rL Solutions i-Presentation Series
Root Cause Analysis Versus Shallow Cause Analysis: What’s the Difference?
Robert J. Latino EVP – Reliability Center, Inc.
rL Solutions i-Presentation Series
RCI Background
Established in 1972 as Corporate R&D Reliability Center for Allied Chemical Corporation (now Honeywell)
Established Charter to Conduct Research and Develop in the Fields of Equipment, Process and Human Reliability
As an Independent Company in 1985, Able to Spread Reliability Concept and Methods to All Industry
Researched Healthcare Culture and Market with Fay Rozovsky of The Rosovsky Group in 1997 and Revised Methodologies & Software Accordingly
Experts in Critical Thinking Framework as opposed to content within given industries
rL Solutions i-Presentation Series
Recent Publications
Root Cause Analysis: Improving Performance for Bottom-Line Results, 1999, 2002 and 2006, Robert J. Latino, Taylor & Francis
The Handbook of Patient Safety Compliance, 2005, Fay Rozovsky and Dr. Jim Woods, Jossey Bass [contributing author]
Error Reduction in Healthcare, 1999, Patrice Spath Editor, Jossey Bass [contributing author]
Taking Risky Business Out of the MRI Suite, Materials Management in Healthcare Magazine, 2006, Robert J. Latino, Fay Rozovsky and Tobias Gilk
Optimizing FMEA and RCA Efforts in Healthcare, ASHRM Journal, 2004, Volume 24, No. 3, pages 21 – 28
Root Cause Analysis Versus Shallow Cause Analysis: What’s the Difference?”, Speaker, ASHRM 2005 National Conference
Intelligence and Security Informatics International Conference Proceedings, The Root Causes of Terrorism, May 2005, Department of Homeland Security (DHS)
rL Solutions i-Presentation Series
1. Analytical Process Review 1. Analytical Process Review
2. Analytical Tools Review 2. Analytical Tools Review
3. A Case Study: Contrasting the Difference 3. A Case Study: Contrasting the Difference
Here We Go!
Hit any key to begin at your own pace.
rL Solutions i-Presentation Series
Insanity is when we do the same thing over and over again and
expect a different result.
- Albert Einstein
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Is This Insane?
(A brief movie, 7 slides – hit any key to resume.
rL Solutions i-Presentation Series
Brainstorming: A technique teams use to generate ideas on a particular subject. Each person in the team is asked to think creatively and write down as many ideas as possible. The ideas are not discussed or reviewed until after the brainstorming session. (ASQ)
Problem Solving: The act of defining a problem; determining the cause of the problem; identifying, prioritizing and selecting alternatives for a solution; and implementing a solution. (ASQ)
Trouble Shooting: To identify the source of a problem and apply a solution to "fix” it. (http://www.fairfield.k12.ct.us/develop/cdevelop02/glossary.htm) – Synonyms: Trial-And-Error and “Band-Aid Fixes”.
Root Cause Analysis: A method used to identify and confirm the causes of performance problems or adverse trends and identify the associated corrective actions needed to prevent recurrence of the causes. Root Cause Analysis (RCA) techniques apply investigative methods to unravel complex situations to determine root causes of performance problems, identify associated causal factors, check for generic implications of an event, determine if an event is recurrent, and to recommend corrective actions. (www.alwaysimproving.com)
rL Solutions i-Presentation Series
The Essential Elements Of RCA
Identification of the Real Problem to be Analyzed in the First Place
Identification of the Cause-And-Effect Relationships that Combined to Cause the Undesirable Outcome
Disciplined Data Collection and Preservation of Evidence to Support Cause-And-Effect Relationships
Identification of All Physical, Human and Latent Root Causes Associated with Undesirable Outcome
Development of Corrective Actions/Countermeasures to Prevent Same and Similar Problems in the Future
Effective Communication to Others in the Organization of Lessons Learned from Conclusions
If any one of these essential elements are missing, then we are not doing true “RCA”.
rL Solutions i-Presentation Series
Common Analysis Process Tools
5-WHYS
FISHBONE
LOGIC TREE
Why?
Why?
Why?
Why?
Why?
1
5
2
3
4
How Can?
How Can?
How Can?
How Can?
rL Solutions i-Presentation Series
The 5 - Whys
5-WHYS1. Uses Limited
Cause-And-Effect
2. Modes Are Dependent Upon Each Other
3. Uses Linear Path by Asking WHY?
4. Promotes Use of Opinion as Fact
5. Promotes Belief That Only One (1) Root Cause Exists
Why?
Why?
Why?
Why?
Why?
