Doing RCA Right!

TM

Proactive RCA: Turning RCA Into ROI

2011 Reliability Center, Inc.

Doing RCA Right! TM

1972 1985:
Allied Chemical R&D
1985 Present:
RCI

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
2011 Reliability Center, Inc.

Doing RCA Right! TM

Sample Client Listing

2011 Reliability Center, Inc.

Doing RCA Right! TM

Is This Insane?

2011 Reliability Center, Inc.

Doing RCA Right! TM

Common
Acronyms

Root Cause Analysis (RCA)

Performance Improvement (PI)
Continuous Improvement (CI)
Problem Solving (PS)
Trouble Shooting (TS)
Six Sigma/Lean Six Sigma (SS/LSS)
Brainstorming

No Matter What Acronym We

UseThis is Simply Critical Thinking!
2011 Reliability Center, Inc.

Whats The
Problem?

Doing RCA Right! TM

Performance GAP Analysis

System Units of Measurement (%)

Potential/Desired State

Actual/Current State

GAP = Undesirable Outcomes

Time
2011 Reliability Center, Inc.

Doing RCA Right! TM

FMEA and Opportunity Analysis

Where do candidates for RCA come from now?

Proaction
FMEA

Reaction

Opportunity
Analysis

FMEA

Regulatory
Events (Suits)

OA
SRE

Root Cause Analysis

2011 Reliability Center, Inc.

Doing RCA Right! TM

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

32

Adverse
Events
Involving
Children

Wrong
Dose

Length of
Stay
Extended

Increased Claims

21

Car Risks

Engine
Light

Engine
Malfunction

Car Will Not Drive

10

30

2011 Reliability Center, Inc.

Doing RCA Right! TM

Introducing FMEAs Sister

- Opportunity Analysis (OA)
The Basic OA Analysis Process:
1.
2.
3.
4.

Perform preparatory work

Collect data
Calculate the loss
Determine the Significant Few
2011 Reliability Center, Inc.

Doing RCA Right! TM

1A - Perform Preparatory Work

Identify The Scope of Analysis
Healthcare

ED

Cardiac

Pediatrics

Oncology

LDR

Pulp Mill

Paper
Mill

Finishing

Storage

Project
Planning

Project
Prep

Project
Execution

Project
Close

Industry

Raw
Material
Service

Purchase
Order

Will one department or process be involved in the Analysis, or

Many? Dont try and tackle world hunger in such an analysis, you
will lose your team!
2011 Reliability Center, Inc.

Doing RCA Right! TM

1B - Perform Preparatory Work

Define What is a FAILURE/LOSS in
the system you are analyzing?

2011 Reliability Center, Inc.

Doing RCA Right! TM

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)
2011 Reliability Center, Inc.

Doing RCA Right! TM

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
Dispensed

Medication
Transported

Medication
Prepared

2011 Reliability Center, Inc.

Doing RCA Right! TM

1C- Perform Preparatory Work (OA)

Sample Failure Modes
Sub
System

Event

Mode

Freq.

Impact/Occurrence

Total Annual
Loss

$473,200

(Preventable=$2595
Non-Preventable=$4685)

Doctor
Writes
Order

ADE

Prescribing
Error

130

$3,640

Paper
Machine

Unexpected
Shutdown

Pump Failure

40

$50,000

Ice
Maker

Cant Use
Ice Cubes

Ice Fused
Together

365

$2/day

$2,000,000
$730

2011 Reliability Center, Inc.

Measuring Loss Impact

Per Occurrence

Doing RCA Right! TM

Sub
System

Event

Mode

Freq.

Impact Per
Occurrence

Total
Annual
Loss

Regulatory
Scrutiny
Litigation $$
Labor
Costs

Materials

Loss of Reputation
($$)
Cost of
Investigation

ELOS/Production
Losses

TJC/OSHA
$$
Customer
Complaints

2011 Reliability Center, Inc.

Doing RCA Right! TM

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?)

Block Diagram
Sub
System

Event

Mode

Loss Definition
Freq.

Impact Per Occurrence

Total Annual
Loss

OA Worksheet
2011 Reliability Center, Inc.

