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Root cause analysis

This Presentation is discussing step by step how to conduct root cause analysis for sentinel events and near misses

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Root cause analysis

  1. 1. ROOT CAUSE ANALYSIS Dr. Mohamed Mosaad Hasan MD, MPH, CPHQ, CPPS, GBSS
  2. 2. SENTINEL EVENTS Rosie King’s video
  3. 3. ROOT CAUSE ANALYSIS Is a process done in response to occurrence of sentinel event or near miss. The aim of root cause analysis is to conduct intensive analysis to reach the embedded problems in the system and solve it.
  4. 4. RCA- SEQUENTIAL STEPS 1- Define the problem  Ask what is wrong, what is involved: conditions, activities, materials.  Ask when: day ,date, time, shift, time pattern, schedule.  Ask where: site, area department, physical environment, step in process.  Ask how the what or who is affected, how much, how many, work practice, omission / commission.  Ask who is involved: patients, caregivers, other staff, vendors, visitors.  Review relevant documents.  Consider other data collection options: surveys, observations, interviews.
  5. 5. RCA- SEQUENTIAL STEPS 2- perform task / process analysis  divide a process into steps by sequencing actions, instructions, conditions ,tools , and materials associated with the performance of the task (flowchart).  learn exactly what was supposed to happen.  contrast the baseline with what actually happened (based on initial data collection).
  6. 6. RCA- SEQUENTIAL STEPS 3- perform change /different analysis:  compare the task /steps successfully performed to the same task /steps when unsuccessful.  analyze the difference.  describe for each difference its effect on the situation.
  7. 7. RCA- SEQUENTIAL STEPS 4- perform control barriers/ safe guard analysis:  analyze safeguards needed to prevent the event.  analyze missing or ineffective safeguards. Safeguards may be :  physical: safety equipment and devices; locks, walls.  Natural: distance and time (limited exposure).  information: caution such as labels , alarms.  knowledge: making information constantly available.  administrative: safety policies and procedures, regulations, supervisory practices, training, education, communication process.
  8. 8. RCA- SEQUENTIAL STEPS 5- Begin cause and effect analysis  List each undesirable step of the occurrence  considering each a primary effect  using data collected to date , determine what causes allowed or forced each effect to occur  show the relationship between each cause and effect
  9. 9. RCA- SEQUENTIAL STEPS  continue the cause and effect analysis until :  Cause is outside the organization control to correct.  Primary effect is fully explained.  No other causes can be found to explain the effect.  Further analysis will yield no additional benefit in correcting the problem.  List all validated causes.
  10. 10. QUALITY TOOLS
  11. 11. FLOWCHART Definition: A flowchart is a pictorial representation displaying the:  Actual sequence of steps and their inter- relationships in a specific process in order to identify hand-off (appropriate and inappropriate), inefficiencies, redundancies, inspections, and waiting steps; and/or  Ideal sequence of steps, once the actual process is known.
  12. 12. Symbols Used in Flowcharts Start / End Process Step Decision Connector No Yes A
  13. 13. FLOWCHART Use when:  Identifying and describing a current process  Questioning whether there is a process  Questioning whether actual process meets current policy/procedure  Analyzing problems to determine causes  Redesigning the process as part of the action  Designing a new process
  14. 14. FLOWCHART Steps:  Determine the boundaries (the start and stop points) of the process under review.  Brainstorm to identify all activities and decision points in the process;  Place all activities and decision points in sequence. Cont..
  15. 15. FLOWCHART  Design the flowchart, placing:  each activity in a box (square or rectangle)  each decision in a diamond,  ovals or circles for the start and stop points,  connecting arrows indicating the flow.  If there is more than one "output" arrow from an activity box, it probably requires a decision diamond; Cont...
  16. 16. FLOWCHART  Analyze the flowchart, looking for process "glitches": inefficiencies, omissions/gaps, redundancies, barriers, etc.  Also look for the smooth parts of the process to use as models or "best practices" for improvement;  Decide whether to correct steps within the current process, design a new process, or do corrections first, then redesign in the future.
  17. 17. INTERPRETING A FLOWCHART Step 1 - Examine each process step Bottlenecks? Poorly defined steps? Ineffective sequence? Delays? Weak links? Step 2 - Examine each decision symbol Can this step be eliminated? Step 3 - Examine each rework loop Can it be shortened or eliminated? Step 4 - Examine each activity symbol Does the step add value for the end- user?
