lessons

You will learn the theory behind performance improvement and you will be well on your way to understanding what management needs to do to really improve safety, quality, equipment reliability, and operational/financial performance.

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2. Read the book:

TapRooT® Root Cause Analysis Implementation

You will know how to implement a real, effective root cause analysis system for low-to-medium risk incidents as well as major accidents.

3. If you haven’t done it already, attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Courses. See the list of our upcoming public 5-Day TapRooT® Courses held around the world at this link:

http://www.taproot.com/store/5-Day-Courses/

And don’t take any more bad advice from experts who don’t know what they are talking about!

PS: If you have questions or want to discuss what you read in the books, contact me (Mark Paradies) at 865-539-2139 or by e-mail by clicking HERE.

Root Cause Analysis for the FDA

September 13th, 2017 by

RootCauseAnalysis

What does the FDA want when you perform a root cause analysis?

The answer is quite simple. They want you to find the real, fixable root causes of the problem and then fix them so they don’t happen again.

Even better, they would like you to audit/access your own processes and find and fix problems before they cause incidents.

And even better yet, they would like to arrive to perform a FDA 483 inspection and find no issues. Nothing. You have found and fixed any problems before they arrive because that’s the way you run your facility.

How can you be that good? You apply root cause analysis PROACTIVELY.

You don’t want to have to explain and fix problems found in a FDA 483 inspection or, worse yet, get a warning letter. You want to have manufacturing excellence.

TapRooT® Root Cause Analysis can help you reactively find and fix the real root causes of problems or proactively improve performance to avoid having quality issues. Want to find out how? Attend one of our guaranteed root cause analysis courses. See:

http://www.taproot.com/courses

I’d suggest one of our public 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Courses to get started. Then have a course at your site to get everyone involved in improving performance.

Want more information before you sign up for a course? Contact us by CLICKING HERE.

German Regulators Pull Pharmaceutical Manufacturing License for Bad Root Cause Analysis

August 16th, 2017 by

How can bad root cause analysis get a pharmaceutical manufacturer in trouble? Read this article:

http://www.fiercepharma.com/manufacturing/german-regulators-yank-manufacturing-certificate-from-dr-reddy-s-india-plant

See the regulator’s report here:

http://eudragmdp.ema.europa.eu/inspections/gmpc/searchGMPNonCompliance.do;jsessionid=Nfjr4BxTjUIchrw5Cz8sxg2ks-g1ohm3P0FCWfkI-pRSLAnTUiyt!385493004?ctrl=searchGMPNCResultControlList&action=Drilldown&param=43089

The first step to using advanced root cause analysis is to get your people trained. But AFTER the training, management must ensure that the system is being used, the results are being documented, and the corrective actions are getting implemented.

What does management need to know about root cause analysis? They should know at least as much as the investigators and they need to know what their role is in the root cause analysis process. That’s why we wrote the new book:

Root Cause Analysis Leadership Book

TapRooT® Root Cause Analysis Leadership Lessons

Get your copy now and make sure that you are managing your high performance systems.

Where did you eat last weekend? (or, why do companies continue to not learn from their mistakes?)

July 24th, 2017 by

Happy Monday. I hope everyone had a good weekend and got recharged for the week ahead.

Every few weeks, I get a craving for Mexican food. Maybe a sit-down meal with a combo plate and a Margarita, maybe Tex-Mex or maybe traditional. It’s all good.

Sometimes, though, a simple California Style Burrito does the trick. This weekend was one of those weekends. Let’s see, what are my choices…? Moe’s, Willy’s, Qdoba, Chipotle?

Chipotle? What??!!!

Unfortunately, Chipotle is back in the news. More sick people. Rats falling from the ceiling. Not good.

It seems like we have been here before. I must admit I did not think they would survive last time, but they did. What about this time? In the current world of social media we shall see.

For those of us in safety or quality, the story is all too familiar. The same problem keeps happening. Over and Over…and Over

So why do companies continue to not learn from mistakes? A few possible reasons:

**They don’t care
**They are incompetent
**They don’t get to true root causes when investigating problems
**They write poor corrective actions
**They don’t have the systems in place for good performance or performance improvement

TapRooT® can help with the last three. Please join us at a future course; you can see the schedule and enroll HERE

So, what do you think? Why do companies not learn from their mistakes? Leave comments below.

