This Presentation is discussing step by step how to conduct root cause analysis for sentinel events and near misses

1. ROOT CAUSE ANALYSIS
Dr. Mohamed Mosaad Hasan
MD, MPH, CPHQ, CPPS, GBSS

2. SENTINEL EVENTS
Rosie King’s video

3. ROOT CAUSE ANALYSIS
Is a process done in response to
occurrence of sentinel event or near
miss.
The aim of root cause analysis is to
conduct intensive analysis to reach the
embedded problems in the system and
solve it.

4. RCA- SEQUENTIAL STEPS
1- Define the problem
 Ask what is wrong, what is involved: conditions, activities,
materials.
 Ask when: day ,date, time, shift, time pattern, schedule.
 Ask where: site, area department, physical environment, step
in process.
 Ask how the what or who is affected, how much, how many,
work practice, omission / commission.
 Ask who is involved: patients, caregivers, other staff, vendors,
visitors.
 Review relevant documents.
 Consider other data collection options: surveys, observations,
interviews.

5. RCA- SEQUENTIAL STEPS
2- perform task / process analysis
 divide a process into steps by sequencing actions,
instructions, conditions ,tools , and materials associated
with the performance of the task (flowchart).
 learn exactly what was supposed to happen.
 contrast the baseline with what actually happened (based
on initial data collection).

6. RCA- SEQUENTIAL STEPS
3- perform change /different analysis:
 compare the task /steps successfully performed to
the same task /steps when unsuccessful.
 analyze the difference.
 describe for each difference its effect on the
situation.

7. RCA- SEQUENTIAL STEPS
4- perform control barriers/ safe guard analysis:
 analyze safeguards needed to prevent the event.
 analyze missing or ineffective safeguards.
Safeguards may be :
 physical: safety equipment and devices; locks, walls.
 Natural: distance and time (limited exposure).
 information: caution such as labels , alarms.
 knowledge: making information constantly available.
 administrative: safety policies and procedures,
regulations, supervisory practices, training, education,
communication process.

8. RCA- SEQUENTIAL STEPS
5- Begin cause and effect analysis
 List each undesirable step of the occurrence
 considering each a primary effect
 using data collected to date , determine what
causes allowed or forced each effect to occur
 show the relationship between each cause and
effect

9. RCA- SEQUENTIAL STEPS
 continue the cause and effect analysis until :
 Cause is outside the organization control to
correct.
 Primary effect is fully explained.
 No other causes can be found to explain the
effect.
 Further analysis will yield no additional benefit
in correcting the problem.
 List all validated causes.

10. QUALITY TOOLS

11. FLOWCHART
Definition: A flowchart is a pictorial
representation displaying the:
 Actual sequence of steps and their inter-
relationships in a specific process in
order to identify hand-off (appropriate
and inappropriate), inefficiencies,
redundancies, inspections, and waiting
steps; and/or
 Ideal sequence of steps, once the actual
process is known.

12. Symbols Used in Flowcharts
Start / End
Process Step
Decision
Connector
No
Yes
A

14. FLOWCHART
Use when:
 Identifying and describing a current
process
 Questioning whether there is a process
 Questioning whether actual process
meets current policy/procedure
 Analyzing problems to determine causes
 Redesigning the process as part of the
action
 Designing a new process

15. FLOWCHART
Steps:
 Determine the boundaries (the start and
stop points) of the process under review.
 Brainstorm to identify all activities and
decision points in the process;
 Place all activities and decision points in
sequence.
Cont..

16. FLOWCHART
 Design the flowchart, placing:
 each activity in a box (square or rectangle)
 each decision in a diamond,
 ovals or circles for the start and stop points,
 connecting arrows indicating the flow.
 If there is more than one "output" arrow from an activity box,
it probably requires a decision diamond;
Cont...

17. FLOWCHART
 Analyze the flowchart, looking for process
"glitches": inefficiencies, omissions/gaps,
redundancies, barriers, etc.
 Also look for the smooth parts of the process to
use as models or "best practices" for
improvement;
 Decide whether to correct steps within the
current process, design a new process, or do
corrections first, then redesign in the future.

