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’?

Doing RCA Right! TM

© 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

Doing RCA Right! TM

© 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

Doing RCA Right! TM

© 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)

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© 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

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© 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

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© 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!

Doing RCA Right! TM

© 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

Doing RCA Right! TM

© 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