1
5
2
3
4
rL Solutions i-Presentation Series
The Ishikawa Fishbone Diagram
FISHBONE1. Does NOT Use
Cause-And-Effect
2. Modes Are NOT Dependent Upon Each Other
3. Uses Brainstorming Primarily
4. Allows Use of Opinion as Fact
5. Promotes Belief That All Causes Are Within Categories Used
Commonly Used Categories (Fish Bones)
• Methods, Machines, Materials & Manpower (4-M’s)
• Place, Procedure, People & Policies (4-P’s)
• Surroundings, Suppliers, Systems & Skills (4-S’s)
rL Solutions i-Presentation Series
Essential Elements of RCAEssential Elements of RCA
PrPreserving Event Dataeserving Event Data
OOrdering the Analysis Teamrdering the Analysis Team
AAnalyzing Event Datanalyzing Event Data
CCommunicating Findings & ommunicating Findings & RecommendationsRecommendations
TTracking For Bottom Line racking For Bottom Line ResultsResults
rL Solutions i-Presentation Series
Logic Tree
LOGIC TREE1. Uses Cause-And-
Effect
2. Modes Are Dependent Upon Each Other
3. Seeks All Possibilities By Asking HOW CAN?
4. Uses Evidence to Prove All Hypotheses
5. Identifies Decision Making Errors and Systems Flaws
How Could?
How Could?
How Could?
How Could?
Why?
EVENT
MODES
rL Solutions i-Presentation Series
X
Events vs. Modes
Accident/Incident
Response
Did the response to the accident/incident make the consequences worse?
X
Consequence
rL Solutions i-Presentation Series
The “Root” System
Component CausesComponent Causes(Physical)(Physical)
Decision RootsDecision Roots(Human)(Human)
Deficiencies in Deficiencies in Organizational Organizational SystemsSystems(Latent)(Latent)
Consequences
Actions
Intent
{{
HOW’s
WHY’s
rL Solutions i-Presentation Series
Some Human Factors Affecting Decision Making
PhysicalPhysical
Decision RootsDecision Roots(Human)(Human)
LatentLatent
NewNewTechnologyTechnology
(Automation)(Automation) Mis-Mis-ConstructionConstruction
(Mis-Perception)(Mis-Perception)
PlanPlanContinuationContinuation
(Cues)(Cues)NormalizationNormalization
OfOfDevianceDeviance(Safety)(Safety)
FailuresFailuresTo AdaptTo Adapt
(Procedures)(Procedures)BreachBreach
Of DefensesOf Defenses(Swiss(Swiss
Cheese)Cheese)
Stress andStress andWorkloadWorkload
(Tunnel Vision)(Tunnel Vision)
Coordination Coordination Failures Failures
(Goals & Priorities)(Goals & Priorities)
Source: The Field Guide to Human Error Investigations – Sydney Dekker, Ashgate, 2002.
rL Solutions i-Presentation Series
What Do You See? The Mind is a Mysterious Thing
A bird in the the hand is
worth two in the bush
Perceptions are mental models developed in the brain to interpret incoming information the way it SHOULD
BE versus the way that it IS.
rL Solutions i-Presentation Series
LATENT
HUMAN
PHYSICAL
Remember The Swiss Cheese Model? James Reasons, Human
Error, 1990
Defenses (Barriers)
rL Solutions i-Presentation Series
Contrast to A Contrast to A Detective’s RoleDetective’s Role
EventEvent
Failure ModesFailure Modes
Hypotheses/Hypotheses/VerificationVerification
Physical RootsPhysical Roots(Consequences)(Consequences)
Latent RootsLatent Roots(Intent)(Intent)
Human RootsHuman Roots(Actions)(Actions)
CrimeCrime
RCA ANALYSTS DETECTIVES
FactsFacts
Leads/Leads/EvidenceEvidence
ForensicsForensics (How’s)(How’s)
OpportunityOpportunity
MotiveMotive(Why’s)(Why’s)
Top BoxTop Box ““Police Scene”Police Scene”
rL Solutions i-Presentation Series
Software Based
Time (Efficiency)
Acc
ura
cy (
Eff
ecti
ven
ess)
Hours Months
Lo
Hi
RCA: Effectiveness vs. Efficiency vs. Strength of Evidence
Trouble shooting
Brainstorming
Problem Solving
Disciplined RCA
Lo
Hi
Stren
gth
of E
viden
ce
rL Solutions i-Presentation Series
Breadth and Depth Check
5-WHYS
FISHBONE
LOGIC TREE
Why?
Why?
Why?
Why?
Why?
1
5
2
3
4
How Can?
How Can?
How Can?
How Can?
Breadth
Dep
th
rL Solutions i-Presentation Series
A Case Study: Endobronchial Fire
R.P.: A 65 year old man was admitted with hemoptysis in October 2002. He underwent right upper lobectomy on December 14, 1999. His final diagnosis was adenocarcinoma (T1NoMo). He received radiotherapy and chemotherapy for recurrent malignancy in August of 2002.
