Updated: Sep 15
There is an incredible amount of valuable information in every organization that is never gathered, organized and analyzed. Information that would lead to hundreds of latent weaknesses that we inherently know exist in our policies, programs, processes and procedures. The more of these latent weaknesses that we identify and address, the fewer events and injuries we will have. And time and money that is spent dealing with latent weaknesses and their adverse consequences can be returned to mission critical tasks.
That valuable information can be readily accessed if we just knew how to get at it. In three decades as a root cause practitioner, it always surprises me when I find out that my clients are not mining this data. Organizations in regulated industries have defined processes to monitor performance, document the gaps and take corrective actions. Most of them use a graded approach: about 90% of the issues are simply corrected on the spot. About 10% may be investigated further to determine the most likely (apparent causes). And the most serious issues (about 1% or less of the total) are significant enough to warrant a formal root causes analysis.
It is in the 90% of the low-level issues that this valuable information lies dormant. Yet most organizations do very little in the way of gathering, organizing and analyzing these low-level problems to a sufficient degree. The status quo has been to fix it and get back to what we were doing.
I've been challenging this status quo for years, but without offering much more than general advice to develop and implement a robust trending and analysis program, so that when a negative trend is identified, we can launch a deeper investigation. I recognize now that there was something missing; the process by which we tap into the 90% pool of low significance issues and mine the valuable information that they can provide.
To tap into this valuable set of information requires a bit of effort, but less than you might think. Up to now, most organizations are reluctant to invest much time in investigating low level events because pulling out any causal analysis tools meant it was going to take a lot of time. We often resort to best guesses or brainstorming the possible causes. However, brainstorming does not provide as valuable results as a disciplined approach would.
In order to have sufficient data to identify adverse trends, we need to input more accurate data into the trending system; information that better describes the causes for the issue. If we could do a better job of analyzing the low-level issues and input the resulting causes using trend codes, without spending too much time, we would quickly build a large data base of information that we can trend and analyze. The process for analyzing that 90% pool of low-level issues is our tip of the week.
Tip of the Week:
To quickly investigate the pool of low-level issues to dramatically improve the quality of the information going into your trending programs, consider the following:
Gather and organize available information into the BlueDragon Framework (i.e. the timeline, the administrative requirements and the physical barriers).
Develop about 10 focused, evidence-based Lines of Inquiry (LOIs) to evaluate any performance gaps as well as to analyze the effectiveness of the requirements and physical barriers that should have prevented the issue. For a low-level event, this initial set-up should take less than an hour.
Call a 1-hour Zoom /WebEx meeting (or your platform of choice) with personnel that can answer the LOIs. This may include personnel that were involved in the issue, their supervisors, other observers and subject matter experts.
Using the LOIs, conduct cause & effect analysis to identify the deepest causes.
The results should be tagged with the appropriate trend codes and entered into the trending and analysis program.
This is one of the best features of the BlueDragon Framework; the same model that is used for the more rigorous Apparent Cause Evaluations (ACEs) and Root Cause Analyses (RCAs) can be used for HCA Rapid Investigations. And by conducting rapid investigations on the 90% pool of low-level issues, personnel practice and gain proficiency in the methodology, which will serve them well when performing ACEs or RCAs.
With a robust trending program, negative trends will be better defined and the subsequent ACE or RCA can get to the deepest-seated causes that, when corrected, will eliminate the latent weaknesses that are the point of origin for recurring events.
If you would like additional information on dramatically improving the effectiveness of your root cause analysis, visit us at: https://dle-services.com/bluedragon