  18. 18. Fire Drill Preparation Flowchart A Yes No Yes No Yes No NoYesYes No Yes NoFirst drill in set? A Inform the drill leader and improvise Props? Search Torpedo Room Radios still not available ? Borrow from Quartermasters Check with Radiomen Radios available? Props available? Enough red hats? Drill monitors test the radios Monitors go to Logroom to get red hats, radios, and drill props Complete the Drill Brief Drill monitors take station Search the boat for red hats No No Yes Yes Discrepancy? All personnel on station ? Correct it Put simulation on the appropriate gages Drill leaders walk around to ensure all monitors are on station Spot check safety intervention points Order initial conditions set Find them and put them on station
  19. 19. CAUSE AND EFFECT DIAGRAM Also called Ishikawa or Fishbone
  20. 20. CAUSE-AND-EFFECT DIAGRAM  Definition: The cause-and-effect diagram is a tool generally used to gather all possible causes as an overview,  The ultimate goal being to uncover the root cause(es) of a problem.  The specific problem is usually stated as a negative outcome ("effect") of a process, e.g., late transfer of patients from the inpatient facility to skilled nursing facilities.
  21. 21. CAUSE-AND-EFFECT DIAGRAM  The diagram is a visualization of relationships between the outcome of a particular system or process, the major categories of that system or process (the main branches), and causes and subcauses (sub-branches off main branches). Steps  Start with the outcome (problem statement) on the right of the paper, halfway down; draw a horizontal line across the middle of the paper with an arrow pointing to the outcome;
  22. 22. CAUSE-AND-EFFECT DIAGRAM  Determine and define the major categories which describe the system or process under review, e.g.,  5ps: (or) 5ms: People Manpower Provisions Materials Policies Machines Procedures Methods Place Measurements
  23. 23. BASIC LAYOUT OF CAUSE AND EFFECT DIAGRAMS EFFECT Manpower (People) Methods (Procedures) Materials (Policies) Machines (Plant) Environment
  24. 24. CAUSE-AND-EFFECT DIAGRAM  Link the major categories (representing process and structure) to the outcome with diagonal lines angled from the horizontal line away from the outcome;  Brainstorm to identify possible main causes of the negative outcome and link each to one of the major categories, using horizontal lines (parallel to the main outcome line) touching the appropriate diagonal line;
  25. 25. CAUSE-AND-EFFECT DIAGRAM  Identify any possible sub-causes of main causes by using the "Five-Why" technique.  Evaluate the draft diagram as a team to determine the accuracy of the placement of issues and lines;
  26. 26. CAUSE-AND-EFFECT DIAGRAM Once the diagram seems appropriate to the team, further evaluate for:  Obvious improvement options;  Causes already resolved or eliminated; Causes easily resolved or eliminated;  Issues raised which require more in-depth assessment to be understood.
  27. 27. CAUSE & EFFECT EXAMPLE MJII p. 29 Bed Assignment Delay Information provided courtesy of Rush-Presbyterian-St. Luke’s Medical Center System incorrect Machine (PCIS)Timing Hospital procedures Communication Patient waits for bed Not entered Not used No trust Need more training Functions not useful Not used pending discharge Discharged patient did not leave Wait for results Wait for lunch Wait for ride Call housekeeping too late Wait for MD Call housekeeping too early Think it will take more time Patient arrives too early Transfer too early from another hospital Call housekeeping when clean Nursing shortage Unit clerk staffing Unit clerk training Resources Unit clerk unaware of discharge or transfer On break Not told Shift change Reservation unaware Not entered Unit switch bedAdmitting unaware bed is clean Delayed entry Sandbag Too busy Inappropriate ER admittance Many transfers Specialty beds Cardiac monitors Double rooms Physician did not write order Medicine admit quota Physician misuse – inpatient MD procedures
  28. 28. THE FIVE WHYS What is it?  A tool to help uncover the root cause or real reason for the issue  It is a variation of the approach used in fishbone analysis When would you use it?  When you have identified an issue and want to deepen your understanding of it and its underlying causes  It avoids group moving into ‘fix it’ mode and addressing the symptoms of an issue without understanding the root causes Issue Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why …
  29. 29. PROCESS OF FIVE WHYS • Clearly define the issue to be tackled and write it on the left side of the paper • Complete the diagram by moving from left to right. Move from the problem/issue statement by asking the question “why?” • Ask the group “why?” and capture the responses • For each response, again ask the question “why?”. Continue to record responses and move across to the right of the diagram. Try to go to five levels of “why?” • At the end of the analysis it is often helpful to circle the most significant insights that have been gained
  30. 30. FIVE WHYS – EXAMPLE Revenue budget not balanced Costs too high Income too low Premises costs 8.5% Staffing costs 86% of the budget. Income heavily reliant on LEA formula. Schools facilities are underused Teachers used to support pupils with SEN. Large number of management points Staffing very stable Historic. Have allowed some queue jumping. Cleaners local people with strong connection to school. Employ own cleaning staff at high rates. Plan still has 3 years to run. Roll drop in January Coordinator’s salary now in main school budget. School decided not to reapply 2 years ago. Knock-on impact in other areas e.g. FSM, SEN Health and safety issues. LEA cut back on community use of school. Greater variety of facilities available. Governing body have stopped s/keeper overtime. Premises staff costs 3.5% Low number of TAs Teachers are 70% 5 year routine maintenance plan undercosted. New Council sports centre opened locally LEA uses January PLASC for Fair Funding formula. Beacon school funding not renewed School not used for external events.