18. INTERPRETING A FLOWCHART
Step 1 - Examine each process step
Bottlenecks? Poorly defined steps?
Ineffective sequence? Delays?
Weak links?
Step 2 - Examine each decision symbol
Can this step be eliminated?
Step 3 - Examine each rework loop
Can it be shortened or eliminated?
Step 4 - Examine each activity symbol
Does the step add value for the end-
user?

19. Fire Drill Preparation Flowchart
A
Yes No
Yes
No
Yes
No
NoYesYes
No
Yes
NoFirst drill
in set?
A
Inform the drill
leader and improvise
Props?
Search
Torpedo Room
Radios
still not
available
?
Borrow from
Quartermasters
Check with
Radiomen
Radios
available?
Props
available?
Enough
red hats?
Drill monitors
test the radios
Monitors go to Logroom to get red
hats, radios, and drill props
Complete the
Drill Brief
Drill monitors
take station
Search the
boat for
red hats
No
No
Yes
Yes
Discrepancy?
All
personnel
on station
?
Correct it
Put simulation
on the
appropriate
gages
Drill leaders walk
around to ensure
all monitors are
on station
Spot check safety
intervention points
Order initial
conditions set
Find them
and put them
on station

21. CAUSE AND EFFECT DIAGRAM
Also called Ishikawa or Fishbone

22. CAUSE-AND-EFFECT DIAGRAM
 Definition: The cause-and-effect diagram is a
tool generally used to gather all possible
causes as an overview,
 The ultimate goal being to uncover the root
cause(es) of a problem.
 The specific problem is usually stated as a
negative outcome ("effect") of a process, e.g.,
late transfer of patients from the inpatient
facility to skilled nursing facilities.

23. CAUSE-AND-EFFECT DIAGRAM
 The diagram is a visualization of relationships
between the outcome of a particular system or
process, the major categories of that system or
process (the main branches), and causes and
subcauses (sub-branches off main branches).
Steps
 Start with the outcome (problem statement) on
the right of the paper, halfway down; draw a
horizontal line across the middle of the paper
with an arrow pointing to the outcome;

24. CAUSE-AND-EFFECT DIAGRAM
 Determine and define the major categories
which describe the system or process under
review, e.g.,
 5ps: (or) 5ms:
People Manpower
Provisions Materials
Policies Machines
Procedures Methods
Place Measurements

25. BASIC LAYOUT OF
CAUSE AND EFFECT DIAGRAMS
EFFECT
Manpower
(People)
Methods
(Procedures)
Materials
(Policies)
Machines
(Plant)
Environment

26. CAUSE-AND-EFFECT DIAGRAM
 Link the major categories (representing
process and structure) to the outcome with
diagonal lines angled from the horizontal
line away from the outcome;
 Brainstorm to identify possible main causes
of the negative outcome and link each to
one of the major categories, using
horizontal lines (parallel to the main
outcome line) touching the appropriate
diagonal line;

27. CAUSE-AND-EFFECT DIAGRAM
 Identify any possible sub-causes of main
causes by using the "Five-Why" technique.
 Evaluate the draft diagram as a team to
determine the accuracy of the placement of
issues and lines;

28. CAUSE-AND-EFFECT DIAGRAM
Once the diagram seems appropriate to the
team, further evaluate for:
 Obvious improvement options;
 Causes already resolved or eliminated;
Causes easily resolved or eliminated;
 Issues raised which require more in-depth
assessment to be understood.

29. CAUSE & EFFECT EXAMPLE MJII p. 29
Bed Assignment Delay
Information provided courtesy of
Rush-Presbyterian-St. Luke’s Medical Center
System incorrect
Machine (PCIS)Timing
Hospital procedures Communication
Patient waits
for bed
Not entered
Not used
No trust
Need more training
Functions not useful
Not used
pending discharge
Discharged patient
did not leave
Wait for results
Wait for lunch
Wait for ride
Call housekeeping
too late
Wait for MD
Call housekeeping
too early
Think it will take
more time
Patient arrives
too early
Transfer too early
from another hospital
Call housekeeping
when clean
Nursing shortage
Unit clerk staffing
Unit clerk training
Resources
Unit clerk unaware
of discharge or transfer
On break
Not told
Shift change
Reservation
unaware
Not entered
Unit switch bedAdmitting unaware
bed is clean
Delayed
entry
Sandbag
Too busy
Inappropriate
ER admittance
Many
transfers
Specialty beds
Cardiac monitors
Double rooms
Physician did
not write order
Medicine
admit quota
Physician misuse –
inpatient
MD procedures