By the way, my Burrito from Moe’s was great!

Six Sigma: Better Root Cause Analysis and Corrective Actions

June 22nd, 2017 by

I remember first learning about root cause analysis during Six Sigma training. The main methods we used were 5 Whys and Fishbone diagrams, but somehow we had a hard time arriving at good corrective actions. It took time and testing to get there, and still the fixes were not always robust.

Since then, I have learned a lot more about RCA. Unguided deductive reasoning tools like 5 Whys or Fishbones rely heavily on the knowledge and experience of the investigator. Since nobody can be an expert in every contributing field, this leads to investigator bias. Or, as the old adage goes: “If a hammer is your only tool, all your problems will start looking like nails”.

Other issues with deductive reasoning are investigations identifying only single causes (when in reality there are several), or ignorance of generic root causes that have broader quality impacts. Results will also be inconsistent; if several teams analyze the same issue, results can be wildly divergent. Which one is correct? All of them? None?

This is where the TapRooT® methodology has benefits over other tools. It is an expert system that guides investigators to look at a range of potential causal factors, like human engineering, management systems and procedures. There are no iterations of hypotheses to prove or disprove so investigator bias is not a problem.

The process is repeatable, identifies all specific and generic causes and guides the formulation of strong corrective actions. It is centered on humans, systems and processes, and the decisions they make every day.

The supporting TapRooT® Software is designed to enable investigators to keep efforts focused and organized:

  1. define the problem in a SnapCharT®
  2. identify Causal Factors and Root Causes with the Root Cause Tree®, and
  3. formulate sustainable corrective actions using the Corrective Action Helper® module

The TapRooT® process avoids blame, is easy to learn and quickly improves root cause analysis outcomes.

In Six Sigma parlance, the SnapCharT® is used for problem definition (Define), the Root Cause Tree® and trending for root cause identification (Measure and Analyze), and the corrective action process to define effective fixes (Improve).

#TapRooT_RCA

To Hypothesize or NOT to Hypothesize … that is the Question!

May 16th, 2017 by

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Yet again, another article in Quality Progress magazine (May 2017 – Solid Footings) suggests that the basis for a root cause analysis is a hypothesis.

We have discussed the problems of starting a root cause analysis with a hypothesis before but it is probably worth discussing it one more time…

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Don’t start with the answer.

Starting with the answer (a hypothesis) is a bad practice. Why? Because of a human tendency called “confirmation bias.” You can read about confirmation bias in the scientific literature (do a Google search) but the simple answer is that people focus on evidence that proves their hypothesis and disregard evidence that conflicts with their hypothesis. This is a natural human tendency that is difficult to avoid if you start with a hypothesis.

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I’ve seen many root cause experts pontificate about investigators “keeping an open mind” and disprove their own hypothesis. That’s great. That’s like saying, “Don’t breath.” Once you propose an answer … you start to believe it and PROVE it.

What should you do?

Use a system that doesn’t start with a hypothesis.Try TapRooT® Root Cause Analysis.

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You will learn to use a SnapCharT® to collect information about what happened without jumping to conclusions.

Once you understand what happened and identify the Causal Factors, you will then be ready to analyze why the Safeguards failed (find the root causes) without jumping to conclusions by using advanced tools: the Root Cause Tree® Diagram and the Root Cause Tree® Dictionary.

This system gets you to think beyond your current knowledge!

The system has been proven to work at major companies and different industries around the world.

Want to learn more to improve quality and safety at your company? Attend one of our public root cause analysis courses. See the list of upcoming courses at:

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

Healthcare Professionals! Please come visit the TapRooT® Booth at the NPSF Conference

May 10th, 2017 by

If you are coming to the conference (May 17 – 19), please stop by and see us at Booth 300; Per Ohstrom and I will both be there.

Of course TapRooT® can help you with patient safety and reducing Sentinal Events. But there are many more ways to use TapRoot® in your hospital:

Improve Employee Safety and reduce injuries

Improve Quality, reduce human error, and make your processes more efficient

We hope to see you there. We have a free gift for the first 500 people, so don’t miss out!

