Root Cause Analysis: Step by Step

Overview

• Concept: Root Cause Analysis (RCA) aims to eliminate the root causes of problems to prevent recurrence.
• Analogy: Addressing the root of a weed to permanently remove it.
• Application: Used across industries to stop repetitive errors in medical, manufacturing, and distribution.

Key Definitions

• Fault: Incorrect documentation directions.
• Weakness: Missing or unclear information leading to multiple decision paths.
• Nonconformance: Failure to meet a requirement.
• Containment: Ensuring nonconforming products/services do not harm customers.
• Correction: Replacing nonconforming items.
• Root Cause: Underlying fault in a process/system leading to undesired outcomes.
• Corrective Action: Steps taken to address and prevent recurrence of a root cause.

Five Steps to Success

1. Establish Team

   • Importance of including process owners and decision-makers.
   • Avoid solely top-management committees.
   • Include front-line workers for practical insights.

2. State the Problem

   • Requires a clear, concise statement including what, where, when, how, who, and affected standards.
   • Example: Overdose case at St. Hope Medical Clinic.

3. Define the Cause

   • Rules for establishing cause-effect relationships.
   • Focus on system causes, not just human error.
   • Tools include:
     • Brainstorming
     • Fishbone Diagram
     • 5 Whys
     • Scatter Diagram
     • Control Chart
     • Statistical Analysis
     • Stratification
     • Pareto Analysis

4. Test for True Root Cause

   • Root Cause Statement should be concise.
   • Use "first domino to topple" analogy for testing.
   • Ensure the root cause is actionable.

5. Implement Corrective Actions

   • Actions must directly address the root cause.
   • Evaluate if similar problems may exist elsewhere.
   • Review change effectiveness through internal audits.

Conclusion

• Failing to address root causes can lead to repeated issues, negative outcomes, and lawsuits.
• Management culture plays a crucial role in continuous improvement and setting standards.
• Leadership commitment is essential, but the solution requires deeper inquiry.

About Mark McCulley

• Business owner, trainer, and presenter with extensive leadership experience.
• ISO auditor with Professional Quality Assessments and Principal of Continual Improvement.
• Enjoys physical activities and has grown children in California.

References

• Videos on RCA and 5 Whys.
• Articles on Heparin dosage errors and the Checklist Manifesto.
• Resources from Transformance Advisors on acronyms and definitions.