Monthly Archives: March 2015

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LionChasingGazelle

The lion and gazelle have to be at the top of their game each and every day. If they get lazy, they lose.

The Apollo Root Cause Analysis methodology can help you maintain a competitive advantage, but only if you use it completely and consistently.

How are you ensuring that you maintain and improve your lead?

Can you measure what you have achieved since your Apollo Root Cause Analysis methodology training, or has it become just another initiative that didn’t work?

You spent the time and effort learning a proven methodology that solves event-based problems every time, and perhaps it has become a company standard tool. But the creation of the reality chart and incident report are only steps on the journey. We also need to focus on creating an effective problem-solving culture (for alumni: page 109 in your manual). The culture part of the equation can be easy to overlook, but it is this holistic approach that will help you get the most out of the Apollo Root Cause AnalysisTM method.

If we do nothing after the initial implementation of the Apollo Root Cause Analysis methodology, entropy kicks in and the system begins to unravel. Any shortfall from the potential gain becomes considered “normal” and root cause analysis just gets accepted as another initiative that didn’t work.

10TonneEntropy_Graph

With this in the back of our minds, we have to put supports in place to develop a solid platform on which incremental change can be applied to achieve ever greater gains.

10TonneEntropy_Graph2

To help enhance your company’s problem-solving culture and get maximum benefit from your Apollo Root Cause Analysis program:

1) Ensure your senior leadership team is fully aware of your efforts.

Try to get an influential sponsor to regularly mention root cause analysis in group communications. Remember that everyone’s reality is different, so time and energy spent with this team creating that common reality is going to pay dividends.

2) Implement Leader Standard Work.

(See chart below for an example) This ensures the ball is kept rolling from leadership down the chain. Developing formal, measured business processes can really help with this, along with good visual management tools.

*HOD = Head of Department

LeaderStandardWorkExample

3) Increase awareness of the benefits and gains brought about by your successes.

Celebrate the gains!

4) Involve union and safety reps.

If this is done correctly, these folks can be your biggest evangelists. You can then use them as a resource. The “No Blame” approach of the Apollo Root Cause Analysis methodology should make it easier to sell.

5) Create a robust, visible, and measured action tracking system.

Unlike work orders that are in a CMMS, these actions have a tendency to fade away. Ideally you would create one place for all actions, making them easy to prioritize. 

Ultimately, you have to use it or lose it and these five tactics have the potential to help a great deal towards establishing a problem-solving culture and embedding it into an organization. 

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Author: Kevin Stewart

At some point, most companies will want to see quantifiable metrics showing that their Root Cause Analysis (RCA) program has resulted in a positive return on investment (ROI).

ROI is relatively easy to calculate as a dollar value when it comes to tangibles such as equipment or production time. Things can seem trickier when trying to assign a dollar value to safety improvements resulting from an RCA program. Try to keep it simple.

This formula –

Cost of the Problem x Likely Recurrence / Cost of the Fix = ROI

is a straightforward way to begin quantifying the ROI of your RCA program, including its effects on safety.

Let’s look at how we might calculate these costs.

Cost of the Fix

  • Cost of an RCA investigation (you may need to include the initial training, though this should drop off as it is amoritized out over the program, as well as whatever time, resources, and people are required to conduct the investigation itself).
  • Cost of whatever resources are needed to implement a solution. Don’t forget to include new equipment, parts, additional training, and anything else that is directly attributable to the implementation.

When you eliminate a problem, calculating what you have saved depends a lot on the problem itself and what its rate of reoccurrence is. For instance, if you figure out what was causing a particular machine to fail at a rate of once/year, you won’t see the benefits of your solution for another year. It can take several years and solving many different problems to see the total value of an RCA program.

Improved safety isn’t as impossible to quantify as it might seem. While most companies don’t publicly discuss this type of equation because it can seem insensitive, chances are your company does calculate the monetary cost of an injury or death on the job. These figures may be a bit outdated, but the Mine Safety and Health Administration at the US Department of Labor offers an online calculator, which takes into account both direct costs (like workers’ comp claims) and indirect costs (like training a new worker and lower morale), as one example.

