rl solutions i-presentation series reliability center, inc. presents…

rL Solutions i-Presentation Series

Reliability Center, Inc.Presents…


Root Cause Analysis Versus Shallow Cause Analysis: What’s the Difference?

Robert J. Latino EVP – Reliability Center, Inc.


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


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)


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.


Insanity is when we do the same thing over and over again and

expect a different result.

- Albert Einstein


Is This Insane?

(A brief movie, 7 slides – hit any key to resume.


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)


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”.


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?


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


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)


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


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


X

Events vs. Modes

Accident/Incident

Response

Did the response to the accident/incident make the consequences worse?

X

Consequence


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


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.


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.


LATENT

HUMAN

PHYSICAL

Remember The Swiss Cheese Model? James Reasons, Human

Error, 1990

Defenses (Barriers)


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”


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


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


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.


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?


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


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


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


Sample Verification Log “The Proof”


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


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?


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

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