490-Root Cause Analysis Revised For Miami 16

Analysis (RCA)
Introduction to Root Cause
© Copyright, Joint Commission International

What is a Root Cause
– Root Cause: The underlying source
of an error, failure, or accident
– Most errors, failures, or accidents

have multiple causes, but fewer

(often one) root cause.
2
Client name/ Presentation Name/ 12pt - 2
What is a Root Cause
Analysis?
– A Root Cause Analysis seeks to
determine the root cause of an error,
failure, or accident.

3
What does Root Cause
Analysis (RCA) do?
Multiple tools, including 5 Types of causes: Apparent and
Whys and Ishikawa Underlying
– Identify the causes that lead to variation

from our performance expectation.
Performance Types of Variation: Common

Cause and Special Cause

Expectation: What we
want to happen (e.g. 0 variation
Sentinel events)
In other words—what is causing us to

miss our performance goals?
4
Analysis (RCA) do?



Sentinel events)

5
Performance Expectations
– A standard that we want to meet
– Room service delivered within 30 minutes
– Zero Sentinel Events
– Lab work completed within 24 hours
– Good performance expectations are
– Measurable
– Specific

– Within our control
– RCAs are most effective when they
analyze a failure of a clear performance
expectation
6
Analysis (RCA) do?



Sentinel events)

7
Types of Causes
Apparent Causes Underlying Causes
–“Proximate Causes” –The causes that lead to
–What factor(s) led our apparent cause
directly to the “error”? –What factor(s):
–Usually, easy to see – Allowed the “error” to
happen
– Failed to prevent the
“error”
– Started a chain of

events that led to the
“error”
–May be a Root Cause
–Usually, harder to see
8
Types of Causes in a Car
Accident
Apparent Causes Underlying Causes
–Driver did not hit the brakes –Driver reaction time slow
fast enough to avoid hitting because of lack of sleep the
the car in front of them Why? previous night
Why? –Driver did not get enough
sleep because they were
stuck in the ED until 3 AM,
but still needed to report for
their 7 AM shift
–Driver needed to report at 7

Why?
AM because the hospital was
short-staffed on this holiday
weekend.
–The hospital was short
Why? staffed because they do not
have a staffing plan that
assures adequate staff on
holidays. 9
The Five Whys
– We have just performed a simplified
version of the first RCA technique:
the Five Whys.

12
How to Use the Five Whys
– First, ask “Why did this error occur?”
– The driver didn’t hit the brakes fast
enough.
– Then, ask “Why did that occur?”
– They were tired

– They were stuck in the ED until 3 AM
13
Why not the Six Whys?
– Asking “Why” five times is generally
sufficient to identify a root cause.
– If you have not discovered a
satisfying root cause after asking
“why” five times, keep going until

you do.
14
The Washington Monument
The Washington Monument
The chemicals
is deteriorating.
we spray on the
building are very
harsh Because
the bugs
Why? are
attracted
Why? to the
To clean brightest
pigeon Spiders eat the object at
droppings bugs that live

Pigeons eat dusk.
on the
spiders that monument
nest near the
monument
Why?
Why?
Why?
15
Exercise: The Five Whys
– Arrange yourself in groups of 4-7.
– Select a single error, accident, or
failure.
– For the purposes of this exercise,
you may use a fictional failure.

– Perform the Five Whys as a group, to
discover the root cause.
16
RCA Team Makeup
– Good RCA Teams often include the
following:
– People involved (directly or indirectly) in the
failure
– Team Leader
– Objective
– Not part of the process
– Experience conducing RCAs

– Not always the most senior member of the
team
– 5-8 members
18
Problems with the Five Whys
– Although it is a useful tool, the “Five
Whys” does have faults.
– Root cause depends on the group’s knowledge
– Different groups = different root causes
– It can be difficult to know when you have
discovered the real root cause

– There may be several answers that answer a
single “why?” By selecting one, we choose
simplicity over complexity, and may miss
important causes that are not the main cause
It may be helpful to consider a tool that
attempts to collect allClient
of name/
the Presentation
potential causes 19 of
Name/ 12pt - 19
an error.
Tool 2: Ishikawa Diagram
– If you are concerned about capturing
and assessing multiple root causes,
consider using the Fishbone Tool.
– Like “5 Whys,” this tool requires a
team to brainstorm causes.