Cost of the Problem Reoccurring

Cost of the initial problem in equipment, production delays, man hours, workers’ comp claims, medical costs, absenteeism, turnover, training new employees, lower productivity, decreased morale, legal fees, increased insurance costs.

At first glance the equation doesn’t quite make sense for a safety “near miss.” If it missed then what did it cost? Is the answer nothing? So the ROI is:  0 x likely recurrence/cost of the fix = 0? The answer obviously must include the potential cost. The cost to the business if the issue was on target and hadn’t missed. It all becomes subjective then. How do you put a cost on maybes?

It might help to look at the statistics of how an incident occurs. Take the cost to the business if a single major accident occurred (every business has this unspoken cost locked away somewhere) and then very simply do the math. One near miss will be worth 0.003 of that cost. Tally up your near misses and now go back to the formula.

AccidentPyramid_V2

As an example, say your data indicates you have 3000 near misses in two years, or 4.1 incidents per day. Then you put a program in place and now you have 3000 near misses in four years, or 2.1 incidents per day. This translates to 3000 fewer near misses in two years time. Per the above calculations, this would generate 3000 x 0.003 or nine fewer major incidents at whatever cost your company assigns to that type of incident. This becomes the savings for your ROI (or the Cost of the Problem in our equation) and can be attributed to the safety program of which the RCA process is a part.

This formula will assist in calculating an ROI on an individual RCA, which is necessary to show that the process is working and providing value so you can justify the program. However, since most safety programs track TRIR (Total Recordable Injury Rate) or something to that effect, you will also need to show that the RCA program affects this, too. This will be difficult because the safety program is in place and doing other things to prevent safety incidents before they happen. How do you attribute a reduction in near misses to preventive programs versus items put in place from an RCA?

You may never be able to separate these items. Even with detailed records, it is not always clear why people do what they do. The best thing you can do is to track when an RCA program was incorporated and then show the improvement in your safety metric, in TRIR, or near misses.

You can use this information to justify the program with the argument that the RCA process is part of the overall safety program and it really doesn’t matter which gets the credit as long as we have continued to drive safety improvements. The RCA program should be a small part of the overall safety program costs since there are usually several full time safety people involved, committee meetings, safety initiatives, programs, etc.

It doesn’t matter how you slice and dice it, the return on investment for your RCA program boils down to: What will it cost me to fix the problem now? – versus – What is the cost if this problem happens again?

Author: Jack Jager

An effective root cause analysis process can improve business outcomes significantly. Why is it then that few organisations have a functioning root cause analysis process in place?

Here are the top 6 sure-fire ways to kill off a Root Cause Analysis program

1. Don’t use it.

The company commits to the training, creates an expectation of use and then doesn’t follow through with commitment, process and resources! Now come on, how easy is it to devalue the training and deliver a message that the training was just to tick someone’s KPI box and that the process doesn’t really need to be used.

2. Don’t support it.

Success in Root Cause Analysis would be the ultimate goal of each and every defect elimination program. To achieve success however, requires a bit more than just training people in how to do it. It requires structures that initially support the training, that mentor and provide feedback on the journey towards application of excellence and thereafter have structures that delineate exactly when an investigation needs to take place and that delivers clear support in terms of time and people to achieve the desired outcome. Without support for the chosen process the expected outcomes are rarely delivered.

3. Don’t implement solutions.

To do all of the work involved in an investigation and then notice that there have been no corrective actions implemented, that the problem has recurred because nothing has changed, has got to be one of the easiest ways to kill off a Root Cause Analysis process. What happens when people get asked to get involved in RCAs or to facilitate them when the history indicates that nothing happens from the efforts expended in this pursuit? “I’m too busy to waste my time on that stuff!”

4. Take the easy option and implement soft solutions.

Why are the soft controls implemented instead of the hard controls? Because they are easy and they don’t cost much and we are seen to be doing something about the problem. We have ticked all the boxes. But will this prevent recurrence of the problem? There is certainly no guarantee of this if it is only the soft controls that we implement. We aren’t really serious about problem solving are we, if this is what we continue to do?

5. Continue to blame people.

The easy way out! Find a scapegoat for any problem that you don’t have time to investigate or that you simply can’t be bothered to investigate properly. But will knowing who did it, actually prevent recurrence of the problem?

