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Root Cause Analysis! #1 Powerful Tool for Problem-Solving

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Introduction

Root cause analysis is a powerful tool that can help you solve problems and improve your outcomes. By identifying the root causes of problems, you can prevent them from happening again. This can lead to significant improvements in your processes, performance, and bottom line.

In this blog post, we will discuss the basics of root cause analysis and how you can use it to solve problems in your own business. We will also provide some tips for writing a root cause analysis report.

 

So if you are looking for a way to improve your problem-solving skills, root cause analysis is a great place to start

What is root cause analysis?

image of root cause analysis

Root cause analysis (RCA) is a systematic approach to identifying the underlying causes of problems. It is a powerful tool that can be used to improve patient safety, develop new treatments for diseases, and troubleshoot machine failures.

 

RCA involves identifying the symptoms of a problem, gathering data, and then asking “why” repeatedly to identify the root causes. This can be a challenging process, but it is essential to identify the true root causes of problems so that they can be prevented from happening again.

 

RCA is a valuable tool that can be used in a variety of settings, including healthcare, medicine, and machine troubleshooting, problem solving. By understanding the root causes of problems, we can make informed decisions about how to improve our systems and processes, and ultimately prevent future problems.

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Why is it important?

 

It can help to identify the true root causes of problems, rather than just the symptoms.

It can help to prevent future problems by identifying and addressing the underlying causes.

It can help to improve communication and collaboration between different teams or departments.

It can help to build trust and confidence among stakeholders.

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How does it work?

The RCA process typically involves the following steps:

 

Define the problem. What is the problem that you are trying to solve? What are the symptoms of the problem?

Gather data. Collect information about the problem, such as reports, logs, and interviews.

Identify causal factors. What are the factors that contributed to the problem? These factors can be both immediate and underlying.

Determine the root cause(s). What are the root causes of the problem? These are the factors that, if changed, would prevent the problem from happening again.

Recommend solutions. What can be done to prevent the problem from happening again?

RCA is a valuable tool that can be used to improve patient safety, develop new treatments for diseases, and troubleshoot machine failures. By understanding the root causes of problems, we can make informed decisions about how to improve our systems and processes, and ultimately prevent future problems.

 

Here are some examples of how root cause analysis can be used:

  1. In healthcare, RCA can be used to identify the root causes of medical errors. This information can then be used to improve patient safety and prevent future errors.
  2. In medicine, RCA can be used to understand the root cause of diseases. This information can then be used to develop new treatments and prevention strategies.
  3. In machine troubleshooting, RCA can be used to identify the root causes of machine failures. This information can then be used to prevent future failures and improve machine reliability.
  4. In Aviation
  5. In IT Operations
  6. In finding root cause of chronic diseases

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Application of root cause analysis in healthcare

Example:

Performance Health Partners have written an  article “Developing an Effective Root Cause Analysis in Healthcare” on their website. This information will be useful for those who want to know details about the RCA process in healthcare. I am giving it here for the benefit of my readers.

How can healthcare organizations develop an effective root cause analysis in healthcare? Read on to learn how your organization can improve outcomes and reduce costs.

 

What is Root Cause Analysis for Healthcare?

 

Root Cause Analysis (RCA) “is a structured method used to analyze serious adverse events” in healthcare. (1) The goal of an RCA is to identify any underlying problems in processes that increase the likelihood of an error with a non-punitive approach.   When done effectively, an RCA can identify factors that contributed to an adverse event so that measures can be put in place to address contributing factors, improve patient safety, reduce incidences happening in the future and reducing the costs associated with risk.

 

Creating a safe, fear-free environment for incident reporting is important in order to initiate a thorough Root Cause Analysis. Reporting an incident triggers the initiation of an RCA.

 

Furthermore, the methodology used to conduct the RCA is important in understanding why an incident happened, and how to prevent it from happening in the future.

 

By systematically analyzing the causes and effects of the various components of a process, a RCA is used to identify breakdowns in processes and systems that contributed to an adverse event. When done effectively, root cause analysis in healthcare can improve safety, reduce future incidents, and ultimately lower total cost of risk.

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Three Questions to Answer

 

While methodologies may differ, the RCA process is designed to answer three questions:

 

  1.     What happened?
  2.     Why did it happen?
  3.     What can be done to prevent it in the future?

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7 Types of Tools for Root Cause Analysis in Healthcare

  1. 5 Whys

This is a simple tool that is appropriately used to get to the root cause of a straight forward problem that does not necessitate the use of advanced statistics.

Simply ask the question “Why?” five times, which allows you to discover the root cause of the problem more clearly when you find that the answers to the “Why” questions are interrelated.

For example:

  1.         Why did the patient break his hip? Answer: Because he fell.
  2.         Why did the patient fall? Answer: Because he lost his balance.
  3.         Why did he lose his balance? Answer: Because he had nothing to hold onto.
  4.         Why was there nothing for him to hold onto? Answer: He was unable to use his walker.
  5.         Why was he unable to use his walker? Answer: The walker was in the closet and not readily accessible for his use.