Are you attending the ASQ World Conference on Quality in Charlotte?

April 19th, 2017 by

If you are attending the conference, please stop by the TapRooT® Booth (#213) and say hello. Chris Vallee, Per Ohstrom, and I will be there.

The first 500 visitors will receive a special gift, the world’s fastest root cause analysis tool!

Bring a business card and enter the drawing for cool TapRooT® stuff during the Tuesday exhibit hall extravaganza.

Want to see the new TapRooT® VI 6.2.0 software? Come by on Tuesday from 09:00-1:30 and we’ll be happy to walk through a quality example for you.

See you then!

Why do Audits fail and why do I have so many repeat findings? Take a detour!!!

March 27th, 2017 by

Have you ever performed an audit and got frustrated when you found the same issues as the last audit? I feel your pain….we all have. Why does this happen so much? Because most companies audit programs look a little like this:

Screen Shot 2017-03-27 at 4.00.54 PM

Q: What is missing from this picture?

A: Root Cause Analysis, of course!!

Many companies actually have good programs for FINDING problems without having a good program for FIXING problems. If you want problems fixed, root cause analysis has to be part of it. So on the road to improvement, take a DETOUR to Root Cause Land!

Screen Shot 2017-03-27 at 4.13.20 PM

For your program to be effective, it should look more like this:

Screen Shot 2017-03-27 at 4.04.23 PM

The best way to do root cause analysis on audits? TapRooT®.

We have a new course, TapRooT® for Audits, that we will be holding in Charlotte, NC on May 4-5. Why not join us? For more information and to register, click HERE

What’s Wrong with this Data?

March 20th, 2017 by

Below are sentinel event types from 2014 – 2016 as reported to the Joint Commission (taken from the 1/13/2017 report at https://www.jointcommission.org/assets/1/18/Summary_4Q_2016.pdf):

Summary Event Data

 Reviewing this data, one might ask … 

What can we learn?

I’m not trying to be critical of the Joint Commissions efforts to collect and report sentinel event data. In fact, it is refreshing to see that some hospitals are willing to admit that there is room for improvement. Plus, the Joint Commission is pushing for greater reporting and improved root cause analysis. But, here are some questions to consider…

  • Does a tic up or down in a particular category mean something? 
  • Why are suicides so high and infections so low? 
  • Why is there no category for misdiagnosis while being treated?

Perhaps the biggest question one might ask is why are their only 824 sentinel events in the database when estimates put the number of sentinel events in the USA at over 100,000 per year.

Of course, not all hospitals are part of the Joint Commission review process but a large fraction are.  

If we are conservative and estimate that there should be 50,000 sentinel events reported to the Joint Commission each year, we can conclude that only 1.6% of the sentinel events are being reported.

That makes me ask some serious questions.

1. Are the other events being hidden? Ignored? Or investigated and not reported?

Perhaps one of the reasons that the healthcare industry is not improving performance at a faster rate is that they are only learning from a tiny fraction of their operating experience. After all, if you only learned from 1.6% of your experience, how long would it take to improve your performance?

2. If a category like “Unitended Retention of a Foreign Body” stays at over 100 incidents per year, why aren’t we learning to prevent these events? Are the root cause analyses inadequate? Are the corrective actions inadequate or not being implemented? Or is there a failure to share best practices to prevent these incidents across the healthcare industry (each facility must learn by one or more of their own errors). If we don’t have 98% of the data, how can we measure if we are getting better or worse? Since our 50,000 number is a gross approximation, is it possible to learn anything at all from this data?

To me, it seems like the FIRST challenge when improving performance is to develop a good measurement system. Each hospital should have HUNDREDS or at least DOZENS of sentinel events to learn from each year. Thus, the Joint Commission should have TENS or HUNDREDS of THOUSANDS of sentinel events in their database. 

If the investigation, root cause analysis, and corrective actions were effective and being shared, there should be great progress in eliminating whole classes of sentinel events and this should be apparent in the Joint Commission data. 

This improved performance would be extremely important to the patients that avoided harm and we should see an overall decrease in the cost of medical care as mistakes are reduced.