Doing RCA Right! TM

3 - Calculate the Loss (OA)

Sub System

Event

Mode

Medicine
Order
Process

ADE

Wrong
Medicine

Paper
Machine

Unexpected
Shutdown

Pump
Failure

Frequency

20 per Year

40 per Year

Cum. Impact
Per Occurrence

Total
Annual Loss

$2,182

$43,640

$50,000

$2,000,000

Apply Loss Formula:

Frequency X Sum of Impacts = Total Annual Loss

2011 Reliability Center, Inc.

Doing RCA Right! TM

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
2011 Reliability Center, Inc.

Doing RCA Right! TM

4 - Determine the Significant Few

The Pareto Split
Sub
System

Event

Mode

The Pareto Split

80 / 20 (or less)
% $$$

Frequency

Impact Per
Occurrence or
Severity

Total
Loss/Yr

Grand Total

$1000

Pareto Cut

.80

Significant Few

800

% EVENTS
2011 Reliability Center, Inc.

Doing RCA Right! TM

4 - Determine the Significant Few

The Business Case!
100%

% of Loss

90%
80%
70%
60%
50%
40%
30%
20%
10%
0%

RCA

Events

10

PI

Significant Few
2011 Reliability Center, Inc.

Doing RCA Right! TM

Exercise Time!
The Car Example

2011 Reliability Center, Inc.

Doing RCA Right! TM

Terminology

PROACT RCA Methodology/

Process Steps
PReserving Event Data (Evidence)

Investigation
Phase

Ordering the Analysis Team

Analyzing Event Data
Communicating Findings &
Recommendations
Tracking For Bottom Line Results

Analysis Phase

Correction Action
Phase

2011 Reliability Center, Inc.

Doing RCA Right! TM

Undesirable
Outcome

Physical Root
Causes

Human Root Causes

Latent Root
Causes
Policies &
Procedures

Human Factors

Communication

Technology

Training

Management
Oversight

Deficient Organizational Systems

2011 Reliability Center, Inc.

Lets Reverse The

Path Now!

Doing RCA Right! TM

The Logic Tree Cause and Effect RCA

EVENT: Least Acceptable
Consequence of an
Undesirable Outcome

How Could?
How Could?
PR
HR
LR

Deepest
Significant
Underlying
Causes

How Could?
How Could?
Why?
2011 Reliability Center, Inc.

Doing RCA Right! TM

Reasons Swiss Cheese Model

James Reasons, Human Error, 1990

Incorrect
Medication
Dispensed

Patient Has
Allergic
Reaction

Decision to
Curb Scope of
Formulary

P
H
Y
S
I
C
A
L

H
U
M
A
N

Unavailability of
Correct
Medication

L
A
T
E
N
T
Pressure to Cut
Budget By 10%

2011 Reliability Center, Inc.

Doing RCA Right! TM

Putting Failure Into Proper Context

What would you say is the Problem in this
case?

The Womans Tee

2011 Reliability Center, Inc.

Doing RCA Right! TM

Case Study Time

Pick a Failure!

2011 Reliability Center, Inc.

Doing RCA Right! TM

Human Factors

Why Do Mix-Ups Occur?

The LIVESTRONG Mix-Up Potential

Yellow wristbands can be a visual signal of a

patients request for a DNR
2011 Reliability Center, Inc.

Doing RCA Right! TM

Did You Know?

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
2011 Reliability Center, Inc.

Doing RCA Right! TM

Did You Know?

Why Do Mix-Ups Occur?

Human Factors in Design Brain Processing Capability

10 Chunks

8044580645
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)
2011 Reliability Center, Inc.

Doing RCA Right! TM

Is Seeing,
Believing?

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.
2011 Reliability Center, Inc.

Procedures and Proper

Communication CAUTION!

Doing RCA Right! TM

Engineering Logic
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."

2011 Reliability Center, Inc.

Doing RCA Right! TM

Procedures and Proper

Communication CAUTION!

Why I Got Fired

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

2011 Reliability Center, Inc.

Doing RCA Right! TM

Thanks for Your Time and

Participation, We Hope You Enjoyed
Our Session.
Thanks for the Opportunity!
www.Reliability.com
2011 Reliability Center, Inc.