2011 AHCA/NCAL QUALITY SYMPOSIUM
SAN ANTONIO, TEXAS
A Focus on Prevention: Finding
the Root Cause
John M. “Chick” Stepahin, Ph.D.
Thursday, February 17, 2011
If you think the effort involved in
quality improvement is not
worth it, consider the cost of
failure…
Do it right the first time






Zero defects
Quality circles
Statistical process control
Professional results in daily efforts (PRIDE)
Total quality management
Kaizen
Root cause analysis can be a powerful tool
to help determine current obstacles to
improvement, as well as identify those
particular areas in which operational and
process improvements might produce the
greatest benefits.
Reactive verses proactive
The difference between QA and QI
As the name implies, the root cause is the
most basic reason a problem has
(reactive) or could (proactive) occur…
Root cause analysis techniques are most
often used in the reactive mode….
…to uncover the reason(s) for problems
that have already occurred
Root cause analysis is only one of the
many tools that should be used to
support any quality improvement
effort. Used in a “reactive mode,” it
can prevent problems from recurring.
Used in a “proactive mode,” it can
examine current operations and help
to identify areas and activities that
can be improved.
Definition: Root cause analysis is
identifying the most basic reason for an
undesirable condition or problem which,
if eliminated or corrected, would have
prevented it (the condition or problem)
from existing or occurring.
Most management texts agree that the
normal management functions include:




Planning
Organizing
Directing
Controlling
Plan
Control
Prevention
Direct
Organize
There are many root cause analysis
techniques…..
…the good news is that almost any of them could/should work for
almost any problem.
Problem Nature
Change
Analysis
Barrier
Analysis
Events and
Causal Factors
Analysis
Tree
Diagrams
Organizational
Good
Best
____
Better
Activity or Process
Good
Best
Good
Better
Reorganization
Best
Good
____
Better
New or Changed Activity
Best
Better
____
Good
Personnel
Good
Best
Better
____
Accident or Incident
Good
Better
Best
Good
RCA Methods

Less Structured approaches:
 Intuition
 Networking
 Experienced

More Structured approaches:








PERT, CPM, or other time-event networks
Flowcharts or process charts
Process control charts
Trend analysis
Pareto diagrams
Nominal group techniques
Brainstorming
Etc.
Scientific Process and Root Cause
Analysis:






Defining the problem
Formulating Hypotheses
Gathering appropriate data
Evaluating potential solutions
Objectively test and revise the solutions
Develop a final list of potential solutions
Overall System
Continual
Improvement
Customer
Expectations
Problem
Reporting
Root Cause
Analysis
Fault
Correction
Performance
Based
Assessment
Project/Process
Management
Trend Analysis
RCA Techniques…





Change Analysis
Barrier Analysis
Events and Causal Factors Analysis
Tree Diagrams
Etc.
Change Analysis…
…is an analytical technique which applies a
systematic approach to problem solving by
examining the effects of change. Change
analysis may be performed in a reactive mode
by analyzing unwanted events or problems, or
in a proactive mode by identifying the potential
effects of changes before they are
implemented.
Change analysis is perhaps the simplest of all the
formal root cause analysis techniques and that
most likely to be influenced by subjectivity or
bias.
Barrier analysis….
…the focus is on the barriers or
safeguards that should have prevented or
mitigated the unwanted event or problem.
Barrier analysis normally is used in a
reactive mode to solve surfaced problems
or investigate events.
Barrier analysis also can help to identify
missing safeguards, those that might have
prevented the problem if they had been in
place.
Events and Causal Factors Analysis…
…provides a detailed analysis of the
event sequence and associated causes
or conditions. Events and causal factors
charting is a very effective tool for
analyzing “why” an event happened.
Events and causal factors analyses often
are used in conjunction with other root
cause analysis techniques, particularly
change and barrier analysis.
Tree Diagrams…
…are graphical displays of an event which
logically describes each of the event’s
contributing factors. Tree diagrams are
extremely useful in helping visualize and
analyze more complex systems or problem
situations.
When used reactively to investigate accidents and
events, they are called fault or root cause trees.
When used proactively to systematically plan and
organize requirements for organizations,
programs and projects, or future improvements,
they are called positive trees.
Other structured root cause analysis
techniques:




Management Oversight and Risk Tree
Analysis (MORT)
Human performance evaluation systems
Cause and effect (fishbone) diagrams
Others
The quality journey and your destination…
There are different levels at which
organizations might presently be operating.
Where are you?
1st level - finding and correcting of problems,
with many being washed downstream.
2nd level – finding and fixing problems in such a
manner they do not recur.
3rd level – the organization seeks to prevent
problems or faults – they do not let them
occur.
Root cause analysis is only one piece of the
puzzle in your quality journey. Although root
case analysis is a vital element of any quality
and productivity program, it is most effective
when used in conjunction with the other
elements.
Root Cause Analysis
case study application
2011 AHCA/NCAL Quality Symposium:
Inspiring Excellence in Long Term
Care
I hope our session today
reinforced your dedication to
striving for excellence and
provided you another tool and
insight for your quality journey!
John M. Stepahin
chick@stepahin.com
903.238.4463