– Also known as a “Fishbone Diagram”
20
The Ishikawa Tool
Start with an explanation of the “problem”
The basic
explanation of
the problem.

21
The Ishikawa Tool
Draw “bones” for each category of causes
I missed my
flight

22
The “Bones”
– Consider what are
likely to be the
major categories of
causes that might
be causing your
problem

– Seek 3 to 6
categories
– Consider “the 4 M’s”
23
The Four M’s
– The Four M’s can help you
remember to consider all of the
aspects of a problem.
– Materials
– Methods
– Manpower
– Machines

– Useful way to remind you to consider
aspects of the problem that you
might forget.
24
The Ishikawa Tool
Draw “bones” for each category of causes
Machines Materials
I missed my
flight

Methods Manpower
25
The Ishikawa Tool
Drill down on each category
Machines Materials
Materials Cause 1
I missed my
flight

Methods Manpower
26
The Ishikawa Tool
With the “5 Whys” we only get one
answer each time we ask “Why?”
Materials
Apparent Cause 1
Why?

Underlying Cause 3
Why?
Why?
27
The Ishikawa Tool
With the Ishikawa Tool, we can have
multiple answers each time we ask “why”.
Materials
The underlying Apparent Cause (Materials)

causes are all the
causes that led to Why? Why? Why?

the apparent cause.
They do not need to
relate to the
“Materials”
category
29
The Ishikawa Tool
For each new underlying cause, we ask
why multiple times again….
Materials
Apparent Cause 1 (Materials)
Underlying Cause
Why?

Underlying Cause
Underlying Cause “X” Underlying Cause
Underlying Cause
Underlying Cause
Why?
Underlying Cause
Underlying Cause “Y”
30
The Ishikawa Tool
Sub-divide each cause into sensible
divisions
Keep subdividing by asking “Why?” to get
to more specific causes.
Materials
Ink smudged on my ticket
Nervous about flight
Budget crisis
New pen supplier

Office too warm
New office manager wants
to lower costs
Passport doesn’t match ticket
31
The Ishikawa Tool
• Does everything in the “Materials” bone need
to relate to materials?
Materials
Ink smudged on my ticket
Nervous about flight
Budget crisis
New pen supplier

Office too warm
New office manager wants
to lower costs
Passport doesn’t match ticket
32
How far down do we drill?
– Keep separating causes into sensible
subdivisions.
– You subdivided enough when the
“branches” are:
– Specific

– Measurable
– Controllable
33
The Ishikawa Tool
Machines Materials
Machines Cause 1 Materials Cause 1
Sub-subcause
Materials Cause 2 Sub-subcause
Machines Cause 2 Sub-subcause

Sub-subcause
Sub-subcause
Sub-subcause
Sub-subcause
Sub-subcause Sub-subcause
Machines Cause 3
Sub-subcause
The basic
explanation of
the problem.

Methods Cause 1
Sub-subcause
Methods Cause 2 Sub-subcause
Sub-subcause
Sub-subcause
Sub-subcause
Manpower Cause 1
Sub-subcause
Manpower Cause 2 Sub-subcause

Sub-subcause
Methods Manpower
34
Exercise: Ishikawa Diagram
– In small groups, create your own
Ishikawa diagram.
– For the purposes of today’s exercise,
focus only on one of the “bones.”
Machines Materials
Machines Cause 1 Materials Cause 1

Materials Cause 2
Su
Su
Sub-subcause
Sub-subcause
bc
bc
Machines Cause 2 Sub-subcause

au
au
Su
Su
Su
Sub-subcause
se
se
bc
bc
bc
Sub-subcause
Su use
Su
Sub-subcause
au
Sub-subcause
au
au
bc
bc
se
se
se
Sub-subcause
au
a
Machines Cause 3
se
The basic
explanation of
Methods Cause 1
the problem.
e
Sub-subcause
us
Methods Cause 2 Sub-subcause

a
bc
Sub-subcause
Manpower Cause 1
Su
se
Sub-subcause
se
Sub-subcause
se
se
se
au
au
au
au
au
c
c
c
se
se
se
el
el
bc
el
Sub-subcause
bc
lev
Sub-subcause
lev
lev
Sub-subcause
4 th
au
au
4 th
au
4 th
Su
Su
Manpower Cause 2
bc
bc
bc
Su
Su
Su
Sub-subcause
Sub-subcause
Methods Manpower
se
se
au
au
c
c
el
el
lev
lev
4 th
4 th
35
Problems with Ishikawa
Diagrams
– The complexity of the tool can be
difficult to know which is the “key”
root cause
– Requires more time

