TapRooT ® Changing the Way the World Solves Problems TapRooT ® Presentation SMARTER Corrective...

TapRooT®

Changing the Way the World Solves Problems

TapRooT® Presentation

SMARTER Corrective Actions

Revision 0, 7/00

HUMAN ENGINEERING

labe ls NI

arrangement/p lac ement

d is p lay s NI

p lan t/un i td i ffe renc es

Human - Mac h ineIn te rfac e

moni to ringa le rtnes s NI

hous ek eep ingNIhot/c o ld

l igh ts NI

no is y

equ ipment guard NI

W orkEnv i ronment

k nowledge-

bas ed dec is ionrequ i red

Complex

Sy s tem

moni to ring toomany i tems

errors notde tec table

erro rs notrec ov erab le

Non-Fau l tTo le ran t Sy s tem

c ontro ls NI

c ramped quarte rs

wet/s l i c k

too ls /ins truments NI

ex c es s iv el i fting

obs truc tion

Pages 93-1 12

h igh rad ia tion /c ontamination

©Copyright 2000 by System Improvements Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.2

The most basic cause (or causes) that can reasonably be identified that management has control to fix and, when fixed, will prevent (or significantly reduce the likelihood

or consequences of) the problem's recurrence.

Root Cause Definition


Fixing Root Causes to Improve Performance

• Problems alert us to the need for improvement.

• We could try to "change anything/everything" but it's more effective to pinpoint fixes.

• For most problems we can identify changes that will enhance performance and eliminate the problem.

• You need a reliable, systematic process to find fixable root causes.


Choosing the Right Investigation Program

• Must satisfy JCAHO requirements

• Must identify true, fixable root causes consistently

• Must be credible with the work force and encourage their active participation in the investigation and review process

• Must not overextend our ability to investigate and follow-up on incidents

• Must allow collection, comparison, and measurement of root causes to provide meaningful trends

• Must have consistency of results to facilitate the sharing throughout organization of lessons learned to prevent recurrence


TapRooT®

• Use technique called SnapCharT®

• To understand what happened and how it happened.

• Use TapRooT® Root Cause Tree®

• To use systematic process to find each problem's root causes.

• SMARTER Corrective Actions and Corrective Actions Helper®

• To develop effective fixes


Diagram of TapRooT® Process

Read through NCPSTriage Cards

DetermineSequence of

Events(SnapCharT)

DefineCausal Factors

Analyze EachCausal Factor's

Root Causes(Root Cause

Tree)

Develop &Evaluate

CorrectiveActions

(SMARTER)

Report andImplement Corrective

Actions(DoD RCA Form)

Review EventReport

Analyze EachRoot Caus's

Generic Cause(Root Cause

Tree)


SnapCharT®

“Condemnation without investigation is the height of ignorance.” Albert Einstein

SnapCharT® Allows You To:

• Have a thorough Understanding of “What Happened”

• Spot missing or conflicting information

• Keep focused on the incident (maintain objectivity)


SnapCharT® Simple Example

Person walks to car

Person steps in pothole

Transported to hospital & treated

Person sprains ankle

Car in usual spot in company lot

Pothole reported 4 weeks ago -

no action taken

Parking lot light out

No barricades around hole

Hole not visible after dark

Light failed 3 days ago - not reported

Incident Reason for the Root Cause Analysis

Events Who did what? What equipment did what?

Condition or Causal Factor Amplifying information. Explains event.


TapRooT® Root Cause Tree ®

Chance is a word without sense; nothing can exist without cause. Voltaire

TapRooT® Root Cause Tree ® Allows You To:

• Determine why people make mistakes

• Determine why equipment fails

• Understand the system causes behind incidents


TapRooT® Root Cause Tree®

• 15 questions to help team isolate causes for human performance problems AND

• A “Tree” of incident causes

Used to:

• Systematically guide team to the root causes of human performance & equipment problems

• Focus on finding fixable causes rather than on placing blame

• Provide common language for discussions & trending


TapRooT® Root Cause Example

Not Used / Not Followed

PROCEDURES

procedure use not required but should be

no procedure

procedure not available or inconvenient for use

procedure difficult to use

typo

sequence wrong

facts wrong

situation not covered

wrong revision used

second checker needed

> 1 action / step

checkoff misused

Followed Incorrectly

format confusing

no checkoff

graphics NI

limits NI

excess references

details NI

Wrong

Pages 36-52

mult unit references

data/computations wrong or incomplete

equip identification NIambiguous instructions

misused second check

TapRooT® Root Cause


TapRooT® Generic Cause

• A systems issue/problem that allows a root cause to exist

• Fixing the generic cause eliminates whole classes of specific root causes

13

Develop SnapC

harT®

Get S

tarted- D

etermine w

hat you are investigating D

efine seq

uen

ce of events

- Identify missing or needed

information

- Investigate further to find missing

information

Defin

e causal factors

Root C

ause Analysis

An

alyze each C

ausal F

actor’s Root

Cau

ses- A

nalyze one Causal F

actor at a tim

e- B

egin at the top of the Tree and w

ork through the questions to determ

ine w

hat Basic C

ause Categories apply

- Exam

ine all of the Basic C

ause C

ategories that apply to determine

what root causes apply

Use th

e TapR

ooT® R

oot Cau

se Tree

®

Diction

ary for defin

itions to all of th

e q

uestion

s and

root causes on

the R

oot C

ause T

ree®

©C

opyright 2000 by System Im

provements Inc., K

noxville, TN

. All R

ights Reserved W

orldwide. D

uplication Prohibited.


Corrective Actions

• S pecific

• M easurable

• A ccountable person

• R easonable

• T imely

• E ffectiveness review

• R eview for unintended consequences


Corrective Action Implementation

Incident

Immediate Fixes

Long TermCorrective

ActionsRecommended

FixesImplemented

Re-Analyze &Develop New

CorrectiveActions

TEST

Share with OtherFacilities

Evaluate & Decideon Implementation

DocumentDecision

Implement Fixes

TEST

Done

Re-Analyze &Develop New

CorrectiveActions

Investigation

STARTHERE

On-Site

Document

OtherFacilities

No

Yes

Doesn'tWork

Effective

MeasureEffectiveness

Document/Track/

Validate

Document/Track/

Validate

MeasureEffectiveness

Effective

Doesn't Work

Off-Site


QUESTIONS?

HUMAN ENGINEERING

labe ls NI

arrangement/p lac ement

d is p lay s NI

p lan t/un i td i ffe renc es

Human - Mac h ineIn te rfac e

moni to ringa le rtnes s NI

hous ek eep ingNIho t/c o ld

l igh ts NI

no is y

equ ipment guard NI

W orkEnv i ronment

k nowledge-

bas ed dec is ionrequ i red

Complex

Sy s tem

moni to ring toomany i tems

erro rs notde tec table

erro rs notrec ov erab le

Non-Fau l tTo le ran t Sy s tem

c ontro ls NI

c ramped quarte rs

wet/s l i c k

too ls /ins truments NI

ex c es s iv el i fting

obs truc tion

Pages 93-1 12

h igh rad ia tion /c on tamina tion

TapRooT ® Changing the Way the World Solves Problems TapRooT ® Presentation SMARTER Corrective...

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