Root Cause Analysis RCA - Syndicate of Hospitals in Lebanon

Root Cause AnalysisI. Performance ImprovementWhen a performance factor is missing & a gap in performancehas occurred, a solution, or intervention, usually becomes clear.Ex.: If workers lack information about what is expected of them,obvious interventions would include:1. Implementation of written policies,2. job descriptions,3. or verbal directions.Root Cause Analysis5

Root Cause AnalysisII.Root Cause AnalysisA. DefinitionIt is a methodology for finding & correcting the mostimportant reasons for performance problems.Is the most basic causal factor(s), which if corrected orremoved will prevent the recurrence of a situation.Troubleshooting/Problem solvingRoot Cause AnalysisSeek solutions to specificdifficultiesDirected at underlying issuesRoot Cause Analysis8

Root Cause AnalysisII.Root Cause AnalysisApplicationCar will not startCar is not being maintainedaccording to recommendedservice scheduleEABBattery is deadDAlternator is well beyond itsdesigned service lifeCAlternator doesnot functionRoot Cause Analysis9

Root Cause AnalysisThe point is to dig belowthe symptoms and findfundamental,underlying decisionsand contradictions thatled to the undesiredconsequences.Root Cause Analysis10

Root Cause AnalysisProblems awayKill them at the rootRoot Cause Analysis11

Root Cause AnalysisRoot Cause AnalysisCorrect or eliminateroot causesNot addressing the immediateobvious symptomsRoot Cause Analysis12

Root Cause AnalysisBy directingcorrective measuresat Root CausesComplete prevention ofrecurrenceby a single interventionlikelihood of problemrecurrencewill be minimizedNot always possibleRoot Cause Analysis13

Root Cause AnalysisRoot Cause AnalysisInteractive ProcessTool ofContinuousimprovementRoot Cause Analysis14

Root Cause AnalysisII.Root Cause AnalysisB. General Principles of RCA1. RCA is aiming at the rootcauses rather than merelytreating the symptomsRoot Cause Analysis15

Root Cause AnalysisII.Root Cause AnalysisB. General Principles of RCA (contn’d)2. RCA must be performedsystematically, with conclusionsand causes backed up bydocumented evidenceRoot Cause Analysis16

Root Cause AnalysisII.Root Cause AnalysisB. General Principles of RCA (contn’d)3. There is usually more than one rootcause for any given problems.Root Cause Analysis17

Root Cause AnalysisII.Root Cause AnalysisB. General Principles of RCA (contn’d)4. The analysis must establish allknown causal relationshipsbetween the root causes and thedefined problems.Root Cause Analysis18

Root Cause AnalysisII.Root Cause AnalysisC. Goals of RCA Find out WHAT happened ?Brief description of the eventWhen did the event occur?Failure identificationof what exactly went wrongRoot Cause Analysis19

FEAR FACTORRoot Cause Analysis20

Root Cause AnalysisII.Root Cause AnalysisC. Goals of RCA Find out WHY it happened ?People issues?Computer / data issue?Environmental issues?Leadership issues?Communication?Uncontrollable factors?Failure analysisdiscover the root causeRoot Cause Analysis21

Root Cause AnalysisII.Root Cause AnalysisC. Goals of RCAFind outWHAT CAN BE DONE TO PREVENT IT ?Failure resolutionprovide a solution that prevent recurrenceRoot Cause Analysis22

D. Types of causesRoot Cause Analysis1. Physical Causes:Tangible, material items failed in some wayex.: a car’s break stopped working2. Human Causes:People did something wrong or did not do something that wasneededHuman causes lead to physical causesex.: no one filled the break fluid, which led to the brakes failure3. Organizational Causes:A system, process, or policy that people use to make decisions or dotheir work is faultyex.: no one person was responsible for vehicle maintenance, andeveryone assumed someone else had filled the brake fluidRoot Cause Analysis23

Root Cause AnalysisWE ARE ALL HUMANSWE ALL MAKE MISTAKESHow we manage these mistakes differRoot Cause Analysis24