31. THE FIVE WHYS
What is it?
 A tool to help uncover the root
cause or real reason for the issue
 It is a variation of the approach
used in fishbone analysis
When would you use it?
 When you have identified an issue
and want to deepen your
understanding of it and its
underlying causes
 It avoids group moving into ‘fix it’
mode and addressing the
symptoms of an issue without
understanding the root causes
Issue
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why
Why …

32. PROCESS OF FIVE WHYS
• Clearly define the issue to be tackled and write it on the left
side of the paper
• Complete the diagram by moving from left to right. Move from
the problem/issue statement by asking the question “why?”
• Ask the group “why?” and capture the responses
• For each response, again ask the question “why?”. Continue to
record responses and move across to the right of the diagram.
Try to go to five levels of “why?”
• At the end of the analysis it is often helpful to circle the most
significant insights that have been gained

33. FIVE WHYS – EXAMPLE
Revenue budget
not
balanced
Costs too high
Income too low
Premises costs 8.5%
Staffing costs 86% of
the budget.
Income heavily
reliant on LEA
formula.
Schools facilities are
underused
Teachers used to support pupils with SEN.
Large number of management points
Staffing very stable
Historic.
Have allowed some queue jumping.
Cleaners local people with strong
connection to school.
Employ own cleaning staff at high rates.
Plan still has 3 years to run.
Roll drop in January
Coordinator’s salary now in main school budget.
School decided not to reapply 2 years ago.
Knock-on impact in other areas e.g. FSM, SEN
Health and safety issues.
LEA cut back on community use of school.
Greater variety of facilities available.
Governing body have stopped s/keeper overtime.
Premises staff costs
3.5%
Low number of TAs
Teachers are 70%
5 year routine
maintenance plan
undercosted.
New Council sports centre
opened locally
LEA uses January PLASC
for Fair Funding formula.
Beacon school funding
not renewed
School not used for
external events.

34. KEPNET-TREGOE (IS-IS NOT) MATRIX
 Purpose : Isolate and Identify causes of quality problems
by assisting managers in recognizing factors that
underlie defects in a process.
 Advantages
 Relates possible causes to specific categories
 Identifies process problems
 Simplifies development of ways to resolve the problems

35. KEPNET-TREGOE (IS-IS NOT) MATRIX
 Creation Steps
 Characterize the problem
 Easily understood by QI team
 Create agreement on the nature of the predicament
 Create the Is-Is Not Matrix
 Who is involved in the process or problem? (No blame game)
 What inputs or outputs are involved in the process or problem?
 When does the problem occur? In what portion of the process?
 Where does the problem occur? In what part of the organization or
what location?
 How important is the problem to the process? How extensive is the
problem?
 QI Team formulates entries for each cell
 Emerging patterns identify deficiencies in the process

36. KEPNET-TREGOE (IS-IS NOT) MATRIX
Is (
PROCESS)
Is not ( problem)
Who is involved in the process or
problem
What inputs or outputs are
involved in the process or problem
When does the problem occur? In
what portion of the process
Where does the problem occur? In
what part of the organization or
what location?
How important is the problem to
the process? How extensive is the
problem?

37. SPECIFY THE SOLUTION
 Brainstorming.
 Affinity Diagram.
 Multi- voting.

38. BRAINSTORMING

39. BRAINSTORMING
 Definition: Brainstorming is a structured group
process used to create as many ideas as
possible in as short a time as possible, e.g.,
one session, and to elicit both individual and
group creativity.
 Structured Brainstorming: Everyone in the
group gives an idea in rotation or passes until
the next round.
 Unstructured Brainstorming: Everyone in the
group gives ideas as they come to mind.

