The RCA

The majority of times that a Root Cause Analysis (RCA) is ‘required’ is often due to some type of threshold of pain being met. Someone is hurt, we’ve had an environmental excursion, we lost a lot of money in throughput or equipment damage, we violated some regulation, etc. Essentially, when the ‘suits’ show up, something bad has happened and we will do an RCA whether we like it or not. This is the basis of ‘reactive RCA’, where we respond to an incident that has already met certain defined requirements, often called ‘triggers’. [Read more…]

In last month’s introductory article, we discussed some of the barriers to selling not only the concept of Root Cause Analysis (RCA) but also the recommendations generated as a result of these analyses. We also laid the framework for making better predictions by generating and accessing better data—namely predicting our Mean Time between Failure (MTBF) and Mean Time to Restore (MTTR) earlier and, therefore, implementing a fix faster.

Given this background, let’s explore how we can now justify conducting a RCA and implementing the recommendations as a result of the analysis. By and far, conducting a true RCA is viewed as luxury not a necessity. Think about the objections we hear when we offer the idea of gathering RCA teams. What follows is a list of common objections to RCA accompanied by rational justifications that any manager can employ. [Read more…]

Veteran professionals in the Reliability field view every business as a system. All systems have 1) inputs, 2) a transformation of those inputs in some form or fashion and 3) outputs. Just think about that for a minute; think about your schools, banks, manufacturing plants, small businesses…they are all systems. [Read more…]

Fatigue regulations and guidelines have been long established in aviation, transportation and the nuclear industries (just to name a few). The science is solid supporting the correlation between human fatigue, and poor decision-making/poor responsiveness.

So why aren’t such fatigue regulations required in healthcare as a matter of standard like in other industries? Is there something different about the physiology and/or anatomy of a healthcare worker versus a pilot, truck/bus driver or nuclear operator? [Read more…]

[Editor: originally posted Jan 23, 2015]

For those that are football enthusiasts and looking forward to the upcoming Superbowl, we are intrigued by the recent scandal in the NFL. The scandal involves the allegation that somehow the New England Patriots’ footballs used in the game against the Colts last week, were deflated and did not meet the minimum PSI requirements of the NFL to be ‘legal’ for game use. The allegation involves the possible tampering of the NE footballs to attain that ‘deflated’ state. Conceivably this would make it more desirable to throw and catch in the conditions of the game. [Read more…]

What’s Wrong With A Questioning Attitude?

As a key attribute of High Reliability Organizations (HRO), what’s wrong with a questioning attitude? One the surface it would seem like this is something we would encourage all of our employees to do. Certainly they ask such questions because they seek legitimate answers, right? We wouldn’t want to discourage that behavior, would we? [Read more…]

We might be doing a Shallow Cause Analysis (SCA) if … [Read more…]

The Reliability Approach… “Something understood and practiced by engineers and highly specialized technicians,” is apt to be the first reaction of the line supervisor, “certainly not an area where I can be expected to become involved.” Although this reaction is understandable; nothing is farther from reality. Let’s explore why in this paper. Please read until the surprising end (I know it is lengthy) and you will find that these Reliability Principles apply to any industry, any where at any time! [Read more…]

The Greatest Benefit of RCA is Generally an Unknown…Intellectual Capital

Because business is measured based on credits and debits, this is how we must express effectiveness of initiatives in reality. However, the physical costs are NOT the greatest benefit derived from RCA when done properly. [Read more…]

Measuring the Effectiveness of RCA in an Organization

Understanding now what perspective the executives have of an RCA initiative, how should RCA efforts be designed to report their results to the “C” level? Many would like to say “to express the results in a manner that demonstrates an increase in patient safety”. In a perfect world that would be nice, but what single metric expresses an increase in patient safety? Is there a line item on the Income Statement (IS) or Balance Sheet (BS) labeled “patient safety”? Not likely. [Read more…]

If 100 healthcare executives were polled about their definitions of “root cause analysis”, there would be 100 different answers. Here in is the problem, understanding the intent and power of Root Cause Analysis (RCA). For this reason, RCA is viewed as having either limited or phenomenal value to an organization. This article will seek to strip away the labels associated with RCA brands and focus on the processes, their results and how they are communicated (or miscommunicated) to executive management. Effective RCA efforts can fail because of their inability to demonstrate their value to the bottom-line of the organization. [Read more…]

In a recent BMJ article entitled ‘Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?‘, the authors’ state “Although RCA’s have been proposed as a mechanism for change, safety scientists believe the lack of improvement of adverse event rates in healthcare is largely because our methods of approaching change are ineffective”. [Read more…]

I often ask my classes ‘If we follow our procedures to the letter, do nothing more and nothing less; would we optimize our system productivity, safety and reliability?’ The answer is NO. [Read more…]

The graphic of the Swiss Cheese Model (attached is an expression from AHRQ) is a good one and one that many will remember and relate to.

However, I would like to expand on that model and express that more commonly, there is a not a singular or linear path to failure. There are typically multiple paths of failure that converge together at some point in time to cause an undesirable outcome. [Read more…]

I think that 5-year olds had a lock on 5Y’s well before it became a ‘named problem solving tool’. How many times have our kids at that age asked ‘Why’ about everything?

How many ‘Why’s’ do we answer before we say, ‘I don’t know, go ask your mother or father!’

Again (to me), the traditional 5-Y tool is technically incapable of expressing multiple paths of logic that occurred simultaneously. It treats failure like it always happens in a linear pattern (never multiple, simultaneous paths). [Read more…]