This isn’t happening.

What can you do to get things started?

1. Push for full reporting of sentinel events AND near-misses at your hospital.

2. Implement advanced root cause analysis to find the real root causes of sentinel events and to develop effective fixes that STOP repeat incidents.

3. Share what your hospital learns about preventing sentinel events across the industry so that others will have the opportunity to improve.

That’s a start. After twelve years of reporting, shouldn’t every hospital get started?

If you are at a healthcare facility that is

  • reporting ALL sentinel events,
  • investigating most of your near-misses, 
  • doing good root cause analysis, 
  • implementing effective corrective actions that 
  • stop repeat sentinel events, 

I’d like to hear from you. We are holding a Summit in 2018 and I would like to document your success story.

If you would like to be at a hospital with a success story, but you need to improve your reporting, root cause analysis and corrective actions, contact us for assistance. We would be glad to help.

Top 3 Reasons for Bad Root Cause Analysis and How You Can Overcome Them…

February 7th, 2017 by

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I’ve heard many high level managers complain that they see the same problems happen over and over again. They just can’t get people to find and fix the problems’ root causes. Why does this happen and what can management do to overcome these issues? Read on to find out.

 

1. BLAME

Blame is the number one reason for bad root cause analysis.

Why?

Because people who are worried about blame don’t fully cooperate with an investigation. They don’t admit their involvement. They hold back critical information. Often this leads to mystery accidents. No one knows who was involved, what happened, or why it happened.

As Bart Simpson says:

“I didn’t do it.”
“Nobody saw me do it.”
“You can’t prove anything.”

Blame is so common that people take it for granted.

Somebody makes a mistake and what do we do? Discipline them.

If they are a contractor, we fire them. No questions asked.

And if the mistake was made by senior management? Sorry … that’s not how blame works. Blame always flows downhill. At a certain senior level management becomes blessed. Only truly horrific accidents like the Deepwater Horizon or Bhopal get senior managers fired or jailed. Then again, maybe those accidents aren’t bad enough for discipline for senior management.

Think about the biggest economic collapse in recent history – the housing collapse of 2008. What senior banker went to jail?

But be an operator and make a simple mistake like pushing the wrong button or a mechanic who doesn’t lock out a breaker while working on equipment? You may be fired or have the feds come after you to put you in jail.

Talk to Kurt Mix. He was a BP engineer who deleted a few text messages from his personal cell phone AFTER he had turned it over to the feds. He was the only person off the Deepwater Horizon who faced criminal charges. Or ask the two BP company men who represented BP on the Deepwater Horizon and faced years of criminal prosecution. 

How do you stop blame and get people to cooperate with investigations? Here are two best practices.

A. Start Small …

If you are investigating near-misses that could have become major accidents and you don’t discipline people who spill the beans, people will learn to cooperate. This is especially true if you reward people for participating and develop effective fixes that make the work easier and their jobs less hazardous. 

Small accidents just don’t have the same cloud of blame hanging over them so if you start small, you have a better chance of getting people to cooperate even if a blame culture has already been established.

B. Use a SnapCharT® to facilitate your investigation and report to management.

We’ve learned that using a SnapCharT® to facilitate an investigation and to show the results to management reduces the tendency to look for blame. The SnapCharT® focuses on what happened and “who did it” becomes less important.

Often, the SnapCharT® shows that there were several things that could have prevented the accident and that no one person was strictly to blame. 

What is a SnapCharT®? Attend any TapRooT® Training and you will learn how to use them. See:

TapRooT® Training

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2. FIRST ASK WHAT NOT WHY

Ever see someone use 5-Whys to find root causes? They start with what they think is the problem and then ask “Why?” five times. Unfortunately this easy methods often leads investigators astray.

Why?

Because they should have started by asking what before they asked why.

Many investigators start asking why before they understand what happened. This causes them to jump to conclusions. They don’t gather critical evidence that may lead them to the real root causes of the problem. And they tend to focus on a single Causal Factor and miss several others that also contributed to the problem. 

How do you get people to ask what instead of why?