40. EXPERIMENTS HAVE SHOWN---
BRAINSTORMING WILL
TYPICALLY GENERATE THREE TIMES
THE QUANTITY OF IDEAS THAN THAT
GENERATED BY THE SAME INDIVIDUAL
WORKING SEPERATELY

41. BRAINSTORMING
Lists generated may relate to:
 Problems or topics
 Components of a process
 Indicators, criteria, elements for data
collection
 Possible solutions Structure

42. RULES
1. PEOPLE MUST FEEL SAFE TO
PARTICIPATE
2. DURING BRAINSTORMING---
NO JUDGEMENT
NO CRITICISM
3. GENERATE AS MANY IDEAS AS
POSSIBLE
4. ENCOURAGE TO BE CREATIVE
5. BUILD ON EACH OTHER’S IDEAS
6. WRITE DOWN EXACTLY WHAT IS SAID
DO NOT DISCUSS IDEAS

43. FIVE STEPS OF BRAINSTORMING
 Define the subject and direction of the session;
 Allow time for initial, individual thought;
 Establish a time limit for the entire session;
 Request ideas according to the predetermined
structure; keep circling the issue until all ideas
are recorded
 Clarify all ideas generated to assure accuracy
and understanding.

44. ADVANTAGES
1. ENCOURAGES CREATIVE THINKING
2. HELPS TO IDENTIFY
=POSSIBLE CAUSES
=AREAS FOR IMPROVEMENT
=POSSIBLE SOLUTIONS
3. ALLOWS FOR DIFFERENT POINTS
OF VIEW
4. ENCOURAGES PARTICIPATION

45. AFFINITY DIAGRAM
 Definition: An affinity diagram is an organizational
tool most often used at the beginning of a team's
work to organize large volumes of ideas or issues
into major categories.
 The ideas may have come from the group's initial
brainstorming session.

46. AFFINITY DIAGRAM
 "Affinity" means close relationship or
connection, or similarity of structure;
 When developing an Affinity Diagram, it is
most important to determine the primary
issue and major related subgroups in order
to grasp the appropriate relationships, links,
or connections.

47. AFFINITY DIAGRAM
Steps:
 Define the primary issue, using neutral, broad
language;
 Brainstorm - use cards or adhesive notes which
can be moved and sorted;
 Display in random fashion all ideas for the team
(on a wall or table);
Cont..

48. AFFINITY DIAGRAM
 Each team member participates in sorting the
ideas into major groupings -- in silence and
quickly, without discussion and without time for
contemplation -- until team consensus is reached;
 Discuss the major groupings and create a concise
title for each grouping;
 Draw the affinity diagram, based on major
groupings, linking all ideas related to each
grouping.

49. AFFINITY DIAGRAM
 Each team member participates in sorting the
ideas into major groupings -- in silence and
quickly, without discussion and without time for
contemplation -- until team consensus is reached;
 Discuss the major groupings and create a concise
title for each grouping;
 Draw the affinity diagram, based on major
groupings, linking all ideas related to each
grouping.

50. DISPLAY THE GENERATED IDEAS
ISSUES IN IMPLEMENTING CONTINUOUS PROCESS IMPROVEMENT
Behavior
modifications may
take longer than
time available Too many
projects at once
Everybody
needs to change
but me
Data collection
process needs
Need new data
collection
system
Developing
product without
developing
process
Too busy to
learn Don’t know what
customer wants
Short-term
planning mentality
Pressure for
success
Lack of training at
all levels
Lack of
management
understanding of
need for it
Competition
versus
cooperation
Need to be
creative
Some people will
never change
What are the
rewards for using
tools
Lack of follow-
up by
management
Unrealistic
allotment of
time
Lack of trust in
the process
Not using
collected
data
Which comes first,
composing the
team or stating the
problem?
Want to solve
problem before
clearly defined

