Root cause analysis

ROOT CAUSE ANALYSISDr. Mohamed Mosaad Hasan

MD, MPH, CPHQ, CPPS, GBSS

SENTINEL EVENTS

Rosie King’s video

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.

RCA- SEQUENTIAL STEPS1- 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, stepin 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.

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).


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.


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.


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


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.

QUALITY TOOLS

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.

Symbols Used in Flowcharts

Start / End

Process Step

Decision

Connector

No

Yes

A

FLOWCHARTUse 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

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..

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...

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.

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?

Fire Drill Preparation Flowchart

A

YesNo

Yes

No

Yes

No

NoYesYes

No

Yes

NoFirst drill

in set?

A

Inform the drill

leader and improvise

Props?Search

Torpedo Room

Radiosstill not

available?

Borrow from

Quartermasters

Check with

RadiomenRadios

available?

Props

available?

Enoughred hats?

Drill monitors

test the radios

Monitors go to Logroom to get redhats, radios, and drill props

Complete the

Drill Brief

Drill monitorstake station

Search theboat forred hats

No

No

Yes

YesDiscrepancy?

Allpersonnelon 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

CAUSE AND EFFECT DIAGRAM

Also called Ishikawa or Fishbone

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.


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;


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

BASIC LAYOUT OF

CAUSE AND EFFECT DIAGRAMS

EFFECT

Manpower

(People)

Methods

(Procedures)

Materials

(Policies)

Machines

(Plant)Environment


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;


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;


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.

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 waitsfor bed

Not entered

Not used

No trust

Need more training

Functions not useful

Not usedpending discharge

Discharged patientdid not leave

Wait for results

Wait for lunch

Wait for ride

Call housekeepingtoo late

Wait for MD

Call housekeepingtoo early

Think it will takemore time

Patient arrivestoo early

Transfer too earlyfrom another hospital

Call housekeepingwhen clean

Nursing shortage

Unit clerk staffing

Unit clerk training

Resources

Unit clerk unawareof discharge or transfer

On break

Not told

Shift change

Reservationunaware

Not entered

Unit switch bedAdmitting unawarebed is clean

Delayedentry

SandbagToo busy

InappropriateER admittance

Manytransfers

Specialty beds

Cardiac monitors

Double rooms

Physician didnot write order

Medicineadmit quota

Physician misuse –inpatient

MD procedures

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 …

PROCESS OF FIVE WHYS

• Clearly define the issue to be tackled and write it on the leftside of the paper

• Complete the diagram by moving from left to right. Move fromthe 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 torecord 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 mostsignificant insights that have been gained

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.

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


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


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?

SPECIFY THE SOLUTION

Brainstorming.

Affinity Diagram.

Multi- voting.

BRAINSTORMING

BRAINSTORMINGDefinition: Brainstorming is a structured group

process used to create as many ideas aspossible in as short a time as possible, e.g.,one session, and to elicit both individual andgroup creativity.

Structured Brainstorming: Everyone in thegroup gives an idea in rotation or passes untilthe next round.

Unstructured Brainstorming: Everyone in thegroup gives ideas as they come to mind.

EXPERIMENTS HAVE SHOWN---

BRAINSTORMING WILL

TYPICALLY GENERATE THREE TIMES

THE QUANTITY OF IDEAS THAN THAT

GENERATED BY THE SAME INDIVIDUAL

WORKING SEPERATELY

BRAINSTORMING

Lists generated may relate to:

Problems or topics

Components of a process

Indicators, criteria, elements for data

collection

Possible solutions Structure

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

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.

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

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.

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.

AFFINITY DIAGRAM

Steps:

Define the primary issue, using neutral, broadlanguage;

Brainstorm - use cards or adhesive notes whichcan be moved and sorted;

Display in random fashion all ideas for the team(on a wall or table);

Cont..

AFFINITY DIAGRAM

Each team member participates in sorting theideas into major groupings -- in silence andquickly, without discussion and without time forcontemplation -- until team consensus is reached;

Discuss the major groupings and create a concisetitle for each grouping;

Draw the affinity diagram, based on majorgroupings, linking all ideas related to eachgrouping.

AFFINITY DIAGRAM

Each team member participates in sorting theideas into major groupings -- in silence andquickly, without discussion and without time forcontemplation -- until team consensus is reached;

Discuss the major groupings and create a concisetitle for each grouping;

Draw the affinity diagram, based on majorgroupings, linking all ideas related to eachgrouping.

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

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

learnDon’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

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

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

learnDon’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?

MULTI-VOTING

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.

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

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

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

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.


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 willbe rated, stated in either positive or negativeterms, but not both;

3. Determine the weight (relative value) of eachcriterion; perhaps some are more important tomeet than others;

Cont..


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

EXAMPLE

WEIGHTED FACTOR MODEL EXAMPLE

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

With your team conduct a root cause analysis for this

case.

Date post:	20-Jul-2015
Category:	Healthcare
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Root cause analysis

Healthcare