During this admission he was found to have bleeding from an obstructing tumor of the right main stem bronchus. Laser bronchoscopy was performed on October 7, 2002. During the procedure, endobronchial fire occurred. This was treated with prompt removal of bronchoscope and endotracheal tube. The patient was reintubated and irrigated with Normal Saline. The patient survived this event, but died in July of 2003 from metastatic lung cancer.
rL Solutions i-Presentation Series
Sample 5-Why
Endotracheal Fire During Bronchos
copy
Fire Initiated in Right
Bronchus
Fuel Source Present in
Right Bronchus
Nitrogen Used to Ventilate
Chamber
Too Much Nitrogen
Introduced
Why?
Why?
Why?
Why?
Why?
rL Solutions i-Presentation Series
Sample Fishbone (4-M’s)
Foreign Debris/ Contamination
Scheduling/Timing Issue
Faulty Bronchoscope Source
Nitrogen Issue
Anesthetic Procedure Issue
Bronchoscopy Procedure Issue
Anesthesiologist Error
Surgeon Error
Methods Machines
Materials Manpower
Fiber Optic Assembly Issue
Fire in Endotrachial Tube During Bronchoscopy
Overload Manufacturer
Inexperienced
Fatigued
rL Solutions i-Presentation Series
Sample Logic Tree
OR/Patient Fire - Sentinel Event
Endotrachial Fire During Yag Laser
Bronchoscopy
Fire Occurred During Procedure
Fire Occurred Prior to
Procedure
Fire Occurred After
Procedure
Fire Initiated Outside the Right
Bronchus
Fire Initiated inside the Right
Bronchus
Presence of Sufficient Oxygen
Presence of Sufficient Fuel
Presence of Sufficient Ignition
Source
Sufficient Fuel Source Within
Patient
Sufficient Fuel Source
Introduced Into Patient
Sufficient Fuel Source On OR
Staff
Sufficient Fuel Source within Atmosphere
Smoldering Tumor
Generating Smoke Plume
Bronchoscope Source
Laser And Fiber Optic Assembly
Damaged
Foreign Debris
ET Tube Ignited
Suff. Additional Gases Intro’d
And Exposed To Laser
HR
A B
C
E
C
E
C
E
C = CauseE = Effect
rL Solutions i-Presentation Series
Sample Logic Tree (Cont’d)
A B
Mismanagement of Anesthetic Gas
Laser Mis-Fired In Bronchoscopy
Tube Oper. Channel
Contaminated Operating Channel
Chemical Contamination
QC Issue - Failure to
Detect Contamination
Contaminated During Cleaning
Process
No QC Inspection in
Place
QC Inspection in Place Less Than
Adequate
QC Inspection in Place and Not
Followed
Decision to Clean Equipment Using Flammable Agent
Decision in Accordance with
Procedure
Decision Not in Accordance With
Procedure
Current Procedure
Inappropriate
No Review Process of
Current Proc. When Vendors
Change
Purchasing Pressures
(Finance vs. Functionality)
PR
HR
LR
LR
LR
HR
LR
rL Solutions i-Presentation Series
Filtering the Results?
Root Causes Identified 5-Whys Fishbone PROACT RCA
Too Much Nitrogen Introduced X X X
Anesthetic Procedure Issue X Evidence proves this not to be true
Fiber Optic Assembly Issue X Evidence proves this not to be true
Anesthesiologist Error X X
Contaminated Operating Channel of Brochoscope Source
X
Contamination During Cleaning Process Using Flammable Agent
X
Purchasing Pressures to Reduce Cost
X
No QC Review Process in Place When Evaluating New Vendor’s Offerings
X
Failure to Detect Contamination Prior to OR Use
X
No QC Inspection of Cleaned Instruments Prior to Use in OR
X
Sufficient Additional Gases Introduced and Exposed to Laser
X
Mismanagement of Anesthetic Gases
X
rL Solutions i-Presentation Series
Conclusion
We should be doing analyses to the breadth and depth of RCA when warranted simply because it is the right thing to do (chronic versus sporadic)!
If we are doing true RCA, compliance will be a by-product. If it is not, there is something very wrong with the regulations/ guidelines.
Our RCA efforts should be directly correlated to patient safety/impact on the patient.
We should thoroughly understand when it is appropriate to use RCA and when it is appropriate to use shallow cause approaches. The rigor of RCA is not appropriate for every situation that arises.
Using “shallow cause” approaches when “root cause” approaches are warranted, will likely result in the missing of key systemic root causes. This will increase the risk of recurrence.
Are we using the appropriate tools for the appropriate situations?
rL Solutions i-Presentation Series
Thank you for your time and interest!QUESTIONS?
For more Information on PROACT, LEAP, FMEA, or Root Cause Analysis in Healthcare contact Gary Bonner at Reliability Center Inc. (RCI) by calling 804.458.06
45 or sending an e-mail to [email protected]
www.proactforhealthcare.comwww.reliability.com
For more information on the rL Solutions product suite, or to learn more about how we have integrated PROACT into our solutions please contact Mike Smith
at rL Solutions by calling (416) 410-8456 x 287 or sending an e-mail to [email protected]
www.rl-solutions.com