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MBA5906E-RootCauseAnalysis.pdf

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Introduction to Root Cause Analysis

What is a Root Cause? Root Cause: The underlying source of an error, failure, or accident

Most errors, failures, or accidents have multiple causes, but fewer (often one) root causes.

What is a Root Cause Analysis? A Root Cause Analysis or RCA seeks to determine the root cause of an error, failure, or accident.

What does an RCA do?

Identify the causes that lead to variation from our performance expectation.

Types of Variation: Common versus Special

Types of causes: Apparent, Underlying, and Root

Performance Expectation: What we want to happen (e.g. 0 Sentinel events)

In other words—what is causing us to miss our performance goals?

Multiple tools, including 5 Whys and Ishikawa

What does an RCA do?

Identify the causes that lead to variation from our performance expectation.

Types of Variation: Common versus Special

Types of causes: Apparent, Underlying, and Root

Performance Expectation: What we want to happen (e.g. 0 Sentinel events)

In other words—what is causing us to miss our performance goals?

Multiple tools, including 5 Whys and Ishikawa

Performance Expectations

A standard that we want to meet • Room service delivered within 30 minutes • Zero Sentinel Events • Lab work completed within 24 hours

Good performance expectations are: • Measurable • Specific • Within our control

RCAs are most effective when they analyze a failure of a clear performance expectation

What does an RCA do?

Identify the causes that lead to variation from our performance expectation.

Types of Variation: Common versus Special

Types of causes: Apparent, Underlying, and Root

Performance Expectation: What we want to happen (e.g. 0 Sentinel events)

Multiple tools, including 5 Whys and Ishikawa

Types of Causes

“Proximate Causes” What factor(s) led directly to

the “error”? Usually, easy to see

The causes that lead to our apparent cause

What factor(s): − Allowed the “error” to happen − Failed to prevent the “error” − Started a chain of events that led

to the “error” May be a root cause Usually, harder to see

Apparent Causes Underlying Causes

Why?

Types of Causes in a Car Accident

Driver did not use the brakes fast enough to avoid hitting the car in front of them

Driver reaction time slow because of lack of sleep the previous night

Driver did not get enough sleep because they were stuck in the ED until 3 AM, but still needed to report for their 7 AM shift

Driver needed to report at 7 AM because the hospital was short- staffed on this holiday weekend.

The hospital was short staffed because they do not have a staffing plan that assures adequate staff on holidays.

Apparent Causes Underlying Causes

Why?

The Five Whys We have just performed a simplified version of the first RCA technique: the Five Whys.

How to Use the Five Whys

First, ask “Why did this error occur?” • The driver didn’t use the brakes fast enough.

Then, ask “Why did that occur?” • They were tired Then, ask “Why did that occur?” • They were stuck in the ED until 3 AM Then, ask “Why did that occur?”

Why not the Six Whys?

Asking “why” five times is generally sufficient to identify a root cause.

If you have not discovered a satisfying root cause after asking “why” five times, keep going until you do.

Washington Monument Example

The Washington Monument is deteriorating.

The Washington Monument

The chemicals we spray on the building are very harsh

To clean pigeon droppings

Pigeons eat spiders that nest near the monument

Spiders eat the bugs that live on the monument

Because the bugs are attracted to the brightest object at dusk.

Why?

Medication Error Example

Medication Error Patient received the wrong medication.

Why?

Most recent lab results not entered

Why?

Entering lab results done in batches every hour or so.

Information missing in Pt. chart

Why?

Doctor prescribed the wrong meds

Renovation work requires a long walk between the lab and the only place results can be entered.

Why?

Exercise: The Five Whys

Arrange yourself in groups of 4-7.

Select a single error, accident, or failure.

For the purposes of this exercise, you may use a fictional failure.

Perform the Five Whys as a group, to discover the root cause.

What did you Learn?

What were your Root Causes?

If this were a real RCA, who would be helpful to have on the team?

What kind of mindset is it important that the team have in order to complete an effective RCA?

RCA Team Makeup

Good RCA Teams often include the following: − People involved (directly or indirectly) in the failure − Team Leader

• Objective • Not part of the process • Experience conducing RCAs • Not always the most senior member of the team 5-8 members

Problems with the Five Whys

Although it is a useful tool, the “Five Whys” does have faults. • Root cause depends on the group’s knowledge

• Different groups = different root causes

• It can be difficult to know when you have discovered the real root cause

• There may be several answers for a single “Why?” By selecting one, we choose simplicity over complexity, and may miss important causes that are not the main cause

It may be helpful to consider a tool that attempts to collect all of the potential causes of an error.

Why?

The Car Accident

Driver did not use the brakes fast enough to avoid hitting the car in front of them

Apparent Causes Underlying Causes

Why?

Driver reaction time slow because of lack of sleep the previous night

Driver did not get enough sleep because they were stuck in the ED until 3 AM, but still needed to report for their 7 AM shift

Driver needed to report at 7 AM because the hospital was short- staffed on this holiday weekend.

The hospital was short staffed because they do not have a staffing plan that assures adequate staff on holidays.

Why?

The Car Accident

Apparent Causes Underlying Causes

Why?

