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Doing RCA Right! TM
© 2011 Reliability Center, Inc.
Proactive RCA: Turning RCA Into ROI
Doing RCA Right! TM
© 2011 Reliability Center, Inc.
RCI Has Worked in 20+ Countries for the Past 28 years and have Trained Over 30,000 Students
Around the World Reps In:
Mexico Canada Saudi Arabia
Brazil Argentina Venezuela
South Africa Australia England
1972 – 1985: Allied Chemical R&D
1985 – Present: RCI
Doing RCA Right! TM
© 2011 Reliability Center, Inc.
Sample Client Listing
Doing RCA Right! TM
© 2011 Reliability Center, Inc.
Is This Insane?
Doing RCA Right! TM
© 2011 Reliability Center, Inc.
No Matter What Acronym We Use…This is Simply Critical Thinking!
• Root Cause Analysis (RCA) • Performance Improvement (PI) • Continuous Improvement (CI) • Problem Solving (PS) • Trouble Shooting (TS) • Six Sigma/Lean Six Sigma (SS/LSS) • Brainstorming
Common Acronyms…
Doing RCA Right! TM
© 2011 Reliability Center, Inc.
Performance GAP Analysis S
yste
m U
nits
of M
easu
rem
ent (
%)
Time
Actual/Current State
Potential/Desired State
GAP = Undesirable Outcomes
What’s The ‘Problem’?
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© 2011 Reliability Center, Inc.
FMEA and Opportunity Analysis Where do candidates for RCA come from now?
FMEA Opportunity Analysis
Regulatory Events (Suits)
Root Cause Analysis
SRE
FMEA OA
Proaction Reaction
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© 2011 Reliability Center, Inc.
Quantifying Risk – Basic Failure Modes and Effects Analysis (FMEA)
Probability X Severity = Criticality
Item Failure Mode
Effect on Other Items
Effect on Entire System
Severity (S)
Probability (P)
Criticality (C = S x P)
Impact on Production
Bearing Failure
Pump Failure
Production Shutdown
8 4 32
Adverse Events Involving Children
Wrong Dose
Length of Stay Extended
Increased Claims 7 3 21
Car Risks Engine Light
Engine Malfunction
Car Will Not Drive 10 3 30
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© 2011 Reliability Center, Inc.
1. Perform preparatory work 2. Collect data 3. Calculate the loss 4. Determine the “Significant Few”
The Basic OA Analysis Process:
Introducing FMEA’s ‘Sister’ - Opportunity Analysis (OA)
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© 2011 Reliability Center, Inc.
ED Cardiac Pediatrics Oncology LDR
1A - Perform Preparatory Work Identify The ‘Scope’ of Analysis
Will one department or process be involved in the Analysis, or Many? Don’t try and tackle world hunger in such an analysis, you will lose your team!
Raw Material Pulp Mill Paper
Mill Finishing Storage
Purchase Order
Project Planning
Project Prep
Project Execution
Project Close
Healthcare
Industry
Service
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© 2011 Reliability Center, Inc.
1B - Perform Preparatory Work
Define ‘What is a FAILURE/LOSS in the system you are analyzing?’
Doing RCA Right! TM
© 2011 Reliability Center, Inc.
What is The Definition of a “LOSS”?
It Depends on Your Perspective: 1. Any event or condition that results in a Sentinel Event/OSHA
Recordable (Risk Management Perspective)
2. Any event or condition that results in an Adverse Drug Event/Production Loss/Customer Complaint (Risk Management Perspective)
3. Any event or condition that results in a “Near Miss” (Quality Management Perspective)
4. Any event or condition that results in an Extended Length of Stay/Production Loss (Claims Perspective)
5. Any event or condition that results in a Order Process Error (Claims Perspective)
Doing RCA Right! TM
© 2011 Reliability Center, Inc.
1C- Perform Preparatory Work/Draw a Block Diagram Basic Medication Order Process Example
Doctor Writes Order
Nurse Communicates To Pharmacy
Order Transcribed by
Pharmacist Order Entered
Medication Prepared
Medication Transported
Medication Dispensed
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© 2011 Reliability Center, Inc.
1C- Perform Preparatory Work (OA) Sample Failure Modes
Sub System
Event Mode Freq. Impact/Occurrence (Preventable=$2595
Non-Preventable=$4685)
Total Annual Loss
Doctor Writes Order
ADE
Prescribing Error
130 $3,640 $473,200
Paper Machine
Unexpected Shutdown
Pump Failure 40 $50,000 $2,000,000
Ice Maker
Can’t Use Ice Cubes
Ice Fused Together
365 $2/day $730
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© 2011 Reliability Center, Inc.
Sub System
Event Mode Freq. Impact Per Occurrence
Total Annual
Loss
Labor Costs Materials Cost of
Investigation ELOS/Production Losses
Customer Complaints
Litigation $$ TJC/OSHA $$
Regulatory Scrutiny
Loss of Reputation ($$)
Measuring ‘Loss” – Impact Per Occurrence
Doing RCA Right! TM
© 2011 Reliability Center, Inc.
2- Collecting the Raw Data The 3 Necessary Tools to Collect Data
“Any Event, Occurrence or Condition that Results in an
ADE (Wrong Type, Frequency or Dose of Medication)” (or Lube
Issue?)
Loss Definition Block Diagram
Sub System
Event Mode Freq. Impact Per Occurrence Total Annual Loss
OA Worksheet
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© 2011 Reliability Center, Inc.