Once again, the SnapCharT® is the best tool to get investigators focused on what happened, find the incidents details, identify all the Causal Factors and the information about each Causal Factor that the investigator needs to identify each problem’s root causes.

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3. YOU MUST GO BEYOND YOUR CURRENT KNOWLEDGE

Many investigators start their investigation with a pretty good idea of the root causes they are looking for. They already know the answers. All they have to do is find the evidence that supports their hypothesis.

What happens when an investigator starts an investigation by jumping to conclusions?

They ignore evidence that is counter to their hypothesis. This problem is called a:

Confirmation Bias

It has been proven in many scientific studies.

But there is an even bigger problem for investigators who think they know the answer. They often don’t have the training in human factors and equipment reliability to recognize the real root causes of each of the Causal Factors. Therefore, they only look for the root causes they know about and don’t get beyond their current knowledge.

What can you do to help investigators look beyond their current knowledge and avoid confirmation bias?

Have them use the SnapCharT® and the TapRooT® Root Cause Tree® Diagram when finding root causes. You will be amazed at the root causes your investigators discover that they previously would have overlooked.

How can your investigators learn to use the Root Cause Tree® Diagram? Once again, send them to TapRooT® Training.

THAT’S IT…

The TapRooT® Root Cause Analysis System can help your investigators overcome the top 3 reasons for bad root cause analysis. And that’s not all. There are many other advantages for management and investigators (and employees) when people use TapRooT® to solve problems.

If you haven’t tried TapRooT® to solve problems, you don’t know what you are missing.

If your organization faces:

  • Quality Issues
  • Safety Incidents
  • Repeat Equipment Failures
  • Sentinel Events
  • Environmental Incidents
  • Cost Overruns
  • Missed Schedules
  • Plant Downtime

You need to be apply the best root cause analysis system: TapRooT®.

Learn more at: 

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

And find the dates and locations for our public TapRooT® Training at:

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

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How can TapRooT® help with your ISO programs (or other management system issues)?

January 25th, 2017 by

Happy Wednesday and welcome to this week’s root cause analysis tips.

Many companies are ISO certified and some of those that are not have some type of management system. There are too many different systems and standards out there to discuss individually, but one of the common themes is continuous improvement.

Whether you use a commonly known management system or developed your own, one of your goals should be to improve your system/business. When I think of a management system, I think of it as a framework for how you manage your business. Whether required or not, incorporating continuous improvement is a smart thing to do.

While ISO has hundreds of standards, some of the most commonly known are 9000 (Quality) and 14000 (Environmental); coming down the pike soon is 45001 (Safety). There are also numerous industry specific standards. Many of the ISO standards use a common framework that includes the PDCA (plan, do, check, act) cycle. This is where TapRooT® can help.

PDCA is a simple process that has been in use widely since the 1950’s. I do not know many processes that have endured that long. So why? Because it is easy and it works.

Picture1

As part of PDCA, you have to determine what to fix, how to fix it, and whether it works. Sounds a little like root cause analysis and corrective action, doesn’t it? So if you were going to use PDCA to help solve your problems, what would you use for root cause analysis? If I were you, I would use TapRooT®. Need help with corrective actions? Use the Corrective Action Helper®, SMARTER Matrix, and Safeguards hierarchy. You can incorporate TapRooT® tools into any improvement framework you use.

Also, don’t forget the importance of auditing. This should be part of your management system as well. We’ve taught auditing with TapRooT® for years, but we recently developed a new course specifically for Auditors, TapRooT® for Audits, and wrote a new book, TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement. The primary topic of the book is auditing, but we also have a short section on PDCA. We’ll be teaching this course in Charlotte, NC in May if you would like to join us. Or, if you are already TapRooT® trained, you can get the book on our store.

Audits Kit

Thanks for reading the blog, and best of luck with your improvement efforts.

Avoid Known Problem-Solving Weaknesses in Process Improvement with TapRooT® Quality Problem-Solving

May 27th, 2016 by

LEARN MORE!

Register for this Pre-Summit Course AND the Quality Track at the 2016 Global TapRooT® Summit and maximize your success!

Using TapRooT® for Audits

May 18th, 2016 by

pablo (96)

Happy Wednesday, and welcome to this week’s root cause analysis column.