The Car Accident

Why? Why?

2 3 41

Why? Why?

Why? Why? Why?

Tool 2: Ishikawa Diagram

The Ishikawa diagram helps us explore the chain of causes in more complex problems.

This tool helps identify a large number of causes, so organizing your diagram is key.

The Ishikawa Diagram

Start with an explanation of the “problem”

The basic explanation of the problem.

Draw “bones” for categories of causes

The Ishikawa Diagram

The basic explanation of the problem.

Tool 2: Diagramming (5 Whys)

Cause 1 (Apparent)

Why? Cause 3 (Underlying)

Why?

Cause 5 (Root)

Why?

Tool 2: Diagramming (Ishikawa)

Cause 1 (Apparent)

Underlying Cause

The Ishikawa Diagram

Ink smudged on my ticket

Passport doesn’t match ticket

Nervous about flight

Office too warm

Budget crisis

New pen supplier

New office manager wants to lower costs

The Ishikawa Diagram

Exploring More Causes

with “Bones” It is easy to overlook aspects of a failure or accident. Consider what are likely to be the major categories of causes that might be causing your problem

−Seek 3 to 6 categories −Consider “the 4 Ms”

The Four M’s

The Four M’s can help you remember to consider all of the aspects of a problem.

−Materials −Methods −Manpower −Machines

Useful way to remind you to consider aspects of the problem that you might forget.

Draw “bones” for each category of causes

MaterialsMachines

ManpowerMethods

I missed my flight

The Ishikawa Diagram

Materials

Apparent Cause (Materials)

Why?

Each apparent cause should be related to the category (e.g., materials)…..

Why? Why?

The Four M’s

….but the underlying cause that led to that apparent cause can be from any category.

How far down do we drill?

Keep separating causes into sensible subdivisions.

You subdivided enough when the “branches” are:

−Specific −Measurable −Controllable

The basic explanation of the problem.

MaterialsMachines

ManpowerMethods

Materials Cause 2 Sub-subcause

Sub-subcause

Manpower Cause 1

Sub-subcause

Machines Cause 1

Sub-subcause

Methods Cause 1 Sub-subcause

Sub-subcause

Machines Cause 2 Sub-subcause

Sub-subcause

Machines Cause 3

Methods Cause 2 Sub-subcause

Sub-subcause

Materials Cause 1

Manpower Cause 2

The Ishikawa Diagram

Problems with Ishikawa Diagrams The complexity of the tool can be difficult to know which is the “key” root cause.

Requires more time

Other RCA Tools

Five Whys and Ishikawa Diagrams are two easy ways to conduct RCAs on understandable processes

For some problems, a statistically-based RCAs may be more useful

What to do with a Root Cause?

A successful RCA produces a Root Cause.

It tells you why you missed your performance expectation.

The next step is to fix the cause.

The solution you select will depend on what type of root cause you have identified.

What does an RCA do?

Identify the causes that lead to variation from our performance expectation.

Types of Variation: Common versus Special

Types of causes: Apparent, Underlying, and Root

Performance Expectation: What we want to happen (e.g. 0 Sentinel events)

Multiple tools, including 5 Whys and Ishikawa

What does an RCA do?

Identify the causes that lead to variation from our performance expectation.

Types of Variation: Common versus Special

Types of causes: Apparent, Underlying, and Root

Performance Expectation: What we want to happen (e.g. 0 Sentinel events)

Multiple tools, including 5 Whys and Ishikawa

Question: Do we have a bad process, or did we experience an unforeseen event?

Two Types of Variation

Is our process functioning but giving us adverse results? (common cause)

Was our process working until it broke? (special cause)

To fix the root cause, we need to know what kind of root cause we have.

The hospital was short staffed because they do not have a staffing plan that assures adequate staff on holidays.

Common Cause

(Process Problems)

MondayMonday TuesdayTuesday WednesdayWednesday 50 years ago50 years ago

•The process reliably produces a similar result •The results of the process do not meet the needs of the “customer”

How Do We Fix

Common Cause Variation? Common cause variation suggests that your outcomes are a result of the process.

If the process does not meet your performance expectations, you must change the process.

Special Cause (Event Problems)

MondayMonday TuesdayTuesday ThursdayThursdayWednesdayWednesday

•The process produces a satisfactory result until an unforeseen problem occurs.

How Do We Fix Special

Cause Variation?

Sources of special cause variation must be identified and eliminated

Eliminating a single special cause does not always mean that the error cannot reoccur.

Common vs. Special

Cause Variation

Attributed to less than 15% of the cause of the problem

Improvement requires change by an individual or avoidance of an isolated event

Cause of at least 85% of the problem

Systems based

Improvement usually requires intense analysis of the system and changes to the system

Special Cause Variation

Common Cause Variation

RCA Summary

What does an RCA do?

Identify the causes that lead to variation from our performance expectation.

Types of Variation: Common versus Special

Types of causes: Apparent, Underlying, and Root

Performance Expectation: What we want to happen (e.g. 0 Sentinel events)

Multiple tools, including 5 Whys and Ishikawa

This analysis helps us understand why we have missed our performance goals