The Root Cause Analysis in Quality Improvement

This is a presentation by Dada Robert in a Your Skill Boost masterclass organised by the Excellence Foundation for South Sudan (EFSS) on Saturday, the 25th and Sunday, the 26th of May 2024.
He discussed the concept of quality improvement, emphasizing its applicability to various aspects of life, including personal, project, and program improvements. He defined quality as doing the right thing at the right time in the right way to achieve the best possible results and discussed the concept of the "gap" between what we know and what we do, and how this gap represents the areas we need to improve. He explained the scientific approach to quality improvement, which involves systematic performance analysis, testing and learning, and implementing change ideas. He also highlighted the importance of client focus and a team approach to quality improvement.

1. ROOT CAUSE ANALYSIS

2. Learning Objectives

3. Traditional problem solving: Type III error Define “Root Cause” Using the 5-whys technique and the fishbone diagram in problem analysis Outline

4. Individuals believe their 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 the true cause of the quality problem Traditional Problem Solving

5. Mental Model: Individual

6. 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

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

8. A problem can be understood better by conducting a comprehensive Root Cause Analysis (RCA) using the following techniques: The “5 Whys” technique Fishbone Diagram Process Mapping Others ? Understanding the problem

9. 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

10. 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

11. “ 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 Definition - Paradies (2005)

12. 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

13. Root Cause Analysis… 13

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

15. Increased Efficiency Improved Problem-Solving Improved Communication Improved Teamwork Improved Quality Benefits of Implementing the 5-whys Technique

16. 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

17. 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’

18. Certain company lost money because the customer refused to pay for the ordered product. Problem: The customer refused to pay for the product Example of Administering the 5-Whys Technique

19. (Problem) The customer refused to pay for the product WHY? The customer saw that there was a damage to the product when it was opened WHY? The product got damaged during the delivery WHY? The product, which is made of glass, fell causing it to crack WHY? There was no safety packaging for the product (The Root Cause)

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

21. 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

22. Agree on the problem statement (also referred to as the effect) Agree on the major categories of causes of the problem (written as branches from the main arrow). Brainstorm all the possible causes of the problem. Ask “Why does this happen?” As each idea is given Continues to ask “Why?” until a deeper/ more actionable cause is attained Constructing a fishbone diagram

23. 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? Constructing a fishbone diagram cont.....

24. 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?

25. 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?

26. Example of fishbone diagram Problem Statement: In the first quarter of 2022, reported defects in production increased to 20%.

27. 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)

28. 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

29. 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