Practicum: Root Cause Analysis Drew Zavatsky Risk Management Division Office of Financial Management 9/18/2018

Goals Understand root cause analysis Practice using different methods Discuss common workplace issues Share best practices 9/18/2018

Key Definitions Root Cause: the underlying reason(s) for the occurrence of an event Root Cause Analysis (RCA): any problem solving method that identifies and treats the source(s) of problems or events to prevent them from recurring 9/18/2018

Why Use Root Cause Analysis? Efficient: use resources to treat causes, rather than symptoms Efficient: ounce of prevention better than a pound of cure 9/18/2018

Symptom v. Root Cause Analysis Symptom Approach: Root Cause Approach: “Errors are often the result of worker carelessness.” “Errors are a result of system issues; people are only part of the process.” “We need to train and motivate workers to be more careful.” “We need to find out why this is happening and fix the problem.” “We don’t have the time or money to get to the bottom of the problem.” “This is critical. We need to fix it now so that it doesn’t happen again.” 9/18/2018

Why Use Root Cause Analysis? Efficient: use resources to treat causes, rather than symptoms Logical: a logical approach to problem solving, using already-existing data Useful: can identify current and future agency improvement needs Healthy: improves agency culture Healthy: Improves agency culture by shifting from a culture of blame to a culture of problem-solving 9/18/2018

Steps in a Root Cause Analysis Verify the incident and define the problem Commission an RCA investigation Map a timeline of the event(s) Identify critical event(s) Analyze the critical event(s) (cause/effect) Identify root causes Support each root cause with evidence Identify and select the best solutions Develop recommendations Write and present the report Track implementation of solutions 9/18/2018

Basic RCA Considerations RCA must be performed systematically Conclusions supported by documented evidence There is usually more than one potential root cause for a given problem RCA must establish all known causal relationships between root cause(s) and the defined problem 9/18/2018

Basic RCA Considerations (cont.) Every problem/issue is an opportunity to improve your organization All employees should be committed to quality improvement Root causes should be understood before taking corrective action 9/18/2018

Root Cause Analysis Team Team should include a cross section of agency staff Brainstorm on causes in several categories: Communication Other Human Factors Equipment Rules/Policies/Procedures Controllable Environmental Factors Uncontrollable Environmental Factors Others Communication: are there barriers to communication of potential risks? To communication of risky situations? 9/18/2018

Root Cause Brainstorming Human factors: Staff Qualifications Actual staff levels v. ideal staff levels Contingency plans for inadequate staffing How is staff performance addressed Impairment Fatigue Distractions 9/18/2018

Root Cause Brainstorming (cont.) Environmental Factors: Was the physical environment appropriate for the circumstances? What systems were in place to identify environmental risks to safety? Did the systems work? Could the systems work under the circumstances? What emergency and failure mode responses had been planned, tested, and or practiced? 9/18/2018

Root Cause Brainstorming (cont.) Uncontrollable Factors: Identify the factors Natural disaster Loss of power Bad weather Actions of a 3rd party Identify what can be done to protect against these factors 9/18/2018

Root Cause Analysis Techniques The “5 Whys” Fishbone “Reactive Method” 9/18/2018

The 5 Whys The method literally requires asking “why” several times Not necessarily restricted to 5 steps Continue to ask until the answer becomes irrelevant Make a chronology Let’s try it! “Irrelevant” ex: gravity. 9/18/2018

Fishbone A fishbone diagram is used when there are many likely causes of an incident Let’s practice using this technique Policies can include instructions. Environment can include design issues. The diagram allows the team to systematically analyze cause & effect relationships. 9/18/2018

Fishbone – how to do it State the issue/problem clearly Label relevant categories for analysis Brainstorm all possible causes, label them in the appropriate category Analyze causes, rank them and circle the most likely ones Investigate the circled causes 9/18/2018

Fishbone – practice tips Try to stay within the area of control of the group Everyone should participate Keep an updated copy of the chart for easy reference by all team members 9/18/2018

Reactive Method Identify Problem Initial Response (Situation Analysis) Repetitive event? (Incident Analysis) Specific to a work group? (Root Cause Analysis) Problem occurs regardless of workgroup or subject? (System Analysis) Always ask: did the solution influence the problem? 9/18/2018

Best Practices Close Calls Be focused, yet open-minded Be patient, quick, and relentless If there are a growing number of close calls, it probably means an RCA should be undertaken. 9/18/2018

Best Practices - Causation Causal statements must clearly show the link between the root cause and the undesirable outcome Do not use negative descriptors Always ask, “is this the only reason this happened?” Failure to act is only causal where there is pre-existing duty to act. Negative words do not describe actual conditions 9/18/2018

Example: no negative words “The agency used a poorly written procedure when putting patients in restraints.” Better to say: “The restraint procedure has 8 point font and no illustrations, so staff don’t use it. This increases the likelihood that restraints are applied incorrectly.” 9/18/2018

Example: fix systems, not people “Staff did not notice the resident was missing for at least 8 hours.” Better to say: “Due to a malfunction in the door/vest wandering alarm, a resident was able to exit the facility undetected.” 9/18/2018

Example: fix “norms” not people “Staff do not communicate on inmate status before shift changes” Better to say: “Shift schedules do not allow staff time to properly communicate about inmate status” 9/18/2018

Open discussion: current issues Are you currently using RCA in your state’s risk management processes? If so, what has been your experience using it? Do you use RCA as a loss prevention technique? Any lessons learned you’d like to share? 9/18/2018

Conclusion RCA leads to a cultural transformation – Solutions, not blame Every problem is an opportunity Everyone participates Thank you for your participation today! Drew Zavatsky Loss Prevention Coordinator Risk Management Division, Office of Financial Management 210 11th Avenue SW Olympia, WA 98504 (360) 902-9813 drew.zavatsky@ofm.wa.gov 9/18/2018