Root Cause Analysis

Course Dates: November 28, 2017 - November 30, 2017
Enrollment Dates: Enroll Anytime
Class Size: 5 (5 places left)
Who can Enroll: Anyone
Course Language: English
Price:  FREE
Root Cause Analysis

About this course

Methodology Overview

Preparation for the Root Cause Analysis

  1. Identify the event or condition to be analyzed (Admin Data Screen)
  2. Assign the team leader and team facilitator (Admin Data Screen)
  3. Assign members to the analysis team (Admin Data Screen)
  4. Determine the data and material to be secured (Data Needs Screen)
  5. Determine the data to acquired (Data Needs Screen)
  6. Collect information prior to the first team meeting (Data Needs Screen)
  7. Document any immediate actions taken (Immed Actions Screen)
  8. Identify proximate causes (Prox Causes Screen)
  9. Generate a detailed sequence of events (Event Sequence Screen)
  10. Generate a detailed sequence of events (Event Sequence Screen)

 

First Root Cause Analysis Team Meeting

  1. Establish expectations
  2. Introduce team members
  3. Identify ground rules
  4. Describe the methodology
  5. Designate a “Parking Lot” (see parking lot icon )
  6. Review and finalize the “proximate (or immediately obvious) cause(s) of the event
  7. Review and finalize the detailed actual (and optimal) sequence of events
  8. Review and finalize the immediate corrective actions (if any)
  9. Mark sequence of event items which may be contributory factors
  10. Brainstorm to identify potentially contributory factors (Brainstorming Screen)
  11. Cue further brainstorming using Barrier Identification (Barrier ID Screen)
  12. Cue further brainstorming using the Sentinel Event Factor Guide (SE Guide Screen)
  13. Edit and affinitize all the brainstorm items (Affinitization Screen)

 

Between the First and Second Root Cause Analysis Meetings (Team Leader and Facilitator)

  1. Complete any remaining items in the Sentinel Event Factor Guide (if submission required)
  2. Develop a preliminary Contributory Factor Diagram (Factor Tree Screen)
  3. Ask “Why?” and “How?” to identify root causes or root contributors
  4. Identify items on the Contributory Factor Diagram as “contributory,” “non-contributory” or “insufficient data”
  5. Assign other team members to collect any data identified as being needed
  6. Optimize the Contributory Factor Diagram

Second Root Cause Analysis Team Meeting

  1. Solicit team input to and modification of the Contributory Factor Diagram
  2. Finalize item designation as “contributory,” “non-contributory” or “insufficient data”
  3. Identify “High-Visibility, Non-Contributory Factors” for special reporting
  4. Finalize the Contributory Factor Diagram, identifying root causes or root contributors (Factor Tree Screen)

Between the Second and Third Root Cause Analysis Meetings (Team Leader and Facilitator)

Prepare several copies of the Contributory Factor Diagram

Third Root Cause Analysis Team Meeting (occasionally requires two meetings)

  1. Present Contributory Factor Diagram for final approval, with changes as team desires
  2. Generate Risk Priority Score for each root contributor (Prioritization Screen)
  3. Generate at least one corrective or improvement action for each identified root cause or root contributor (root causes with a low RPN may be ignored based on available resources) (Recommendations Screen)
  4. For each such action item, identify the responsible person(s), action due date, method of evaluation, responsible party and evaluation follow-up date (Actions Taken – RCs Screen)
  5. Generate at least one corrective or improvement action for each identified incidental finding (optional but valuable for quality improvement) (Incidentals Screen)
  6. For each such action item, identify the responsible person(s), action due date, method of evaluation, responsible party and evaluation follow-up date (Actions Taken – IFs Screen)
  7. Address “Parking Lot” items
  8. Establish plan for communication of analysis report

 

Final Report

  1. Team leader and facilitator finalize written report
  2. Submit report to local risk management advisory committee for approval
    • If approved:
      • Terminate team
      • Distribute report
    • If not approved:
      • Use shortfalls identified by advisory committee to guide root cause analysis team in remediation
      • Resubmit report for approval
    • Distribute report
    • Responsibility for assurance of implementation and follow-up devolves to the organization’s ongoing performance improvement office, or equivalent.

 

 

 

This entry was posted in . Bookmark the permalink.