37
Other RCA Tools
– Five Whys and Ishikawa Diagrams
are two easy ways to conduct RCAs
on understandable processes
– For some problems, a statistically-
based RCAs may be more useful

38
What to do with a Root
Cause?
– A successful RCA produces a Root
Cause.
– It tells you why you missed your
performance expectation.
– The next step is to fix the cause.

– The solution you select will depend
on what type of root cause you have
identified.
39
Analysis (RCA) do?



Sentinel events)

40
Two Types of Variation
To fix the root
cause, we need to
know what kind of
root cause we have.
– Is our process
functioning but giving

The hospital was short us adverse results?
staffed because they (common Cause)
do not have a staffing
plan that assures Or
adequate staff on – Was our process
holidays. working until it broke?
(special cause) 42
Common Cause (Process
Problems)
•The process reliably produces a similar result
•The results of the process do not meet the
needs of the “customer”

Monday Tuesday Wednesday 50 years ago
44
How do we Fix Common Cause
Variation?
– Common Cause Variation
suggests that your
outcomes are a result of
the process
– If the process does not

meet your performance
expectations, you must
change the process
45
Special Cause (Event
Problems)
•The process produces a satisfactory result

until an unforeseen problem.

Monday Tuesday Wednesday Thursday
46
How do we fix Special Cause
Variation?
– Sources of special cause
variation must be
identified and eliminated
– Eliminating a single
special cause does not

always mean that the error
cannot reoccur.
47
Common vs. Special Cause Variation
Common Cause Special Cause
Variation Variation
–Cause of at least –Attributed to less
85% of the problem than 15% of the cause
–Systems based of the problem
–Improvement usually –Improvement
requires intense requires change by an

analysis of the individual or
system and changes avoidance of an
to the system isolated event
54
RCA Summary

69
Analysis (RCA) do?



Sentinel events)
This analysis helps us understand why

we have missed our performance goals
70
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Analysis (RCA)

Introduction to Root Cause

© Copyright, Joint Commission International

– Most errors, failures, or accidents

© Copyright, Joint Commission International

© Copyright, Joint Commission International

– Identify the causes that lead to variation

Performance Types of Variation: Common

© Copyright, Joint Commission International

In other words—what is causing us to

– Identify the causes that lead to variation

Performance Types of Variation: Common

© Copyright, Joint Commission International

In other words—what is causing us to

© Copyright, Joint Commission International

– Identify the causes that lead to variation

Performance Types of Variation: Common

© Copyright, Joint Commission International

In other words—what is causing us to

© Copyright, Joint Commission International

© Copyright, Joint Commission International

© Copyright, Joint Commission International

© Copyright, Joint Commission International

© Copyright, Joint Commission International

© Copyright, Joint Commission International

© Copyright, Joint Commission International

© Copyright, Joint Commission International

© Copyright, Joint Commission International

© Copyright, Joint Commission International

© Copyright, Joint Commission International

© Copyright, Joint Commission International

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The underlying Apparent Cause (Materials)

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Apparent Cause 1 (Materials)

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New pen supplier

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Passport doesn’t match ticket

New pen supplier

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Passport doesn’t match ticket

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Machines Cause 2 Sub-subcause

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Methods Cause 2 Sub-subcause

Manpower Cause 2 Sub-subcause

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Machines Cause 2 Sub-subcause

Methods Cause 2 Sub-subcause

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© Copyright, Joint Commission International

© Copyright, Joint Commission International

– Identify the causes that lead to variation

Performance Types of Variation: Common

© Copyright, Joint Commission International

In other words—what is causing us to

© Copyright, Joint Commission International

© Copyright, Joint Commission International