Chapter 4: Causal Analysis

Root-Cause Analysis (RCA)

 “Just fix it, there is too much to do.”
“We don’t have time to think, we need results
now.”
• Reality - fix symptoms without regard to
actual causes
• Root Cause Analysis - structured and thorough
review of problem designed to identify and
verify what is causing the symptoms
• A Root Cause Analysis (RCA) is a process for
identifying the basic or causal factors that underlie
variations in outcomes.
• An RCA typically allows you to identify the “root” of
the problem in a process, including how, where, and
why a problem, adverse event, or trend exists.
• The RCA is also a way of looking at unexpected
events and outcomes to determine all of the
underlying causes of the event and identify
recommended changes that are likely to improve
them.
• Through an RCA, you can make decisions and look for
sustainable solutions based on data and facts.
• An RCA focuses primarily on systems and processes,
not individual performance.
 Definitions
Cause (causal factor): a condition or event that results in an
effect
Direct Cause: cause that directly resulted in the occurrence
Contributing Cause: a cause that contributed to the
occurrence, but by itself would not have caused the
occurrence
Root Cause: cause that, if corrected, would prevent
recurrence of this and similar occurrences
 How Is Root Cause Analysis Done?

• Teams identify all possible causes

• The actual root causes are identified and

verified

• Corrective action(s) are identified to reduce or

eliminate the problem
 RCA Process
Relationship between cause and effect

• Need for creative thought to identify all

possible causes
• Collect data about the problem
• Analyze data
• Verify causes
 Tools for Analysis
• Fishbone Diagram
• Scatter Diagram - prove cause-effect relationship
• Control Chart - process stable?
• Five Whys
• Stream Diagnostic Chart
• Process Maps (Process Charts, System Flowcharts)
 Cause Effect Diagram
• Visual display of possible causes
• Cause categories include materials, machines,
methods, and people
• Reveals gaps in existing knowledge
• Helps team reach common understanding of
why loss exists
Fishbone Diagram
• In a typical Fishbone diagram, the effect is
usually a problem needs to be resolved, and is
placed at the "fish head". The causes of the
effect are then laid out along the "bones", and
classified into different types along the
branches.
• The main goal of the Fishbone diagram is to
illustrate in a graphical way the relationship
between a given outcome and all the factors
that influence this outcome.
Steps:
Step 1 - Identify and clearly define the outcome or effect to
be analyzed.
Step 2 - Identify the main causes contributing to the effect
being studied.
Establish the major causes, or categories, under which
other possible causes will be listed. You should use category
labels that make sense for the diagram you are creating.
Step 3 - Identify as many causes or factors as possible and
attach them as subbranches of the major branches.
Step 4- Analyze the diagram. Analysis helps you identify
causes that warrant further investigation.
Look for causes that appear repeatedly. These may
represent root causes.
Look for what you can measure in each cause so you can
quantify the effects of any changes you make.
 Scatter Diagram
• Test for possible cause and effect relationships
• Some variation should be expected
• Relationships being tested must be logical
• Visual depiction of relationship
Patterns of Correlation

Quality Improvement Tools

Juran Institute, 1989
Correlation Coefficients

Quality Improvement Tools

Juran Institute, 1989
 Scatter Diagram
70
Relationship Between Time to Admit from ER and Cases Entering ER/Hour

60

50

Data shows strong positive

40 correlation.
Minutes

30

20

10

0
0 5 10 15 20 25

Cases/Hour
 Statistical Process Control
• Process Variation - Common Cause & Special
Cause
• Is the process stable?
• Points outside LCL/UCL warrant investigation
• Alert for problems
 Five Whys
• Describe the problem in specific terms
• For each likely cause ask, “Why did this
happen?”
• Continue for a minimum of five times
• Show logical relationship of each response to
the one that preceded it
• Stop when the team has enough information
to identify the root cause
 Why-Why Diagram Example
Too much work

Not enough No reward

students signed up
Schedule not communicated

No time
to learn
Trainer not New trainer assigned late
prepared
Training Turnover
Class
Cancelled
Flexibility
Materials not Late changes Changes up
completed to class date
Current

Floating due date

Training Dept -
other projects This project-
low priority More info needed
19
 Stream diagnostic chart
• In order to improve a process, it is important to identify the core problems
causing its ineffective functioning
• Road map is required
– To guide the diagnosis of process deficiencies, to track down the core
problem issues, and to set the stage for effective changes of the process
• Stream analysis* approach
– Be based on the systems theory and it assumes that a process is open,
consisting of subsystems, each including a stream of variables, with
many of these variables connected either causally or merely relationally
within the same stream or across streams

*Porras, J.I. Stream analysis: a powerful way to diagnose and manage organizational
change (1990)
 Requirements for users in the diagnostic phase:

1.To organize systems problems into categories.