This week I wanted to share an excerpt from our new book which will be coming out on August 1st, TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement. I hope this small part of the book will help you start to think about being more proactive.

“An Ounce of Prevention is Worth a Pound of Cure.”
Ben Franklin

Around the world, professionals and companies have sought to find a better way to perform investigations on problems and losses. Many of the smartest people and leading companies use TapRooT®.

The TapRooT® Root Cause Analysis System is a robust, flexible system for analyzing and fixing problems. The complete system can be used to analyze and fix simple or complex accidents, difficult quality problems, hospital sentinel events, and other issues that require a complete understanding of what happened and the development of effective corrective actions. However, wouldn’t it be better if you never had to do investigations in the first place?

Many companies do perform audits. Unfortunately, in some cases, this work does not yield improvements. Why? There are many reasons, but the primary reason is lack of good root cause analysis. A company can actually be very good at finding problems, but not be effective at FIXING problems.

Beyond auditing, proactive improvement can take many forms, and when effective, becomes an overall mindset and can put an organization on the path to excellence. If that is the case, why are more companies not proactive? Here are just a few reasons:

  • Time (perceived at least)
  • They don’t have a reason to (not enough pain)
  • They do not have the buy-in (management and employee support)
  • Procrastination (human nature!)
  • They don’t know how (this is where TapRooT® comes in!)

TapRooT®, when used with auditing and proactive improvement programs, can help lead to organizational excellence and reduce the number of investigations required.

Would you like to be one of the first people to get the new book? If so, attend our new course, TapRooT® for Audits, at the Global TapRooT® Summit, August 1-2, in San Antonio. To register for the course (and the summit on August 3-5, click HERE

Calling all Quality People!

May 9th, 2016 by

I had a couple of things I wanted to share with our clients who work in quality:

First, Chris Vallee and I will be at the ASQ World Conference on Quality and Improvement starting Sunday. We will be in Booth 507, so please come and see us!

Second, we will be launching our new course, TapRooT® for Audits, at our 2016 Global TapRooT® Summit. The course will be on August 1-2 in San Antonio. I hope you can join us, and don’t forget to stick around for the summit itself on August 3-5. To register, visit HERE

The course will include a copy of our new book, TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement.

By the way, the new course is not just for quality people, it is for anyone who wants to learn to use TapRooT® for audits. Safety, Quality, Food Safety, Operations, it does not matter. And you do not to be previously trained in TapRooT® to attend.

If you already know how to use TapRooT® for auditing, but work in Quality and want to learn more about process improvement, Chris will be teaching the TapRooT® Quality Process Improvement Facilitator Course at the summit as well.

New TapRooT® for Audits course to debut August 1-2, 2016

March 21st, 2016 by

We are pleased to announce the first TapRooT® course for auditors. We will debut this course as a pre-summit offering before the 2016 Global TapRooT® summit.

TapRooT® is the best method for performing investigations and doing root cause analysis. But wouldn’t it be better if you never had to do the investigations in the first place? Of course, and that is why auditing is so important.

Sadly, most companies take the time and resources to do audits but do not get the desired results. Why? Because corrective actions are developed without proper root cause analysis. That is where TapRooT® comes in.

TapRooT® can be used to perform root cause analysis on any problem, so why not find the problem and do root cause analysis before these problems manifest themselves into incidents? We decided to develop a course for auditors and audit participants to see how TapRooT® works, both reactively, and with audits. Regardless of your role in the audit process, you must understand the entire TapRooT® process to be effective, so this course is for anyone involved in auditing, from auditors themselves, to auditees, to management who is responsible for improvements. Here is the agenda:

DAY ONE

TapRooT® Process Introduction and Initial Audit
SnapCharT® and Exercise
Causal Factors, Significant Issues and Exercise
Root Cause Tree® and Exercise
Generic Causes
Corrective Actions and Exercise

DAY TWO

The Root Cause Tree® and Preparing for Audits with Root Cause Exercise
Audit Programs, Trend and Process Root Cause Analysis
TapRooT® Software Introduction
Frequently Asked Questions about TapRooT®
Final Audit Observation Exercise

Participants in the course will receive a copy of the new book, “TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement.”

