Scribd
Upload
46 views

Root Cause Analysis

This document provides an overview of root cause analysis (RCA). It explains that RCA is a systematic process used to identify the root causes of problems in order to prevent recurrence. The document outlines the steps of RCA, which involve repeatedly asking "why" to drill down to the fundamental reason a problem occurred. Benefits of RCA include improving processes, quality, and safety by addressing underlying causes rather than symptoms. Examples of using RCA to solve issues like delays in the operating theatre or missed diagnoses are also provided.

Uploaded by

MOHAMAD FAUZI AHMAD
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
46 views

Root Cause Analysis

This document provides an overview of root cause analysis (RCA). It explains that RCA is a systematic process used to identify the root causes of problems in order to prevent recurrence. The document outlines the steps of RCA, which involve repeatedly asking "why" to drill down to the fundamental reason a problem occurred. Benefits of RCA include improving processes, quality, and safety by addressing underlying causes rather than symptoms. Examples of using RCA to solve issues like delays in the operating theatre or missed diagnoses are also provided.

Uploaded by

MOHAMAD FAUZI AHMAD
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 21

Noramiza Md Nasir

MBA (Healthcare Management), BSc (Biomedical)


Executive Manager, Technical, Client & Surveyor Management
 Isa method that is used to address a problem
or non conformance, in order to get to the
true root cause of the problem.

 Itis used so we can correct or eliminate the


cause, and prevent the problem from
recurring.
 Resolutions of customer complains

 Dispositionof non-conformance
(related to practice)

 Corrective
plans resulting internal and
customer audits.
Through this training course, you will:

 Understand the meaning of “Root Cause”

 Knowthe steps used to identify the root


cause of problems.
 Root cause is the fundamental breakdown or
failure of a process which, when resolved
prevents a recurrence of the problem.

 Fora particular product problem, root cause


is the factor that when you fix it, the
problem goes away and don’t come back.

 RCA is a systematic approach to get to the


true root causes of our process problems.
 Each problem is an opportunity because it
can tell a story about why and how it
occurred.
 Itis critical that everyone take a personal
and active role in improving quality.

 The true problem must be understood


before action is taken.
 This is critical. We need to fix it for good or
it will come back and burn us.
 To do this well, we must be;-

 both focused and open minded

 both patient and quick

 above all ,we must be persistence


WE PERFORM
RCA TO
PREVENT
TURN BACKS
 If we do a poor job of identifying the RC of
our problems, we will waste time and
resources putting band aids on the symptoms
of the problems.
 Errorare the result of defects in the system.
People are only part of the process.
 We need to find out why this is happening,
and implement mistake-proofs so that it will
not happen again.
 This is critical. We need to fix it for good or
it will come back and burn us.
Benefits of Root Cause Analysis
▪ Identify risk or weak points in process, underlying
or systemic causes and corrective actions

▪ Improve the efficiency and effectiveness of:


• the operations
• quality and safety of care through addressing
the roots of incidents/event

▪ Information from RCA shared between and among


organisation can help prevent future sentinel
events/incidents
 Using a fishbone diagram while brain
storming possible causes helps us to focus
on the various possibilities.
 6 Ms
 Machines  Mother Nature
 Methods (Environment)
 Materials  Manpower (People)
 Measurements
Causes of long waiting time in E.R

Triage Waiting
Ancillary
Room Room
No visits from
Everything nurses
Lab so far
done in Patients
Triage room Dissatisfaction
Radiology so far
One Room

Size and Pharmacyso


far Not
arrangement not
Suitable
standard
Long
Waiting
Receptionist Some items not Time
Improper available
not present
Examination (Zero Stock)
No CGs
Insufficient
Nurses Bad No signs
Communication
Insufficient Equipmentsdid
Physicians Misdiagnosis Unneeded not work good
Investigations

Human Practice Resources


 Said simply RCA is asking WHY the
problem occurs and then continuing to
ask WHY that happened until we reach
the fundamental process element that
failed.
❖ The patient was late in the theatre ,it cause a
delay. WHY?
❖ There was a long wait for a trolley. WHY?
❖ A replacement trolley had to be found. WHY?
❖ The original trolley safety rail was warn and
had eventually broken. WHY ?
❖ It had not been regularly checked for wear.
WHY?
 There was no equipment maintenance
schedule.

 Settingup a proper maintenance schedule


helps ensure that patients should never
again be late due to faulty equipment.

 Thisreduces delay and improves flow. If you


simply repair the trolley or do a one-off
safety rail checks, the problem may happen
again sometime in the future.
 The patient’s diagnosis of skin cancer was
delayed. WHY?
 The excision biopsy report was not seen by
the surgeon. WHY ?
 The report was filed in the patient’s note
without being seen by the surgeon. WHY?
 It
was the receptionist’s job to do the filling.
WHY?
 The junior doctor were busy with other
tasks. WHY?
 The doctor’s other tasks were seen as
more important than filling. The system
has now been changed.

A copy of all biopsy reports is now sent to


the consultant surgeon responsible for the
patient and no reports are filed unless
they have been signed by a doctor.
You will need to communicate the
outcomes to others to ensure that the root
of the problem is understood and that
everyone is focused on working on the
correct problem area, not treating its
systems.
 RCA is a method to focus our efforts on the
true “Root cause” of escapes, so that we
truly prevent their reoccurrence.

 RCA helps us reduce turn backs and


frustrations, maintain customer satisfaction,
and reduce cost significantly.

 Each problem is an opportunity. It contains


the information needed to eliminate the
problem, and to identify the root cause we
have to ask WHY over and over until we find
the cause.
THANK YOU FOR
YOUR ATTENTION

You might also like