Root Cause Analysis_South Sudan QIC.pptx

IRIS SLIDES

1. ROOT CAUSE ANALYSIS

2. Learning Objectives

3. Traditional problem solving: Type III error Define “Root Cause” The 5-whys technique and the fishbone diagram Group work Outline

4. Many health care leaders face the same challenge: Individuals believe their own perceptions of the problem are correct The tendency is to jump in and make improvements – but often, team members will disagree on where to focus This increases the risk of a mismatch between the intervention and true cause of the quality problem Traditional Problem Solving

5. Mental Model: Individual

6. We register some data and ignore other data We do not realize we are making interpretations Our conclusions feel obvious, so we see no need to test our views We see data that confirm our perspective and miss data that don’t By not making our mental models explicit and not testing our views, we create misunderstandings Individual Mental Models

7. The perfect solution to the wrong problem Schwartz, S. & Carpenter, K. (1999) Avoiding “Type 3” Error

8. Without the application of QI, traditional problem solving often leads us here Costly and Ineffective Avoiding “Type 3” Error: The perfect solution to the wrong problem

9. Pragmatic and based on past experience Combines psychology and logic Requires the use of operational definitions Informed by systems thinking Understands types of process variation Grounded in testing and learning cycles RECAP: What is the Science of Improvement? - Adapted from Perla, et al., 2013

10. Measure Change: Family of Indicators Recap: QI TOOL BOX APPROACH Understand Complexity of Quality Challenge: Rich Picture Develop Change Ideas: Driver Diagram Prioritize Problems and Solutions: Focusing Matrix Pareto Charts Find Root Causes: RCA Fishbone Diagram Process Map Translate Data into Information: Run Charts

11. - 5 min discussion for how quality challenges are currently examined How do we analyze a health care quality challenge? 11

12. Types of Errors Type I Error Rejecting a true null hypothesis (false positive) Type II Error Accepting a false null hypothesis (false negative) Type III Error Rejecting a null hypothesis or the wrong reason (applying the perfect solution to the wrong problem) “You’re pregnant” “You’re not pregnant” Adapted from Schwartz, S. and Carpenter, K. (1999) Types of Errors

13. Solving the Wrong Problem Quality Challenge: Very long wait times for HIV test results Proposed Intervention: Increase number of technicians in lab

14. Solving the Wrong Problem Assumption: The problem is lab-level staffing Actual Problem: Stock-outs/shortages of latex gloves in the lab

15. Without the application of QI, traditional problem solving often leads us here Costly and Ineffective Avoiding “Type 3” Error: The perfect solution to the wrong problem

16. Key Lesson: We need to understand the problem before defining the solution

17. Root Cause If fixed, would prevent the problem from happening Contributing Cause Part of the problem, but not enough to cause the problem on its own Direct Cause Directly results in the problem The Problem Poor ART retention Direct, Contributing & Root Causes Direct, Contributing & Root Causes

18. Symptom of the problem Above the surface Relatively obvious Underlying cause of problem Below the surface Not obvious If not fixed, problem is likely to continue

19. “The most basic cause (or causes) that can reasonably be identified that management has control to fix and, when fixed, will prevent (or significantly reduce the likelihood of) the problem’s recurrence.” Root Causes in Health Care Definition - Paradies (2005)

20. These root causes can then be turned into change interventions which QI teams and management can implement A process that is not working A behavior that is adjustable Gaps in knowledge Lack of established standards Lack of guidelines Others? Common Examples of Root Causes

21. Measure Change: Family of Indicators Recap: QI TOOL BOX APPROACH Understand Complexity of Quality Challenge: Rich Picture Develop Change Ideas: Driver Diagram Prioritize Problems and Solutions: Focusing Matrix Pareto Charts Find Root Causes: RCA Fishbone Diagram Process Map Translate Data into Information: Run Charts

22. Root Cause Analysis… 22

23. The “5 Whys” Fishbone Diagram Process Mapping Why Why Tree Others ? QI Tools: Analyzing the Problem

24. Repeated question-asking technique used to explore cause-and-effect relationships Primary goal is to determine the root cause May require more than five! Often uncovers layers of problems The “Five Whys” Technique

25. There is increasing number of clients missing their ARV refill appointment dates WHY? Clients forgot their date of appointment WHY? Appointment reminder calls were not provided WHY? ARV refill line list was not generated WHY? Call reminder SOP not available

26. Often uncover systems problems not incompetent or untrained people “If you pit a good performer against a bad system, the system will win almost every time” – Deming You don’t always need five! Remember – these are still hypotheses that need to be tested, not proven causes The analysis is a part of the QI process, not an endpoint TIPS for using the ‘Five Whys’

27. The “5 Whys” Fishbone Diagram Process Mapping Why Why Tree Others ? QI Tools: Analyzing the Problem

28. Also known as Cause & Effect Diagram or Ishikawa Chart Brainstorming tool Pictorial representation of categories of causes leading to quality “effect” Helps identify multiple causes of a single problem QI Tool: Fishbone Diagram

29. Building a Fishbone Diagram Building a fish bone diagram Effect Problem Event Major Cause Category Major Cause Category Major Cause Category Major Cause Category Cause Cause Cause Cause Cause Cause Cause Cause

30. The problem statement is placed at the head of the “fish” Brainstorm the major categories of the problem or use common cause categories: » People. What staff behaviors and characteristics lead to the problem? » Process/Policy. What procedures lead to the problem? » Equipment/Supplies. Is there equipment that leads to the problem? » Environment. Does the immediate environment contribute? Building a Fishbone Diagram

31. Major cause categories of the problem e.g.: 6Ms : Manpower, Management, Measurement, Methods, Materials 8Ps : Promotion, People, Process, Place, Policy, Procedure, Product 4Ss : Surroundings, Suppliers, Systems, Skills Client factors, Community factors, Finance, Facilities & Supplies, Equipment 6 Performance Factors : Job expectations , Performance feedback , Environment & tools, Skills & Knowledge , Organisational Support, Motivation The Fishbone diagram: How?