2.To place each problem in its proper category on a
chart (Stream Diagnostic Chart)
3.To agree on and show on the diagnosis chart the
interconnections that exists among all the problems
identified.
4.To systematically root out the funda-mental
(core) problems and the casual chains connecting
them to their manifested symptoms through
analysis of resulting chart.
 Stream Analysis Procedures

• Forming a Change Management Team

Change Management Team (CMT) – a cross-
sectional group of organizational members to
guide and monitor the change process.
Key in this step is to include some points of
view, for it is these perspectives that often
needed to be examined more fully in complex
environments.
Stream Analysis in Problem Diagnosis
The stream approach to system diagnosis is
based in pictorials representing these
organizational problems on a chart. The
chart, called a Stream Diagnostic Chart, is
divided into columns (streams), one for each
organizational dimension considered key by
the user of the chart.
 Components of the Stream Analysis Chart

1. ORGANIZING ARRANGEMENT contains all the

parts of the organization that are set up to
coordinate formally both the behavior of people
and the functioning of various parts of the
organization. It is the formal side of the
organization usually in writing.

Ex: Goals, Strategies, Formal Structure, Admin Policies

and Procedures, etc.
This sends signals about what people in the
system are supposed to be doing.
2. SOCIAL FACTORS encompass all things directly
related to people in the organization: their
characteristics (individual/groups), their patterns
and processes of interaction and features as a large
social group.

Ex: Culture, Interaction Processes, Informal

Patterns & Network, Individual Attributes, etc.
3. TECHNOLOGY encompass all the factors that
directly enter into the transformation of
organizational inputs into organizational outputs.
Ex: Tools, Equipment, Machinery, Design of Jobs,
Work Flow Design, etc.

4. PHYSICAL SETTING includes the concrete

structures and objects on the non-social/non-
technical part of the environment in which people
work.
 Steps:
1. After having been identified, cate-gorized
each problem as primarily reflec-ting
difficulties in one stream and a brief
description of it is placed in the appropriate
column.
2. Specify key interconnections that exist
among the categorized on the chart to represent
all the relationship identified.
3. Identifying Interconnections

Guide Questions:
a. Does one problem seem to be driving or causing
the other?
b. Is one problem simply related to another with
no evident casual relationship?
c. Is one problem seems to cause as well as to be
caused by another?
d. Is there no clear and reasonably significant
relationship between one problem and
another?
4. Analyzing the Problem Chart
Types of Problems

a. Symptoms – problems caused by deeper

problems which are highly visible in the
organization and often driven by a relatively
large number of the other problems. In the
chart, it has many arrows coming in.
– Symptoms are produced by the problem
– The problem causes the symptoms
– When the problem is corrected the symptoms
will cease, but not vice versa
b. Core problem – problem having many arrows
coming out of it signifying that it is driving many
of the other in the organization. Solving this
would do much to reduce the existence of the
problems it drives.

c. Fundamental core problem – one that drives core

problems and often do not exist or cannot be easily
identified, but, when they can, provide maximum
“bang of the buck” when taken care of.
Stream diagnostic chart
 Process Maps
• What is a Process Map?
A pictorial representation of the sequence of
actions that comprise a process.
Why is Process Mapping Important?

• It provides an opportunity to learn about work

that is being performed.
“ You don’t learn to Process Map,
You Process Map to learn.”
• •Most processes today are undocumented.
• Process Maps are used to
• Document processes.
–Provide a reference to discuss how things
get done.
–Describe and understand the work we do.
• Analyze and improve on processes.
–Identify of areas of complexity and re-work.
–To generate ideas for improvement.
–Illustrate process improvements.
Basic Flowchart Languages
 Sample Flowchart Manual Example
PROCEDURES MANUAL Document Code: ER-PM-01

ABC Hospital & Medical Center Revision No. 0 Page 2 of 3

Division: EMERGENCY ROOM Effectivity Date: August 14, 2007

Title: SCREENING AND ASSESSMENT PROCEDURE

Responsibility Activities Remarks

Start

The assigned nurse gets the

Patient Info
patient’s personal information
Assigned Nurse Receive and register such as name, age, address, etc.
Sheet
patient Write data in the information
sheet.

Assigned Nurse Get vital sign The assigned nurse writes vital
signs in the information sheet

Check/ diagnose
ERMO patient The assigned nurse takes
necessary actions based on the
instructions of the ERMO.
Bring patient to
Assigned Nurse appropriate division

Assigned Nurse Ask patient if he has

preferred doctor

Preferred B
no
doctor?

yes

Prepared by: John dela Cruz Approved by: Peter Reyes

 PROCEDURES MANUAL Document Code: ER-PM-01

ABC Hospital & Medical Center

Division: Procedures Manual Example
EMERGENCY ROOM
Revision No. 0 Page 3 of

Effectivity Date: August 14, 2007

3

Title: SCREENING AND ASSESSMENT PROCEDURE

Responsibility Activities Remarks

The assigned nurse if the

Assigned Nurse Locate preferred preferred doctor is within the
doctor hospital premises.

Preferred doctor
Assigned Nurse no Inform patient
can be located?

Assigned Nurse Refer him to doctor- B

yes on-duty

Assigned Nurse Patient

Bring to doctor yes
agree?

no

Assigned Nurse end Release patient

V. Records & References:

1. Patient Information Sheet

Prepared by: John dela Cruz Approved by: Peter Reyes