Root Cause AnalysisE. Sentinel EventsSentinel Event is any unexpected occurrence involvingdeath or serious physical or psychological injury, or the riskthereof.JCAHORoot Cause Analysis25

Root Cause AnalysisIncidents may include:Missing itemsPatient abuseFiresNeedle sticks, MSDS (chemical) spillsPatient or visitor injuryProperty damageRoot Cause Analysis26

Root Cause AnalysisWe cannot changehuman conditionratherwe can changethe conditionsunder whichhumans workRoot Cause Analysis27

Root Cause AnalysisAdverse EventWHOHOWDefenses failedWHYDefenses failedRoot Cause Analysis28

F. Swiss Cheese ModelRoot Cause AnalysisHigh Technology SystemsMany defensive layersEngineeredRely on peopleDepend on procedures &administrative controlsAlarmsPhysical barriersAutomatic shutdownsEtc.SurgeonsAnesthetistsPilotsControl room operatorsRoot Cause AnalysisPolicies & procedures29

Root Cause AnalysisF. Swiss Cheese ModelIn an ideal world, each defensive layer would be intactIn reality, however, they are more likeslices of Swiss cheese, having manyholes, unlike in the cheese, theseholes are continually opening,shutting & shifting their location.Root Cause Analysis30

Root Cause AnalysisF. Swiss Cheese ModelThe presence of the holesin any one “slice” does notnormally cause a badoutcome.Root Cause Analysis31

Root Cause AnalysisF. Swiss Cheese ModelFor a catastrophic error to occur,the holes need to align for eachstep in the process allowing alldefenses to be defeated &resulting in an error.Root Cause Analysis32

F. Swiss Cheese ModelEvery step in a process hasthe potential for failure, tovarying degrees.Ideal System: stack of Swiss cheeseRoot Cause AnalysisHole: opportunity for a process to failEach slice: “defensive layer” in the processopportunity to stop an errorError: may allow problem to pass through a hole in one layer, but in the nextlayer the holes are in different places & the problem should be caught.Root Cause Analysis33

Root Cause AnalysisF. Swiss Cheese ModelThe more defenses you put, the better.Fewer holes&Smaller holesMore likelyto stop / catchthe errorsthat mayoccurRoot Cause Analysis34

Root Cause AnalysisReasons of errors:Adverse EventsActive Failures+Latent ConditionsRoot Cause Analysis35

Root Cause AnalysisAdverse EventsActive Failures+Latent ConditionsUnsafe acts committedby peoplewho are in direct contactwith patient or systemChernobyl example, when operators wronglyviolated plant procedures & switched offsuccessive safety systems, thus creating theimmediate trigger for the catastrophicexplosion in the core.Slips, lapses, mistakes& procedural violationsInevitable “resident pathogens”within the system.They arise from decisionsmade by designers, builders,procedure writers & top level mgt.Root Cause Analysis36

Root Cause AnalysisLatent Conditionscan createMay lie dormant within the system for many yearsbefore they combine with active failures to create an accident1 2Errors provokingconditionswithin thelocal workplaceCan createlong-lasting holesor weaknessesin the defenses•Time pressure•Understaffing•Inadequate equipment•Fatigue•Inexperience•Untrustworthy alarms,indicators•Unworkable procedures•Construction deficitsRoot Cause Analysis37

SWISS CHEESE THEORYMD is yelling toget ThorazineRN has nevergiven ThorazinebeforePhysicianattemptingplacement of leadsPt havingpacemakerprocedureNurse pushes50mg ThorazineslowlyPt develops hiccupsSurgeonis finished– BPdrops to50/24Physician orders 50mgof Thorazine, STATRN leaves procedure room to get Thorazine & looking upin PDR for proper administration techniquesRoot Cause Analysis38

Root Cause AnalysisF. The Process of RCA5 identifiable stepsStep OneDefine the problem What do you see happening ? What are the specific symptoms ?Root Cause Analysis39

Root Cause AnalysisF. The Process of RCA5 identifiable stepsStep TwoCollect Data What proof do you have that the problem exists ? How long has the problem existed ? What is the impact of the problem ?Root Cause Analysis40