We hope to see you in the course! To register:

REGISTER for this course and the 2016 Global TapRooT® Summit (August 1 – 5, 2016).

REGISTER for this 2-day course only (August 1 – 2, 2016).

Error Proofing: Learn Best Practices and Industry Secrets

March 11th, 2016 by

easier

What is the error proofing here?

 

“Easier than making a mistake” … now that is good Human Engineering!

While listening to a radio commercial recently, I heard the announcer say, “Easier than making a mistake!” As a TapRooT® Root Cause Instructor with a quality and human engineering (Human Factors) background, all that I could think about is mistake-proofing, Poka-yoke.

The concept was formalized, and the term adopted, by Shigeo Shingo as part of the Toyota Production System. It was originally described as baka-yoke, but as this means “fool-proofing” (or “idiot-proofing”) the name was changed to the milder poka-yoke. (From Wikipdia)

Now, I did not learn about Dr. Shigeo Shingo during my Human Factors study, even though a large part of training dealt 100% with design and usability from products, to controls and to user graphic user interfaces. On the flip side, Human Factors and Usability was rarely discussed during my Lean Six Sigma certification either, even though Poka-yoke was covered.

Why are two major interactive topics such as Human Factors and Poka-yoke kept in isolation, very dependent on where and what you study? Simple, shared best practices and industry secrets are not always the norm.

Where can you learn about both topics? In San Antonio, Texas during our TapRooT® Summit Week August 1-5.

In the pre-summit 2-Day TapRooT® Quality Process Improvement Facilitator Course, we cover the error of making weak preventative or corrective action items that are not based on the actual root causes found and not optimizing and understanding mistake-proofing that will impact your success in continuous process improvements.

For those that need a deeper understanding of why mistake-proofing should be considered, you should look into signing up for the 2-Day Understanding and Stopping Human Error Course.

Does A Good Quality Management System equate to Compliance?

March 8th, 2016 by

book_graphic_1511

If it is written down, it must be followed. This means it must be correct… right?

Lack of compliance discussion triggers that I see often are:

  • Defective products or services
  • Audit findings
  • Rework and scrap

So the next questions that I often ask when compliance is “apparent” are:

  • Do these defects happen when standard, policies and administrative controls are in place and followed?
  • What were the root causes for the audit findings?
  • What were the root causes for the rework and scrap?

In a purely compliance driven company, I often here these answers:

  • It was a complacency issue
  • The employees were transferred…. Sometimes right out the door
  • Employee was retrained and the other employees were reminded on why it is important to do the job as required.

So is compliance in itself a bad thing? No, but compliance to poor processes just means poor output always.

Should employees be able to question current standards, policies and administrative controls? Yes, at the proper time and in the right manner. Please note that in cases of emergencies and process work stop requests, that the time is mostly likely now.

What are some options to removing the blinders of pure compliance?

GOAL (Go Out And Look)

  • Evaluate your training and make sure it matches the workers’ and the task’s needs at hand. Many compliance issues start with forcing policies downward with out GOAL from the bottom up.
  • Don’t just check off the audit checklist fro compliance’s sake, GOAL
  • Immerse yourself with people that share your belief to Do the Right thing, not just the written thing.
  • Learn how to evaluate your own process without the pure Compliance Glasses on.

If you see yourself acting on the suggestions above, this would be a perfect Compliance Awareness Trigger to join us out our 2016 TapRooT® Summit week August 1-5 in San Antonio, Texas.

Go here to see the tracks and pre-summit sessions that combat the Compliance Barriers.

Stop Normalization of Deviation with Normalization of Excellence

March 3rd, 2016 by

There is no Normalization of Deviation. Deviation IS NORMAL!

If you don’t think that is true, read this previous article:

There is no such thing as “Normalization of Deviation”

In 1946, Admiral Rickover was one of a small group of naval officers that visited the Manhattan Project in Oak Ridge, Tennessee, to learn about nuclear power and to see if there were ways to apply it in the US Navy. He had the foresight to see that it could be applied as a propulsion for submarines – freeing subs from the risky proposition of having to surface to recharge their batteries.

