1. Root Cause Analysis Workshop Pima Medical Institute, Albuquerque, New Mexico Friday; May 18, 2007; 8:30 am

2. Agenda Welcome Introductions and Participant’s Goals How root cause analysis can be used Group Work Student Retention Student Placement Group Report Brief workshop assessment

3. Welcome Goal of workshop Purpose of workshop Process of workshop

4. Introductions Tell me about yourself Role of the facilitator, Linda Hawkins

5. How Root Cause Analysis Is Used & Example Can be used across the board in many different areas Takes time, effort, and should be have a cost benefit, but the overall goal is to take an occurrence, find out what happened and make sure it never happens again. Example: Joe is absent again and was late for 3 classes before mid-terms. When he is in class, he participates in the activities, takes good notes, turns in his homework and adheres to the dress code. He had a 78 average going into the mid-term but last week he took the mid- term exam and did poorly. He is at risk of failure.

6. Overview Discussion What is Root Cause Analysis? A tool designed to help identify not only what and how an event occurred, but also why it happened. Understanding why an event occurred is key to developing effective recommendations Answering the why question helps to identify root causes to prevent recurrences

7. Overview Discussion Definition Root causes are specific underlying causes More specific the better

8. Overview Discussion Definition Root causes are those that can reasonably be identified Must be cost beneficial

9. Overview Discussion Definition Root causes are those management has control to fix Know exactly why a failure occurred

10. Overview Discussion Definition Root causes are those for which effective recommendations for preventing recurrences can be generated Should directly address the identified root causes

11. Overview Discussion Four Major Steps: Data Collection Causal factor charting Root cause identification Recommendation generation and implementation

12. Overview Discussion Data Collection Goal of the data collection is: Probe the data to determine what happened during the occurrence Describe how it happened Understand why it happened

13. Overview Discussion Casual Factor Chart Sequence diagram that describes events Shape convention: What happened (the occurrence)? Logic questions? Causal factors: Start Causal Factor Chart with beginning data collection. It should drive the data collection process. When the occurrence is charted, start identifying the major contributors with logic questions. What are the causal factors?

14. Overview Discussion Casual Factor Chart Joe is absent Why is Joe absent ? Joe missed the bus Why did Joe miss the bus? Joe didn’t have right change Joe was late for the bus Why was Joe late for the bus? Joe didn’t have a bus schedule Joe worked overtime Joe works during banking hours & couldn’t get change Why didn’t Joe have change? Joe leaves for work then class CFCF CFCF

15. Overview Discussion Root Cause Identification Shape convention: Primary issue: Problem category: Root cause category: Near root cause: Root cause: Develop Root Cause Map Purpose is to identifying the underlying reason or reasons for each causal factor

16. Overview Discussion Root Cause Identification Start here w/each CF Equipment difficulty Equipment availability problem? Admin/Mgt Availability Problem? Student Resource Problem? Procedures Issue? Change machine Bus pass dispenser Problem ID Control Problem reporting Problem analysis Audits Corrective Action Corrective actions not yet implemented  Design Input  Design Output No training  Decision not to train  Training requirements not identified Training records system  Training records incorrect  Training records not up to date Training  Job/task analysis  Program design/objectives  Lesson content  Training resources Not used  Not available/inconvenient  Procedure difficult to use  Use not required but should be  No procedure or task Misleading/confusing  Format confusing  More than 1 action per step  Inadequate checklist  Difficult to identify

17. Overview Discussion Root Cause Summary Table Recommendation Generation and Implementation Goal: Achievable recommendations for preventing its reoccurrence Provide Joe a bus route schedule and map Provide Joe a bus pass As required, develop an implementation plan for achievable recommendations

18. Overview Discussion Root Cause Summary Table Casual FactorPaths Through Root Cause MapRecommendations Description Equipment difficultyContact City of Albuquerque for supply of bus routes & maps Joe didn't have a bus ScheduleEquipment reliability program implementationSet up distribution area No ProgramCommunicate to students about availability Description Joe didn't have the right changeEquipment DifficultyProvide bus passes for students through a dispenser Installation/fabricationProvide bus passes for students paid by a grant program Administrative/management systems Procurement control Purchasing specifications Contractor selection Customer interface/services Customer requirements not identified Customer needs not addressed Implementation

19. Overview Discussion Presentation of Results Root Cause Summary Tables Purpose 1. Organize the information compiled during data analysis 2. Root Cause identification 3. Recommendation generation Process 1. First column: general description of causal factor w/background information 2. Second column: path or paths through the Root Cause Map associated with the causal factor 3. Third column: presents recommendations to address each of the root causes identified

20. Group Work Student Retention, Team One Problem description: Student retention at Pima Medical Institute is……. It has caused ……., resulting in….. Student Placement, Team Two Problem description: Student placement at Pima Medical Institute is …… It has caused….., resulting in……

21. Group Reports Student Retention, Team One Student Placement, Team Two

22. Workshop Assessment Did the workshop meet your goals? Do you have any recommendations to improve the workshop? Will you be able to take the information you learned from the workshop and use it? In what way?