  31. 31. KEPNET-TREGOE (IS-IS NOT) MATRIX  Purpose : Isolate and Identify causes of quality problems by assisting managers in recognizing factors that underlie defects in a process.  Advantages  Relates possible causes to specific categories  Identifies process problems  Simplifies development of ways to resolve the problems
  32. 32. KEPNET-TREGOE (IS-IS NOT) MATRIX  Creation Steps  Characterize the problem  Easily understood by QI team  Create agreement on the nature of the predicament  Create the Is-Is Not Matrix  Who is involved in the process or problem? (No blame game)  What inputs or outputs are involved in the process or problem?  When does the problem occur? In what portion of the process?  Where does the problem occur? In what part of the organization or what location?  How important is the problem to the process? How extensive is the problem?  QI Team formulates entries for each cell  Emerging patterns identify deficiencies in the process
  33. 33. KEPNET-TREGOE (IS-IS NOT) MATRIX Is ( PROCESS) Is not ( problem) Who is involved in the process or problem What inputs or outputs are involved in the process or problem When does the problem occur? In what portion of the process Where does the problem occur? In what part of the organization or what location? How important is the problem to the process? How extensive is the problem?
  34. 34. SPECIFY THE SOLUTION  Brainstorming.  Affinity Diagram.  Multi- voting.
  35. 35. BRAINSTORMING
  36. 36. BRAINSTORMING  Definition: Brainstorming is a structured group process used to create as many ideas as possible in as short a time as possible, e.g., one session, and to elicit both individual and group creativity.  Structured Brainstorming: Everyone in the group gives an idea in rotation or passes until the next round.  Unstructured Brainstorming: Everyone in the group gives ideas as they come to mind.
  37. 37. EXPERIMENTS HAVE SHOWN--- BRAINSTORMING WILL TYPICALLY GENERATE THREE TIMES THE QUANTITY OF IDEAS THAN THAT GENERATED BY THE SAME INDIVIDUAL WORKING SEPERATELY
  38. 38. BRAINSTORMING Lists generated may relate to:  Problems or topics  Components of a process  Indicators, criteria, elements for data collection  Possible solutions Structure
  39. 39. RULES 1. PEOPLE MUST FEEL SAFE TO PARTICIPATE 2. DURING BRAINSTORMING--- NO JUDGEMENT NO CRITICISM 3. GENERATE AS MANY IDEAS AS POSSIBLE 4. ENCOURAGE TO BE CREATIVE 5. BUILD ON EACH OTHER’S IDEAS 6. WRITE DOWN EXACTLY WHAT IS SAID DO NOT DISCUSS IDEAS
  40. 40. FIVE STEPS OF BRAINSTORMING  Define the subject and direction of the session;  Allow time for initial, individual thought;  Establish a time limit for the entire session;  Request ideas according to the predetermined structure; keep circling the issue until all ideas are recorded  Clarify all ideas generated to assure accuracy and understanding.
  41. 41. ADVANTAGES 1. ENCOURAGES CREATIVE THINKING 2. HELPS TO IDENTIFY =POSSIBLE CAUSES =AREAS FOR IMPROVEMENT =POSSIBLE SOLUTIONS 3. ALLOWS FOR DIFFERENT POINTS OF VIEW 4. ENCOURAGES PARTICIPATION
  42. 42. AFFINITY DIAGRAM  Definition: An affinity diagram is an organizational tool most often used at the beginning of a team's work to organize large volumes of ideas or issues into major categories.  The ideas may have come from the group's initial brainstorming session.
  43. 43. AFFINITY DIAGRAM  "Affinity" means close relationship or connection, or similarity of structure;  When developing an Affinity Diagram, it is most important to determine the primary issue and major related subgroups in order to grasp the appropriate relationships, links, or connections.
  44. 44. AFFINITY DIAGRAM Steps:  Define the primary issue, using neutral, broad language;  Brainstorm - use cards or adhesive notes which can be moved and sorted;  Display in random fashion all ideas for the team (on a wall or table); Cont..