51. Sort Ideas into Related Groups
Issues in Implementing Continuous Process Improvement
Want to solve
problem before
clearly defined
Too many
projects at once
Data collection
process needs
Need new data
collection
system
Developing
product without
developing
process
Too busy to
learn
Don’t know what
customer wants
Behavior
modifications may
take longer than
time available
Pressure for
success
Short-term
planning mentality
Lack of
management
understanding of
need for it
Lack of training
at all levels
Need to be
creative
Competition
versus
cooperation
Some people
will never
change
What are the
rewards for using
tools
Lack of follow-
up by
management
Unrealistic
allotment of
time
Lack of trust in
the process
Not using
collected
data
Which comes first,
composing the team
or stating the
problem?
Everybody needs
to change but me

52. Create Header Cards
Issues in Implementing Continuous Process
Improvement
(Header Cards)
Breaking through
old way
“Dinosaur”
thinking
Lack of
planning
Organizational
issues
Old
managemen
t culture
Lack of
TQL
knowledge

53. Finished Affinity Diagram
Issues in Implementing Continuous Process Improvement
Breaking through
old way
“Dinosaur”
thinking
Lack of
planning
Organizational
issues
Old
management
culture
Lack of TQL
knowledge
Want to solve
problem before
clearly defined
Too many
projects at once
Everybody
needs to change
but me
Data collection
process needs
Need new data
collection
system
Developing product
without developing
process
Too busy to
learn
Don’t know what
customer wants
Behavior
modifications may
take longer than
time available
Pressure for
success
Short-term
planning mentality
Lack of
management
understanding of
need for it
Lack of training at
all levels
Need to be
creative
Competition
versus
cooperation
Some people will
never change
What are the
rewards for using
tools
Lack of follow-up
by management
Unrealistic
allotment of
time
Lack of trust in
the process
Not using
collected
data
Which comes first,
composing the team
or stating the
problem?

54. MULTI-VOTING

55. MULTI-VOTING
A repetitive process used by a team to select the most
important or popular items from a large list of items
generated by the team
Benefits of Multi-voting
• Reduces a larger list of items.
• Prioritizes team issues.
• Identifies important items.

56. PROCEDURES FOR MULTI-VOTING
Step 1 - Work from a large list
Step 2 - Assign a letter to each item
Step 3 - Tally the votes
Step 5 - Repeat the process

57. MULTI-VOTING EXAMPLE
LACK OF MEETING PRODUCTIVITY
FIRST VOTE TALLY
| A. No agenda | I. Problems not mentioned
|||| B. No clear objectives |||| J. Interrupted by
phone calls
|| C. Going off on tangents || K. Few meaningful metrics
| D. Extraneous topics |||| L. Interrupted by visitors
|| E. Too many "sea stories" ||| M. No administrative support
|||| | F. Vital members missing |||| N. Meetings extended
from meeting beyond allotted time
|||| G. Not enough preparation |||| O. Members distracted by
for meetings pressing operations
|||| H.Unclear charts

58. MULTIVOTING EXAMPLE
LACK OF MEETING PRODUCTIVITY
SECOND VOTE TALLY
B. No clear objectives
F. Vital members missing from meeting
G. Not enough preparation for meetings
J. Interrupted by phone calls
L. Interrupted by visitors
N. Meetings extended beyond allotted time
O. Members distracted by pressing operations

59. PRIORITIZATION MATRIX
 Definition: A Prioritization matrix is a tool used
to select one option from a group of
alternatives, be they problems or solutions.
 It promotes objective decision making.

60. PRIORITIZATION MATRIX
 Steps:
1. Limit the list of options (of problems or solutions)
to no more than eight (8);
2. Select the criteria against which each option will
be rated, stated in either positive or negative
terms, but not both;
3. Determine the weight (relative value) of each
criterion; perhaps some are more important to
meet than others;
Cont..

61. PRIORITIZATION MATRIX
4. Select a scoring method, e.g.:
 Point system:
From 5 = Very important To 0 = Unimportant
 Yes/No system: Criteria Met? Y n Yes; N =
No
 Check mark: Box checked if criteria
met
 + or - system:
+ = Important/criteria met
- = Unimportant/criteria not met

62. EXAMPLE

65. WEIGHTED FACTOR MODEL EXAMPLE

66. ACTION PLANNING
 Once the team selects a solution, an action plan need to
be developed.
 Action plans at a minimum identifies:
 what to be done? (deliverables)
 How a certain task will be done?( implementation Strategies)
 who will do it?( R)
 Time Frame
 A mean of verification that a certain task has been done
 The team leader is responsible of monitoring the
implementation process.