Ask a different question! How do you control what people do? You control them or more correctly their actions by training them, by putting in the right procedures and protocols, by providing clear guidelines into what they can or can’t do, by creating standard work    instructions for everyone to follow and by clearly establishing what the rules are in the work place that must be adhered to.

What sort of controls are these if we measure them against the hierarchy of controls? They are all administrative controls, deemed to be soft controls that will give you no certainty that the problem will not happen again. We know this! So why do we implement these so readily? Because it is the easy way out! It ticks all the boxes, except the one that says “will these corrective actions prevent recurrence of the problem?”

We all understand the hierarchy of controls but do we actually use it to the extent that we should?

6. We don’t know if we are succeeding because we don’t measure anything.

You get what you measure! When management don’t implement or audit a process for completed RCAs it sends a strong message that there is no interest, or little, in the work that is being done to complete the analysis.

Tracking KPIs like, how many RCAs have been raised against the triggers set? How many actions have been raised in the month as a result and, of those actions raised, how many have been completed? If management is not interested in reviewing these things regularly along with the number of RCAs subsequently closed off in a relevant period, then it won’t be long before people notice that no one is interested in the good work being done.

The additional work done to complete RCAs will not be seen as necessary, as it’s not important enough to review and the work or the effort in doing this will then drop away until it’s no longer done at all.

Another interesting point is that if only the number of investigations is reported, and there is no check on the quality of the analysis being completed, then anything can be whipped up as no one is looking! If a random audit is completed on just one of the analyses completed in a month then this implies that the quality of the analysis is important to the organisation.

What message do we send if we don’t measure anything?

In closing, the first step on the road to implementing an effective and sustainable Root Cause Analysis program is to pinpoint what’s holding it back. These Top 6 sure-fire ways to kill off a Root Cause Analysis program will help you identify your obstacles, and allow you to develop a plan to overcome them.

Author: Gary Tyne CMRP

Following the release of a report by economic consultants Frontier Economics(Oct 2014), it was highlighted that the cost of errors in patient safety, which includes the cost of extra treatment, bed space and nursing care as well as huge compensation pay-outs, costs the NHS between £1billion and £2.5billion a year.

In a speech to staff at Birmingham Children’s Hospital (Oct 2014), Jeremy Hunt (Health Secretary) said:

hospital“World class care is not just better for patients it reduces costs for the NHS as well. More resources should be invested in improving patient care rather than wasted on picking up the pieces when things go wrong.”

As far back as 2010 Dame Christine Beasley,  chief nursing officer for England said “using Root Cause Analysis (RCA) tools to understand adverse events is “critical” to improving safety across the NHS.”

The National Patient Safety Agency (NPSA) developed a set of root cause analysis guidelines and instruction documents which were taken over by the NHS Commissioning Board Special Health Authority in 2012.

Although the NPSA did not identify a specific RCA process to be used the toolkit advocates the use of the Fish-bone or Ishikawa diagram as a key tool for identifying contributory factors and root causes. Another method utilized within the NHS is a method called ‘5 Whys’

Whilst both Fishbone and 5 Whys are tools that can be utilized in basic problem solving, both methods have received criticism from within other industries for being too basic and not complex enough to analyze root causes to the depth that is needed to ensure that solutions are identified and the problem is fixed.

There are several reasons for this criticism:

  • Tendency for investigators to stop at symptoms rather than going on to lower-level root causes
  • Inability to go beyond the investigator’s current knowledge – cannot find causes that they do not already know
  • Lack of support to help the investigator ask the right “why” questions
  • Results are not repeatable – different people using Fishbone and 5 Whys come up with different causes for the same problem
  • Tendency to isolate a single root cause, whereas each question could elicit many different root causes
  • Considered a linear method of communication for what is often a non-linear event

Many companies we work with successfully utilize the 5 Why technique or Fishbone for very basic incidents or failures. By utilizing the correct placement of triggers, organizations can use the 5 Why or Fishbone for its basic problem solving and then move to a form of Cause and Effect analysis like the Apollo Root Cause Analysis methodology for more complex problems.

A disciplined problem solving approach should push teams to think outside the box, identifying root causes and solutions that will prevent reoccurrence of the problem, instead of just treating the symptoms.