Root Cause AnalysisF. The Process of RCA5 identifiable stepsStep TwoCollect Data What proof do you have that the problem exists ? Data include conditions before, during & after the occurrence What current actions were taken by the involved personnel Environmental FactorsRoot Cause Analysis41

Root Cause AnalysisF. The Process of RCA5 identifiable stepsStep TwoCollect Data How to collect data, sources of data ?Interviewing personnel most familiar with & directly & indirectly involved inthe incident Record keeping to the incident:* meeting minutes* correspondence* operation logs* maintenance records* equipment history recordsRoot Cause Analysis42

Root Cause AnalysisF. The Process of RCA5 identifiable stepsStep ThreeIdentify Possible Causal Factors / Identify Root Causes What sequence of events leads to the problem ? What conditions allows the problem to occur ? What other problems surround the occurrence of the central problem ?Root Cause Analysis43

Root Cause AnalysisF. The Process of RCAStep Three5 identifiable stepsIdentify Possible Causal Factors / Identify Root CausesUsually people identify 1 or 2 factors then stop, but that is not sufficient With RCA, you don’t want to simply treat the most obvious cause –you want to DIG DEEPERRoot Cause Analysis44

Root Cause AnalysisSeveral Techniques to DIG DEEPERThe most important techniques are:1 25 Whys TechniqueCause-Effect DiagramFishbone DiagramIshikawa MapRoot Cause Analysis45

Root Cause Analysis5 Whys TechniqueBy repeatedly asking the question “Why” (5 is a good rule of thumb), you canpeel away the layers of symptoms which can lead to the Root Cause of aproblem.Benefits of the 5 Whys:1. To identify the root cause of a problem2. To determine the relationship between different root causes of a problem3. It is one of the simplest tools; easy to complete without statistical analysis.When is 5 Whys most useful ?1. When a problem involves human factor or interaction2. In day-to-day business lifeRoot Cause Analysis46

WHY ?WHY ?WHY ?WHY ?WHY ?WHY ?WHY ?WHY ? WHY ?WHY ?WHY ?Root Cause AnalysisWHY ?47

Root Cause AnalysisExample (1)WHY ?Problem Statement:Customers are unhappy because they are being shipped products thatdon’t meet their specifications.1. Why are customers being shipped bad products?-Because manufacturing built products to a specification that is different from whatthe customer sales person agreed to.2. Why did manufacturing build the products to a different specification than that of sales?-Because the sales person expedites work on the shop floor by calling the head ofmanufacturing directly to begin work. An error happened when the specifications erebeing communicated or written down.Root Cause Analysis48

Root Cause AnalysisExample (1) (contn’d)WHY ?Problem Statement:Customers are unhappy because they are being shipped products thatdon’t meet their specifications.3. Why does the sales person call the head of manufacturing directly to start workinstead of following the procedure established in the company?- Because the “start work” form requires the sales director’s approval before work canbegin & slows the manufacturing process (or stops it when the director is out of theoffice).4. Why does the form contain an approval for the sales director ?- Because the sales director needs to be continually updated on sales for discussionswith the CEOIn this case only four Whys four Whys were required to find out that a non-valueadded signature authority is helping to cause a process breakdown.Root Cause Analysis49

Root Cause AnalysisExample (2)WHY ?Problem Statement:You are on your way home from work & your car stops in the middle of the road.1. Why did your car stop?-Because it ran out of gas.2. Why did it run out of gas?-Because I didn’t buy any gas on my way to work3. Why didn’t you buy any gas this morning?-Because I didn’t have any money4. Why didn’t you have any money ?-Because I lost it all last night in a poker game5. Why did you loose your money in last’s night’s poker game?-Because I am not very good at “bluffing” when I don’t have a good handRoot Cause Analysis50

Root Cause AnalysisExample (3)WHY ?Problem Statement:A man comes to the table for some wine and cheese and sees a mouse in the cheese1. Why mouse in the cheese?-Because mouse in the house.2. Why mouse in the house?-Because screen door is open3. Why screen door open?-Because the man put the cat out, and he left the door screen openSolution:Put spring latch for the door screenNot Good Solution:1. Be sure to close the screen door2. Put a note on the door to closethe latchRoot Cause Analysis51