Rickover

But even more amazing than his ability to see how nuclear power could be used, to form a team with exceptional technical skills, and to research and develop the complex technologies that made this possible … he saw that the normal ways that the Navy and industrial contractors did things (their management systems) were not robust enough to handle the risk of nuclear technology.

Rickover set out to develop the technology to power a ship with the atom and to develop the management systems that would assure excellence. In PhD research circles these new ways of managing are often called a “high performance organization.”

Rickover’s pursuit of excellence was not without cost. It made him the pariah in naval leadership. Despite his accomplishments, Rickover would have been forced out of the Navy if it had not been for strident support from key members of Congress.

Why was Rickover an outcast? Because he would not compromise over nuclear safety and his management philosophies were directly opposed to the standard techniques used throughout the Navy (and most industrial companies).

What is the proof that his high performance management systems work? Over 60 years of operating hundreds of naval nuclear reactors ashore and at sea without a single process safety accident (reactor meltdown). And his legacy continues even after he left as head of the Nuclear Navy. The culture he established is so strong that it has endured for 30 years!

Compare that record to the civilian nuclear power industry, refinery process safety incidents, or off shore drilling major accidents. You will see that Rickover developed a truly different high performance organization that many with PhD’s still don’t understand.

In his organization, deviation truly was abnormal.

What are the secrets that Rickover applied to achieve excellence? They aren’t secret. He testified to his methods in front of Congress and his testimony is available at this link:

http://www.taproot.com/content/wp-content/uploads/2010/09/RickoverCongressionalTestimony.pdf

What keeps other industries from adopting the Rickover’s management systems to achieve equally outstanding performance in their industries? The systems Rickover used to achieve excellence are outside the experience of most senior executives and applying the management systems REQUIRES focussed persistence from the highest levels of management.

To STOP the normalization of deviation, the CEO and Presidents of major corporations would have to insist and promote the Normalization of Excellence that is outlined in Rickover’s testimony to Congress.

Sometimes Rickover’s testimony to Congress may not be clear to someone who has not experience life in the Nuclear Navy. Therefore, I will explain (translate from Nuclear navy terminology) what Rickover meant and provide readers with examples from my Nuclear Navy career and from industry.

Read Part 3:  Normalization of Excellence – The Rickover Legacy – Technical Competency

What is the Difference Between a Safety Related Incident and a Quality Problem when using TapRooT®?

September 30th, 2015 by

Quality ControlWelcome to this week’s root cause analysis tips column.

This week I would like to ask the question…what is the difference between a safety incident and a quality problem?

Before you answer that, let me tell you that this is a trick question.

The answer is……drum roll please: there is NO DIFFERENCE. The difference in a safety problem vs. a quality problem is the consequence; there is no difference in the approach you take in investigating.

In TapRooT®, the first thing we always do is to create a SnapCharT®. And the first thing we do when creating a SnapCharT® is to define the incident with a circle. This defines the scope of your investigation. Your circle could contain anything that creates pain for your company and that you would like to prevent from happening again. Examples of things that might go in your circle:

Safety
• Fatality
• Lost time injury
• Recordable injury
• Vehicle accident
• Facility damage
• etc. etc.

Quality
• Defective product (not sent to customer)
• Defective product (sent to customer)
• Customer complaint
• Delayed shipment
• Returns
• etc. etc.

Once you have defined the incident, you map out what happened, define the causal factors, perform root cause analysis, and develop corrective actions.

So start thinking about different ways your company can use TapRooT®. I’ve mentioned Safety and Quality, but there are many more. equipment reliability, environment, security, project delays; the list is really endless.

The more ways you can use TapRooT®, the better ROI you will get from your training. I know from experience when different disciplines in an organization start speaking the same language, there are some great intangible benefits as well. So if you are a safety manager, drag your quality manager with you to training next time. You will be glad you did.

Thanks for visiting the blog and best wishes for your improvement efforts.

Would you like to receive tips like these in your inbox? Our eNewsletter is delivered every Tuesday and includes root cause tips, career development tips, current events and even a joke. Contact Barb at editor@taproot.com to sign up for the TapRooT® Friends & Experts eNewsletter.  

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