Apollo Root Cause Analysis methodology – A New Way of Thinking

ApolloFourSteps

 

The Apollo Root Cause Analysis methodology provides a simple structured approach that can be applied by anyone, at any time on any given event. One of its most powerful attributes is its ability to create a common understanding of contributing causes, and provide a platform to explore a range of creative solutions. Through a simple charting process, everyone involved in an investigation can contribute which generates enthusiasm for the process, resulting in positive problem solving outcomes and experiences.

The key factor for successful problem solving is the inclusion of cause and effect as part of the analytical process.

Root Cause analysis identifies causes, so that solutions are based on controlling those causes, rather than treating the symptoms.

There are many features of the Apollo Root Cause Analysis methodology which naturally fit within any Problem Solving Excellence program.

The Apollo Root Cause Analysis methodology was developed in 1987 by Dean Gano and is utilized across the world in various industries from petrochemical, aerospace, utilities, manufacturing, healthcare and others.

The Apollo Root Cause Analysis process is a 4-step method for facilitating a thorough incident investigation. The steps are:

  • Define the Problem
  • Analyze Cause and Effect Relationships
  • Identify Solutions
  • Implement the Best Solutions

The Apollo Root Cause Analysis methodology is supported by software called RealityCharting™ which is available in full version (standalone or enterprise) or as RealityCharting™ Simplified. The RealityCharting Simplified can be utilized on smaller issues and allows the user to build a cause and effect chart that is no greater than 4 causes high and 5 causes deep. This allows the user of a 5 Whys approach the ability to create a chart using the same thought process adopted in the Apollo Root Cause Analysis™ methodology. It also demonstrates a non-linear output to what was originally considered a linear type problem.

Training in the NHS

In the study titled: ‘Training health care professionals in Root Cause Analysis: a cross-sectional study of post-training experiences, benefits and attitudes’ by Bowie, Skinner, de Wet. A few interesting statistics begin to arise when it comes to training of RCA with the respondents.

When asked ‘What type of training did you receive?’ 81.1% of respondents had said they had received in-house training compared to 6.6% who had received external training.

When asked ‘How long was the training?’ 89% of respondents said they had less than one day training compared to 1.3% who had received more than 2 days.

From industry experience these statistics are quite surprising and can only contribute to poor quality investigations with low prevention success.

Within industry, Apollo Root Cause Analysis methodology trained facilitators are required to take minimum two day in-class training course with a follow up exam. This is also supported by a pathway for accreditation. RCA participants are given awareness training of the Apollo Root Cause Analysis methodology but only the trained facilitators can lead investigations.

Case Study

bandage

A National Health Service Trust hospital was experiencing patient complaints and was exceeding waiting time targets in the antenatal clinic. Several solutions had previously been implemented to solve this problem. However, the problem continued and it was therefore decided to run a thorough investigation utilizing the Apollo Root Cause Analysis methodology.

The root causes of the problem were identified during the investigation along with effective solutions. The solutions were implemented over a period of time. With the solutions implemented an immediate improvement was seen and   waiting time targets were being met.

“We had tried to solve this problem on a number of occasions and stress levels were increasing within the antenatal team. We had previously only dealt with the symptoms and not the root causes. Only after applying the Apollo Root Cause Analysis methodology were we able to see the evidence based causal relationships. I found the tool simple but effective and one that should be utilized in other areas across the NHS” – Midwife/Deputy Manager, Antenatal Clinic, NHS Trust Hospital

Conclusion

In the study titled ‘The challenges of undertaking root cause analysis in health care’ by Nicolini, Waring, and Mengis, (2011) it was concluded that:

“Health services leaders need to provide open endorsement of root cause analysis and of the staff carrying it out; enhance staff participation within learning activities and new analytic tools; and develop capabilities in change management”

Apollo Root Cause Analysis methodology has been taught to well over 100,000 people worldwide over the last 22 years. It has become known as the preeminent RCA methodology and is used in many fortune 500 companies and US government agencies like the Federal Aviation Authority and NASA.

If you are interested in what the Apollo Root Cause Analysis methodology can do for you and would like further information on the methodology please visit the website: http://www.apollorootcause.com

 

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