Root Cause Analysis5 WHYSWHY ?WHY ?WHY ? WHY ?WHY ?Can be used individually or as a part ofFishboneCause-Effect diagramIshikawa MapRoot Cause Analysis52

Root Cause AnalysisBasic Elements ofthe Fishbone Diagram / Cause-Effect Diagram / Ishikawa MapThis diagram represents the relationship between some “effect” and all thepossible “causes”.Major CauseMajor CauseTertiaryTertiarySecondaryTertiarySecondaryTertiarySecondarySecondarySecondarySecondaryTertiarySecondaryTertiaryTertiaryTertiaryEffectSecondarySecondarySecondaryTertiaryTertiarySecondaryTertiaryTertiaryTertiaryTertiaryMajor CauseMajor CauseRoot Cause Analysis53

Root Cause AnalysisMan PowerMaterialMachineryEffectMilieuEnvironmentMethodRoot Cause Analysis54

Root Cause AnalysisBasic Elements ofthe Fishbone Diagram / Cause-Effect Diagram / Ishikawa MapMaterial:Defective raw materialWrong type for jobLack of raw materialRoot Cause Analysis55

Root Cause AnalysisBasic Elements ofthe Fishbone Diagram / Cause-Effect Diagram / Ishikawa MapMan Power:Inadequate capabilityLack of KnowledgeLack of skillStressImproper motivationRoot Cause Analysis56

Root Cause AnalysisBasic Elements ofthe Fishbone Diagram / Cause-Effect Diagram / Ishikawa MapMaterialMachinery / Equipment:Incorrect tool selectionPoor maintenance or designPoor equipment or tool placementDefective equipment or toolRoot Cause Analysis57

Root Cause AnalysisBasic Elements ofthe Fishbone Diagram / Cause-Effect Diagram / Ishikawa MapMaterialMilieu / Environment / Media:Orderly workplaceJob design or layout of workSurfaces poorly maintainedPhysical demands of the taskForces of NatureRoot Cause Analysis58

Root Cause AnalysisBasic Elements ofthe Fishbone Diagram / Cause-Effect Diagram / Ishikawa MapMaterialManagement:No or poor management involvementInattention to taskTask hazards not guarded properlyOther (Inattention, etc.)Stress demandsRoot Cause Analysis59

Root Cause AnalysisBasic Elements ofthe Fishbone Diagram / Cause-Effect Diagram / Ishikawa MapMaterialMethods:No or poor proceduresPractices are not the same as written proceduresPoor communicationRoot Cause Analysis60

Root Cause AnalysisBasic Elements ofthe Fishbone Diagram / Cause-Effect Diagram / Ishikawa MapMaterialManagement System:Training or education lackingPoor employee involvementPoor recognition of hazardsPreviously identified hazards were not eliminatedRoot Cause Analysis61

Root Cause AnalysisF. The Process of RCAStep Four5 identifiable stepsRecommend & Implement SolutionsWhat can you do to prevent the problem from happening again?How will the solution be implemented?Who will be responsible for it?What are the risks of implementing the solution?Root Cause Analysis62

Root Cause AnalysisF. The Process of RCAAt the end, the whole phenomenon must beperiodically monitored to verify resolution &effective recurrence prevention.Root Cause Analysis63

Cause-Effect or Ishikawa DiagramSpinning waferstakes too longBaking waferstakes too longEquipment may failOven isn’t up to temperatureSoleroids failCleaning for broken wafersOven takes a while toWarm up at start of dayUV bulb may burn outPhotolithography stepoften takes toomuch timeMasks not readyMasks being cleanedMasks being inspectedAligning waferstakes too longWorkers align atdifferent speedDeveloping waferstakes too longRoot Cause AnalysisDeveloper not at proper temperatureDeveloper needs to be changed64

