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

2. Goals Understand root cause analysis Practice using different methods
Discuss common workplace issues
Share best practices
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3. 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
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4. Why Use Root Cause Analysis?
Efficient: use resources to treat causes, rather than symptoms
Efficient: ounce of prevention better than a pound of cure
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5. 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.”
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6. 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
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7. 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
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8. 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
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9. 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
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10. 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?
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11. 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
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12. 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?
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13. 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
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14. Root Cause Analysis Techniques
The “5 Whys”
Fishbone
“Reactive Method”
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15. 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.
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16. 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.
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17. 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
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18. 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
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19. 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?
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20. 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.
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21. 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
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22. 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.”
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23. 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.”
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24. 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”
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25. 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?
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26. 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
(360)
9/18/2018