3 - Calculate the Loss (OA)
Apply Loss Formula:
Frequency X Sum of Impacts = Total Annual Loss
Sub System Event Mode Frequency Cum. Impact Per Occurrence
Total Annual Loss
Medicine Order Process
ADE Wrong Medicine
20 per Year $2,182 $43,640
Paper Machine
Unexpected Shutdown
Pump Failure
40 per Year $50,000 $2,000,000
Doing RCA Right! TM
© 2011 Reliability Center, Inc.
4 - Determine the “Significant Few” Significant Few Examples
• 20% or less of the patients, require 80% or more of the care
• 20% or less of your customers, account for 80% or more of your revenues
• 20% or less of your tools are used 80% or more of the time
• 20% or less of your clothes are worn 80% or more of the time
• 20% or less of the staff require 80% or more of your attention
Doing RCA Right! TM
© 2011 Reliability Center, Inc.
4 - Determine the “Significant Few” The Pareto Split
Grand Total = $1000
Pareto Cut = x .80
Significant Few = $ 800
/ The Pareto Split 80 % $$$ % EVENTS
20 (or less)
Sub System
Mode Event Frequency Total Loss/Yr
Impact Per Occurrence or
Severity
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© 2011 Reliability Center, Inc.
4 - Determine the “Significant Few” The Business Case!
Events
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100% %
of
Loss
1 2 3 4 5 6 7 8 9 10
RCA Significant Few
PI
Doing RCA Right! TM
© 2011 Reliability Center, Inc.
Exercise Time! The Car Example
Doing RCA Right! TM
© 2011 Reliability Center, Inc.
PROACT® RCA Methodology/ Process Steps
PReserving Event Data (Evidence) Ordering the Analysis Team Analyzing Event Data Communicating Findings & Recommendations Tracking For Bottom Line Results
Investigation Phase
Analysis Phase
Correction Action Phase
Terminology
Doing RCA Right! TM
© 2011 Reliability Center, Inc.
Policies & Procedures Human Factors Communication Technology Training Management
Oversight
Deficient Organizational Systems
Undesirable Outcome
Physical Root Causes
Human Root Causes
Latent Root Causes
Doing RCA Right! TM
© 2011 Reliability Center, Inc.
How Could?
How Could?
How Could?
How Could?
Why?
EVENT: Least Acceptable Consequence of an
Undesirable Outcome
Deepest Significant Underlying
Causes
PR
HR
LR
The Logic Tree – Cause and Effect RCA
Let’s Reverse The Path Now!
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© 2011 Reliability Center, Inc.
L A T E N T
H U M A N
P H Y S I C A L
Reasons’ ‘Swiss Cheese Model’ James Reasons, Human Error, 1990
Patient Has Allergic
Reaction
Pressure to Cut Budget By 10%
Decision to Curb Scope of
Formulary
Unavailability of Correct
Medication
Incorrect Medication Dispensed
Doing RCA Right! TM
© 2011 Reliability Center, Inc.
Putting ‘Failure’ Into Proper Context What would you say is the ‘Problem’ in this
case?
“The Woman’s Tee”
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© 2011 Reliability Center, Inc.
Case Study Time
Pick a Failure!
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© 2011 Reliability Center, Inc.
Why Do Mix-Ups Occur? The LIVESTRONG Mix-Up Potential
Yellow wristbands can be a visual signal of a patients request for a “DNR”
Human Factors
Doing RCA Right! TM
© 2011 Reliability Center, Inc.
Why Do Mix-Ups Occur?
Procedure Writing – Mixed Case: The attending surgeon shall record in the medical record the correct side for and name of the surgical procedure
Procedure Writing – All Upper Case: THE ATTENDING SURGEON SHALL RECORD IN THE MEDICAL RECORD THE CORRECT SIDE FOR AND NAME OF THE SURGICAL PROCEDURE
Medication MEDICATION
Unique Pattern
Generic Pattern
Did You Know?
Doing RCA Right! TM
© 2011 Reliability Center, Inc.
Why Do Mix-Ups Occur? Human Factors in Design – Brain Processing Capability
10 Chunks
8 0 4 4 8 5 0 4 6 5
804-458-0645
3 Chunks Of all the signals that reach our sensory register, we focus on a few
that seem important (normal capacity is about seven “chunks” of information).
Source: Making Connections: Teaching and the Human Brain (Caine and Caine 1991)
Did You Know?
Doing RCA Right! TM
© 2011 Reliability Center, Inc.
What Do You See?
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.
Is Seeing, Believing?
Doing RCA Right! TM
© 2011 Reliability Center, Inc.
Procedures and Proper Communication – CAUTION!
A wife asks her engineer husband to buy one carton of milk, and if they have eggs, get 6."
A short time later the husband comes back with 6 cartons of milk.
The wife asks him, "Why the hell did you buy 6 cartons of milk?"
He replied, "They had eggs."
Engineering Logic
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© 2011 Reliability Center, Inc.
“Why I Got Fired…”
Procedures and Proper Communication – CAUTION!
My friend was tasked with helping plan the company picnic. As times are tight, he was told that this year the Company would not have an Open Bar but they would cover only the first alcoholic beverage then it would become a Cash Bar. This was the actual implementation of the plan…
Doing RCA Right! TM
© 2011 Reliability Center, Inc.
Thanks for Your Time and Participation, We Hope You Enjoyed
Our Session.
Thanks for the Opportunity!
www.Reliability.com