Cause-Effect or Ishikawa DiagramPayment delaysTime for checksPackages not readyfor shipmentCustomer hasn’t decidedon shipping methodCustomer hasn’t putmaterial into boxClerks do timeconsuming servicesClerk goes to back room pick upmail for customerClerk explains forms to customerTime to approve checksTime to write checksTime for credit cardsCustomer hasn’t filledout customs formsTime to signWorkers align atdifferent speedLong lines at thepost office at 5:00p.m.Clerks on breakClerk buys stampsfrom another clerkNot enough clerks√Customers withmany packagesExtra time when clerkdoesn’t t have the stampsRoot Cause Analysis65

III. RCA Scenarios / Models / ExamplesCase Scenario 1A 73 years old male was admitted with aortic stenosis. The patient also hadDiabetes Mellitus. He underwent an aortic valve replacement. He had anuneventful recovery and was ready for discharge 9 days post-op.On the day of discharge, the staff RN was removing the saline lock from theright forearm. The nurse noticed a small, reddened area around the site. Thenurse reported the findings to the physician, who ordered wet soaks, but didnot delay the discharge. The patient’s temperature was 37.8°C. This was notreported to the physician.Twenty-four hours after discharge, the patient was re-admitted with atemperature of 39°C & was acutely ill. Cultures from the saline lock site,spinal fluid, blood, urine, and sputum were all positive for Staph. Aureus. Thepatient expired.Root Cause Analysis66

Root Cause Analysis What is the policy for changing saline locks? What are the assessmentexpectations if the saline lock is not changed?Does this nursing unit have a policy that all patients on their unit will havea saline lock, regardless of the patient condition?Were the nurses doing the assessment competent in the assessment andmaintenance of IV saline lock?Was the appropriate information communicated to the physician?Root Cause Analysis67

Root Cause Analysis Were the staffing levels appropriate for the needs of the patients on this unit?Did the nurses feel rushed to discharge a patient?Where there other factors that could have potentially diverted the nursefrom conveying all necessary information to the physician prior to discharge?Should the physician have delayed discharge? Were there external factorsinfluencing the surgeon’s decision to discharge (monitoring of LOS by the MDgroup for example)?Root Cause Analysis68

III. RCA Scenarios / Models / ExamplesCase Scenario 2A 24 years old mother underwent a C-section for fetal distress at 32 weeks. Theinfant weighed 2 kgs at birth but appeared in no acute distress. The infant wasadmitted to the neonatal ICU for close observation. The infant progressed welland did not require intubation, IV lines or any invasive procedures.As is the policy in this facility, the mother was instructed t pump her breastsfor feedings. She used the new electronic breast pump that was stored at thenurse’s station on the post partum unit. The mother elected to go homewithout her baby on day four to care for other children at home. When shecame back the hospital, she continued to use the breast pump from postpartum.The infant gained weight & was scheduled for discharge. The evening beforedischarge, the infant became irritable & had episodes of bradycardia. Theneonatologist on call immediately ordered blood cultures & empiricantibiotics. The blood cultures were positive for Pseudomonas Aeruginosa.Despite aggressive therapy by the physicians, the baby expired.Root Cause Analysis69

Root Cause Analysis What is the policy for cleaning & storing the electronic breast pump?Did the mother receive any education on hand hygiene, cleaning herbreasts prior to pumping & ascertaining that the breast pump was cleaned?Was the nurse competent in maternal-child care, including instructions forbreast feeding?The pump was new. Was everyone on the unit oriented to that pump &how to use it?Root Cause Analysis70

Root Cause Analysis How was the breast milk stored?What education had the staff nurses in the NICU received on hand hygiene?What was the census in the NICU? Was there adequate staffing?Were there adequate safeguards in place to make sure the infant got thecorrect mother’s milk?Root Cause Analysis71

Disciplinary ActionQuestions to ask: Will disciplinary action serve to prevent future accidents? Did the individual intentionally violate safe practices policiesand standards? Did a caregiver commits a deliberate reckless act? Is there a pattern of behavior?Root Cause Analysis72

THANK YOURoot Cause Analysis73