32. Suggest numerous potential causes under each category Break down each cause into its potential root causes using the 5-whys technique The Fishbone diagram: How?

33. Root Cause analysis In the period of three months (Jan-March), 2021, only 45% (20/45) of clients who had interruption on treatment in KMWH had been traced and brought back to care Client Far distance for clients to visit facility High level of stigma Side effects of drugs ,HENCE lead to discontinuation Wrong phone number and location hinder proper tracing provider Knowledge gap in tracing Client not notified on time for those on appointment Inadequate clients tracking Late coming for work Inadequate counselling during initiation Poor documentation Delay in generating list of clients to the CHSO and hand over to Covs system No Covs recruited Lack of mobility No phone and airtime for the facility Environment Insecurity Far distance as roads are bad

34. Factors that Influence Performance 1. Clear Job Expectations Know what to do (and why) and to what level of quality? ( Job description, tasks, assignment) 2. Constructive And Timely Performance Feedback Know how well they are doing? How often is constructive feedback provided? ( clinical Meetings, Situation room, Data review meeting, one to one for one to group). 3 Adequate Environment, Tools, & Materials Have the tools to do the job well? Does the work environment enable the desired performance? Are processes and systems effective and efficient? ( Privacy, equipment, orderliness, registers) 4. Motivation, Recognition & Incentives Get recognized and rewarded for good performance? Are incentives offered to drive changes in performance? Are performers self-motivated? (APAS, labour day, departmental awards events…) 5. Appropriate Skills & Knowledge Have knowledge and skill to meet expectations? ( Oriented, trained, mentored, supervised) 6. Organizational/ institutional support Get the organizational support needed to perform – are mission and goals aligned with performance? Are processes conducive to getting the work completed – at a level of acceptable quality? Are systems and interventions available to ensure quality work performance? ( Transport, staffing, financial resources)

35. Cost Culture Measurements Methods Education and training Patient factors/characteristics Team factors Individual factors Organizational factors Task factors For each cause identified, ask variations of why ? Other options could include: Building a Fishbone Diagram

36. Long TB test turnaround times PEOPLE ENVIRONMENT METHODS EQUIPMENT Varying practices for TB screening in OPD Loss to follow-up of TB suspects TB clients non-compliant with medication TB nurse positions short staffed Many sites need to refer lab test to other, larger facility labs High rates of TB in the community Rainy season interrupts transport services Lab charges money for its lab services Clients don’t give correct contact information Documentation in registers is weak Specimens lost between clinic and lab Specimens rejected at lab Stock outs of lab commodities X-ray machine breaks down often Example: Fishbone Diagram

37. After your fishbone is generated, highlight the priority problem areas Data can be collected to quantify how often the different causes occur Identify areas where teams may have data Prioritize issues in terms of severity, frequency and ease of intervention Fishbone Diagram Analysis Solutions

38. Long TB test turnaround times PEOPLE ENVIRONMENT METHODS EQUIPMENT Varying practices for TB screening in OPD Loss to follow-up of TB suspects TB clients non-compliant with medication TB nurse positions short staffed Many sites need to refer lab test to other, larger facility labs High rates of TB in the community Rainy season interrupts transport services Lab charges money for its lab services Clients don’t give correct contact information Documentation in registers is weak Specimens lost between clinic and lab Specimens rejected at lab Stock outs of lab commodities X-ray machine breaks down often Example: Fishbone Diagram Analysis Example: Fishbone Diagram Analysis

39. “Varying practices for TB screening in OPD” “Weak documentation practices in registers” “Specimens rejected at Lab” “Clients don’t give correct contact info” Examples of Root Causes and Solutions Root Causes Solutions In service Training, Job Aids, Skills updates Register review ‘team huddles’ daily Nurse to inspect sample before sending to lab, collect sample in early morning, patient education Obtain 3 contact numbers, on site verification of contact numbers, collaborate with community partners

40. Disagreements and arguments Identifying causes that are too broad Identifying causes the team has no control over, for example: Lack of analysis of the diagram Using the tool as the end result rather than using it to identify root causes Fishbone Diagram: Common Pitfalls

41. Fishbone Diagram Summary Strengths Weaknesses Because “bones” represent multiple factors, many team members will have knowledge to freely engaged and participate Great brainstorming technique to elicit multiple opinions Quickly categorizes problems Cannot be used to define the importance or frequency of a particular issue Teams need to use complementary methods and tools to prioritize problems Doesn’t always capture all of the issues related to a process or problem

42. Group Work Teams will construct a fishbone diagram of their quality challenge (90 minutes)

43. Group Work. Yirol Hospital missed appointment run chart example