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  1. Failure Mode and Effects Analysis

Use this RCA tool to identify which parts in a process are faulty so they can be corrected. It determines the number of times the failure occurs, the actions implemented by the organization to streamline the process in order to prevent the failure from recurring, and if interventions to improve the process were effective.

Many organizations use this tool every time a new process is initiated.

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  1. Fault Tree Analysis

This tool involves the creation of a diagram that looks like a tree where all potential causes of the problem are depicted as branches.  Boolean logic, using the terms “And”, “Or”, or “Not”, are applied to each potential cause in order to identify the root cause of the problem. This tool is generally used for complex processes and by those familiar with utilizing Boolean logic.

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  1. Fishbone Diagram

The shape of a fishbone is used to group potential root causes into different sub-categories such as methods, measurements, materials and many others for easier determination of the cause. This tool is relatively easy to use in determining the root cause in complex processes.

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  1. Scatter plot or scatter diagram

This a quantitative method of determining if two variables are correlated. This tool is often utilized in combination with the fishbone diagram as a means to test potential root causes.

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  1. Pareto chart

This is used to group the frequency or cost of different problems to show their relative significance. The bars show frequency or cost in descending order, while the line shows cumulative percentage or total as you move from left to right. Organizations utilize this tool when they want to show the frequency of problems that occur in process or the costs associated with the breakdown of the process.

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  1. RCA2

Root Cause Analysis Squared was developed by the National Patient Safety Foundation (2015) in an effort to ensure that appropriate and time actions are taken in response to RCA analyses to prevent future harm. The publication is frequently used by health care organizations as a guide on how to conduct efficient and effective RCAs . (5)

 

The RCA2 process involves specific activities that start with defining which events and close calls are worthy of review and which events are blameworthy. Specific guidelines are prescribed for review team membership and timing of each activity throughout the RCA2 process. There is also embedded into the review process active participation by organizational leadership and a strong emphasis on implementation of steps to reduce the risk of a recurrence of the event.

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How do standardized processes and maximize Root Cause Analysis?

 

Conducting an RCA involves data collection, staff interviews, and literature reviews which culminates in identifying the root cause of a problem and recommendations that will minimize or eliminate the risk of recurrence of the incident.

 

Related Articles

Behavioral risk factors : https://maintaincholesterol.com/blog/behavioral-risk-factors/

The dangerous link between smoking and nutrient depletion: https://maintaincholesterol.com/blog/smoking-and-nutrient-depletion/

Status if chronic diseases: https://maintaincholesterol.com/blog/current-status-of-chronic-diseases/

What are chronic diseases? https://maintaincholesterol.com/blog/what-are-chronic-diseases

Risk factors for chronic diseases: https://maintaincholesterol.com/blog/risk-factors-for-chronic-diseases/

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References

Root Cause Analysis. Patient Safety Network. Agency for Healthcare Research and Quality. Retrieved on August 7, 2019 at https://psnet.ahrq.gov/primers/primer/10/root-cause-analysis

“What are common Root Cause Analysis (RCA) tools?”. (March 3, 2017). us. Retrieved on August 7, 2019 at https://www.6sigma.us/gsa/

Foster, P. (Oct. 30, 2018). 5 Root Cause Analysis Tools for More Effective Problem-Solving. Beacon Quality. Retrieved on August 7, 2019 at https://www.ease.io/5-root-cause-analysis-tools-for-more-effective-problem-solving/

“What is Boolean logic?” Lotame. Retrieved on August 10, 2019 at https://www.lotame.com/what-is-boolean-logic/

RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. (2015). National Patient Safety Foundation. Retrieved on August 10, 2019 at https://c.ymcdn.com/sites/www.npsf.org/resource/resmgr/PDF/RCA2_first-online-pub_061615.pdf

What is a Fault Tree Analysis? (March 2002). Quality Progress. Retrieved on August 19, 2019 at http://asq.org/quality-progress/2002/03/problem-solving/what-is-a-fault-tree-analysis.html

Gartlehner G, Schultes M, Titscherl V, Morgan, LC, Bobashev, GV, Williams, P, and West SL. (December 2017). User testing of an adaptation of fishbone diagrams to depict results of systematic reviews. BMC Medical Research Methodology. Retrieved on August 19, 2019 at https://link.springer.com/article/10.1186/s12874-017-0452-z

Hudgins, JD, Goldberg, V, Fell GL, Puder M, and Eisenberg MA. (November 2017). Reducing Time to Antibiotics in Children With Intestinal Failure, Central Venous Line, and Fever. Pediatrics. Vol 140; Issue 5. Retrieved on August 19, 2019 at https://pediatrics.aappublications.org/content/140/5/e20171201.figures-only

 

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