67. CASE STUDY
MS. MARTINEZ, JANUARY 2000
 Ms. Martinez, a divorced working mother in her early
50s with two children in junior high school, was new in
town and had to choose an insurance plan.
 She had difficulty knowing which plan to select for her
family, but she chose City-Care because its cost was
comparable to that of other options, and it had
pediatric as well as adult practices nearby.

68.  Once she had joined CityCare, she was asked to
choose a primary care physician. After receiving
some recommendations from a neighbor and
several coworkers, she called several of the offices
to sign up. The first two she called were not
accepting new patients. She finally found one.

69.  Juggling repairs on their new apartment, finding the best
route to work, getting the children’s immunization records
sent by mail, and making other arrangements to get them
into a new school, Ms. Martinez delayed calling her new
doctor’s office for several months. When she called for an
appointment, she was told that the first available non
urgent appointment was in 2 months; she hoped she
would not run out of her blood pressure medication in the
interim.

70.  When she went for her first appointment, she was
asked to complete a patient history form in the waiting
room. She had difficulty remembering dates and
significant past events and doses of her medications.
After waiting for an hour, she met with Dr. McGonagle
and had a physical exam. Although her breast exam
appeared to be normal, Dr. McGonagle noted that she
was due for a mammogram.

71.  Ms. Martinez called a site listed in her provider
directory and was given an appointment for a
mammogram in 6 weeks. The staff suggested that
she arrange to have her old films mailed to her.
Somehow, the films were never sent, and distracted
by other concerns, she forgot to follow up.

72.  A week after the mammogram, she received a call
from Dr. McGonagle’s office notifying her of an
abnormal finding and saying that she should make an
appointment with a surgeon for a biopsy.
 The first opening with the surgeon was 9 weeks later.
By now, she was very anxious. She hated even to
think about having cancer in her body, especially
because an older sister had died of the disease.

73.  For weeks she did not sleep, wondering what would
happen to her children if she were debilitated or to
her job if she had to have surgery and lengthy
treatment. She was reluctant to call her mother,
who was likely to imagine the worst, and did not
know her new coworkers well enough to confide in
them.

74.  After numerous calls, she was finally able to track
down her old mammograms. It turned out that a
possible abnormal finding had been circled the
previous year, but neither she nor her primary care
physician had ever been notified.

75.  Finally, Ms. Martinez had her appointment with the
surgeon, and his office scheduled her for a biopsy.
The biopsy showed that she had a fairly unusual
form of cancer, and there was concern that it might
have spread to her lymph nodes.

76.  She felt terrified, angry, sad, and helpless all at
once, but needed to decide what kind of surgery to
have. It was a difficult decision because only one
small trial comparing lumpectomy and mastectomy
for this type of breast cancer had been conducted.
She finally decided on a mastectomy.

77.  Before she could have surgery, Ms. Martinez needed
to have bone and abdominal scans to rule out
metastases to her bones or liver. When she arrived at
the hospital for surgery, however, some of this
important laboratory information was missing. The
staff called and hours later finally tracked down the
results of her scans, but for a while it looked as though
she would have to reschedule the surgery.

78.  During her mastectomy, several positive lymph nodes
were found. This meant she had to see the surgeon,
an oncologist, and a radiologist, as well as her primary
care physician, to decide on the next steps.
 At last it was decided that she would have radiation
therapy and chemotherapy. She was given the phone
number for the American Cancer Society.

79.  Before 6 months had gone by, Ms. Martinez found
another lump, this time under her arm. Cancer had
spread to her lung as well.
 She was given more radiation, then more
chemotherapy.
Unfortunately, the condition worsened steadily and
cancer had spread leading to her death.

80.  With your team conduct a root cause analysis for this
case.