  45. 45. AFFINITY DIAGRAM  Each team member participates in sorting the ideas into major groupings -- in silence and quickly, without discussion and without time for contemplation -- until team consensus is reached;  Discuss the major groupings and create a concise title for each grouping;  Draw the affinity diagram, based on major groupings, linking all ideas related to each grouping.
  46. 46. AFFINITY DIAGRAM  Each team member participates in sorting the ideas into major groupings -- in silence and quickly, without discussion and without time for contemplation -- until team consensus is reached;  Discuss the major groupings and create a concise title for each grouping;  Draw the affinity diagram, based on major groupings, linking all ideas related to each grouping.
  47. 47. DISPLAY THE GENERATED IDEAS ISSUES IN IMPLEMENTING CONTINUOUS PROCESS IMPROVEMENT Behavior modifications may take longer than time available Too many projects at once Everybody needs to change but me Data collection process needs Need new data collection system Developing product without developing process Too busy to learn Don’t know what customer wants Short-term planning mentality Pressure for success Lack of training at all levels Lack of management understanding of need for it Competition versus cooperation Need to be creative Some people will never change What are the rewards for using tools Lack of follow- up by management Unrealistic allotment of time Lack of trust in the process Not using collected data Which comes first, composing the team or stating the problem? Want to solve problem before clearly defined
  48. 48. Sort Ideas into Related Groups Issues in Implementing Continuous Process Improvement Want to solve problem before clearly defined Too many projects at once Data collection process needs Need new data collection system Developing product without developing process Too busy to learn Don’t know what customer wants Behavior modifications may take longer than time available Pressure for success Short-term planning mentality Lack of management understanding of need for it Lack of training at all levels Need to be creative Competition versus cooperation Some people will never change What are the rewards for using tools Lack of follow- up by management Unrealistic allotment of time Lack of trust in the process Not using collected data Which comes first, composing the team or stating the problem? Everybody needs to change but me
  49. 49. Create Header Cards Issues in Implementing Continuous Process Improvement (Header Cards) Breaking through old way “Dinosaur” thinking Lack of planning Organizational issues Old managemen t culture Lack of TQL knowledge
  50. 50. Finished Affinity Diagram Issues in Implementing Continuous Process Improvement Breaking through old way “Dinosaur” thinking Lack of planning Organizational issues Old management culture Lack of TQL knowledge Want to solve problem before clearly defined Too many projects at once Everybody needs to change but me Data collection process needs Need new data collection system Developing product without developing process Too busy to learn Don’t know what customer wants Behavior modifications may take longer than time available Pressure for success Short-term planning mentality Lack of management understanding of need for it Lack of training at all levels Need to be creative Competition versus cooperation Some people will never change What are the rewards for using tools Lack of follow-up by management Unrealistic allotment of time Lack of trust in the process Not using collected data Which comes first, composing the team or stating the problem?
  51. 51. MULTI-VOTING
  52. 52. MULTI-VOTING A repetitive process used by a team to select the most important or popular items from a large list of items generated by the team Benefits of Multi-voting • Reduces a larger list of items. • Prioritizes team issues. • Identifies important items.
  53. 53. PROCEDURES FOR MULTI-VOTING Step 1 - Work from a large list Step 2 - Assign a letter to each item Step 3 - Tally the votes Step 5 - Repeat the process
  54. 54. MULTI-VOTING EXAMPLE LACK OF MEETING PRODUCTIVITY FIRST VOTE TALLY | A. No agenda | I. Problems not mentioned |||| B. No clear objectives |||| J. Interrupted by phone calls || C. Going off on tangents || K. Few meaningful metrics | D. Extraneous topics |||| L. Interrupted by visitors || E. Too many "sea stories" ||| M. No administrative support |||| | F. Vital members missing |||| N. Meetings extended from meeting beyond allotted time |||| G. Not enough preparation |||| O. Members distracted by for meetings pressing operations |||| H.Unclear charts
  55. 55. MULTIVOTING EXAMPLE LACK OF MEETING PRODUCTIVITY SECOND VOTE TALLY B. No clear objectives F. Vital members missing from meeting G. Not enough preparation for meetings J. Interrupted by phone calls L. Interrupted by visitors N. Meetings extended beyond allotted time O. Members distracted by pressing operations
  56. 56. PRIORITIZATION MATRIX  Definition: A Prioritization matrix is a tool used to select one option from a group of alternatives, be they problems or solutions.  It promotes objective decision making.
