Post on 13-Apr-2017
Root Cause Analysis
Root Cause Analysis
Root Cause
Problem Occurs/Event
Proximate Cause
Next Level Cause
• Root Cause analysis is a process for identifying the basic casual factors that underlie occurrence of problem or event such as Test got lost, things takes too long and so on).
• Root cause analysis involves asking a series of why questions that probe deeper and deeper to build casual chain leading from problem to root cause.
• Proximate causes are immediate or most apparent reasons for the occurrence. For instance human error.
• The probing must continue until a reason underlying a cause can no longer be identified. When such a cause is identified and fixing the cause could help prevent the occurrence of event; it is a root cause.
Next Level Cause
Next Level Cause
Retained Foreign Object
Counting Error
Erroneous Entry on tally board
RN misunderstood message from surgeon
Crowded OR caused noise & difficulty in hearing
Resident observing procedures make noise
RCA Needs Probing deeper
Example
Root Cause Analysis Tools
Why?Why?
Why?
Why?
Why?
5 Why’s Fishbone Diagram
• A simple tool for looking at one major cause & drilling down to arrive at one root cause.
• A RCA tool when looking at numerous major causes and drilling down to arrive at numerous root causes based on their Cause & Effect Relationships.
Ensuring an Effective RCA• Focus primarily on systems and
processes, not on individual performance.
• Progress from special causes in clinical processes to common causes in organization processes.
• Repeatedly dig deeper by asking “Why?”; then, when answered, ask “Why?” again and so on.
• Focus on causes that team can influence, control and deal with and make changes in systems and processes-either through redesign or development of new systems or processes.
• Is though and credible.
• Root causes are systemic.• Root Causes appear far from the origin of
the failure.• The origins of root causes lie in common
cause variation of organization systems.
Characteristics of Root Causes
RCA: 5 Why’s
5 Whys
Identified problem
Root Cause
Casual factor
Casual factor
Casual factor
Casual factor
Therefore
Why
1. Go Beyond the symptom of the gap and drill down to the root cause
2. Avoid the easy answers such as:
• “It’s because we do not have enough resources or staff” or
• It’s PEDS that is the problem”
3. Data: Are there are metrics on the identified root cause?
• Ask: Is there really a problem?
Stop asking 5 whys, when:
• Corrective action(s) do not change• The answers become less important• Root cause condition is isolated
5 Why - Example
Why are the X-rays delayed?
The exams are taking longer than scheduled
Why does the exam take longer than what is scheduled?
The rad tech is busy with multiple tasks
Why is the rad tech busy?
The rad tech has to answer numerous phone calls.
What do they have to answer the phone?
The phone is in the rad tech area.
Why does the phone ring in the rad tech area?
The phone is programmed for all rad calls to be fielded to the rad tech phone.
Problem Statement : Delays in performing X-rays
Solution: Program the phone to the front desk administrator so the rad tech is not receiving
unnecessary calls
Fishbone or Cause & Effect Diagram
https://www.youtube.com/watch?v=11_pvMrWnks
Fishbone Diagram• A Cause and Effect Diagram that relates the problem and the possible
causes• The cause categories follow the 5M’s and 1E• The diagram begins to show the path to the root cause
ManMaterialEquipment
Mother NatureMethodMeasurement
What’s the Problem?
Steps in Constructing Fishbone Diagram
Define the event Find Causes Find the Root
Cause
Remembering the following 4S’s and/or 6 P’s can be helpful:4S’s: Surroundings, System, Skills & Suppliers6P’s: People, Process, Policies, Procedures, Product (Service being offered) & Place
Guidance for Finding Causes for C&E Diagram
Example of Cause & Effect Diagram/Fishbone Diagram
11
Low rate of Pap smears
Environment
People Equipment
Walk-in appts. Delay scheduled appts.
Have to wait to use exam room
Physical space limited
Space
Space used by other practitionersLong
wait time
Need for Pap
EMR function to flag provider not enabled
Appointments
No reminders for pt. appts.
No process to remind pts. of appts.
Pt. understanding
Limited time to explain procedures
Lack of pt. education regarding procedure
Staff responsibility to provide education not defined
Trained staff
Staff not well trained to use equipment
Limited funds for equipment
Specialty equipment not available. eg. tilting exam table
Staff
Staff not aware of problems with Paps
Competing priorities and time commitments
Svc. not covered by malpractice insurance
Patients
Don’t want exam
Negative past experience
Procedures
Staff not well trained to use equipment
Space used by other practitioners
Short Training Session Staff not well trained
to use equipment
Practice: RCA 5 Whys
Practice Session for RCA: 5 Why’s
Incidence of increased bleeding post surgery
One of the patients had an incidence of increased bleeding post surgery.
Lab investigation revealed that herbal supplements were present in the patient’s system increased the metabolism of several other drugs used in the perioperative period, causing increased bleeding post surgery.
The surgeon interviewed the patient and learnt that the patient had continued the use of herbal supplements right up to the day of the procedure.
After learning that the use of herbal supplements right up to the day of the procedure had caused increased bleeding, the patient was furious & complained that during the preoperative telephone interview he should have received instruction to discontinue herbal supplements prior to day of surgery.
On further inquiry the surgeon found that the preoperative telephone interview is conducted by administrative clerk and the administrative clerk did not inquire about the use of herbal supplements & suggest their discontinuation .
The administrative clerk was called for investigation. The administrative clerk defended that he had inquired and suggested about all things based on “Pre-surgery telephone interview procedure and guideline” such as discontinuation of any oral pain medications day before surgery and had not committed an error.
Identify Root Cause & Suggest Potential solution based RCA
Solution
Solution for Practice Session for RCA: 5 Why’s
Incidence of increased bleeding post surgery
Herbal supplements present in the patient’s system increased the metabolism of several drugs used in the perioperative period
Patient had continued the use of herbal supplements right up to the day of the procedure
During the preoperative telephone interview, patient did not receive instruction to discontinue herbal supplements prior to day of surgery
The administrative clerk did not inquire about the use of herbal supplements & suggest their discontinuation .
Pre-surgery telephone interview procedure and guideline does not require to inquire about use of herbal supplements and suggest its
discontinuation on day before surgery
Event
Root Cause