  57. 57. PRIORITIZATION MATRIX  Steps: 1. Limit the list of options (of problems or solutions) to no more than eight (8); 2. Select the criteria against which each option will be rated, stated in either positive or negative terms, but not both; 3. Determine the weight (relative value) of each criterion; perhaps some are more important to meet than others; Cont..
  58. 58. PRIORITIZATION MATRIX 4. Select a scoring method, e.g.:  Point system: From 5 = Very important To 0 = Unimportant  Yes/No system: Criteria Met? Y n Yes; N = No  Check mark: Box checked if criteria met  + or - system: + = Important/criteria met - = Unimportant/criteria not met
  59. 59. EXAMPLE
  60. 60. WEIGHTED FACTOR MODEL EXAMPLE
  61. 61. ACTION PLANNING  Once the team selects a solution, an action plan need to be developed.  Action plans at a minimum identifies:  what to be done? (deliverables)  How a certain task will be done?( implementation Strategies)  who will do it?( R)  Time Frame  A mean of verification that a certain task has been done  The team leader is responsible of monitoring the implementation process.
  62. 62. CASE STUDY MS. MARTINEZ, JANUARY 2000  Ms. Martinez, a divorced working mother in her early 50s with two children in junior high school, was new in town and had to choose an insurance plan.  She had difficulty knowing which plan to select for her family, but she chose City-Care because its cost was comparable to that of other options, and it had pediatric as well as adult practices nearby.
  63. 63.  Once she had joined CityCare, she was asked to choose a primary care physician. After receiving some recommendations from a neighbor and several coworkers, she called several of the offices to sign up. The first two she called were not accepting new patients. She finally found one.
  64. 64.  Juggling repairs on their new apartment, finding the best route to work, getting the children’s immunization records sent by mail, and making other arrangements to get them into a new school, Ms. Martinez delayed calling her new doctor’s office for several months. When she called for an appointment, she was told that the first available non urgent appointment was in 2 months; she hoped she would not run out of her blood pressure medication in the interim.
  65. 65.  When she went for her first appointment, she was asked to complete a patient history form in the waiting room. She had difficulty remembering dates and significant past events and doses of her medications. After waiting for an hour, she met with Dr. McGonagle and had a physical exam. Although her breast exam appeared to be normal, Dr. McGonagle noted that she was due for a mammogram.
  66. 66.  Ms. Martinez called a site listed in her provider directory and was given an appointment for a mammogram in 6 weeks. The staff suggested that she arrange to have her old films mailed to her. Somehow, the films were never sent, and distracted by other concerns, she forgot to follow up.
  67. 67.  A week after the mammogram, she received a call from Dr. McGonagle’s office notifying her of an abnormal finding and saying that she should make an appointment with a surgeon for a biopsy.  The first opening with the surgeon was 9 weeks later. By now, she was very anxious. She hated even to think about having cancer in her body, especially because an older sister had died of the disease.
  68. 68.  For weeks she did not sleep, wondering what would happen to her children if she were debilitated or to her job if she had to have surgery and lengthy treatment. She was reluctant to call her mother, who was likely to imagine the worst, and did not know her new coworkers well enough to confide in them.
  69. 69.  After numerous calls, she was finally able to track down her old mammograms. It turned out that a possible abnormal finding had been circled the previous year, but neither she nor her primary care physician had ever been notified.
  70. 70.  Finally, Ms. Martinez had her appointment with the surgeon, and his office scheduled her for a biopsy. The biopsy showed that she had a fairly unusual form of cancer, and there was concern that it might have spread to her lymph nodes.
  71. 71.  She felt terrified, angry, sad, and helpless all at once, but needed to decide what kind of surgery to have. It was a difficult decision because only one small trial comparing lumpectomy and mastectomy for this type of breast cancer had been conducted. She finally decided on a mastectomy.
  72. 72.  Before she could have surgery, Ms. Martinez needed to have bone and abdominal scans to rule out metastases to her bones or liver. When she arrived at the hospital for surgery, however, some of this important laboratory information was missing. The staff called and hours later finally tracked down the results of her scans, but for a while it looked as though she would have to reschedule the surgery.
  73. 73.  During her mastectomy, several positive lymph nodes were found. This meant she had to see the surgeon, an oncologist, and a radiologist, as well as her primary care physician, to decide on the next steps.  At last it was decided that she would have radiation therapy and chemotherapy. She was given the phone number for the American Cancer Society.
  74. 74.  Before 6 months had gone by, Ms. Martinez found another lump, this time under her arm. Cancer had spread to her lung as well.  She was given more radiation, then more chemotherapy. Unfortunately, the condition worsened steadily and cancer had spread leading to her death.
  75. 75.  With your team conduct a root cause analysis for this case.

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