Definitions
What is Root Cause Analysis
Root cause analysis (RCA) is:
an error analysis tool
a structured method used to investigate incidents and near hits
a retrospective method for detecting and describing safety or risk hazards
#1 Define the problem
•Clearly articulate the problem
•specific
•observable
•measurable
•Focus on facts rather than assumptions or interpretations
Corrective actions are divided into two categories what are they?
Short-term: < 1 week
Long-term: > 1 week
more complex
additional resources to complete
1 week to 1 month
What are the important elements of managing change
Build and communicate the case for change
Be open, transparent, and strive to build trust.
Communicate in a timely fashion (before, during, and after the change).
Provide opportunities for the audience to offer feedback.
Be an ambassador and advocate for positive change and improvement.
Provide ongoing support to workers and those affected by the change.
For step #7 "Monitor the results"
What are the 3 things you should monitor for?
Monitor for:
•recurrence
•efficiency
•sustainability
Define Consequence
(severity) of harm
person(s), people
property
reputation
Operations, including financial impact
#5 identify the root cause(s)
Identify the root cause(s) of the problem. This is the fundamental issue that set everything else into motion. It might not be the most obvious cause, but it is the one that, if addressed, will prevent the problem from recurring.
What is the Purpose of Incident Reporting
The purpose of the Incident Reporting System (IRS) is to establish the requirements for incident reporting and analysis across Lethbridge Family Services (LFS). This ensures a systematic process is used for reporting, investigating and analyzing incidents, and developing corrective actions to prevent incidents from reoccurring and to share learning from the incidents across the organization.
Peeling Back the Layers: Which cartoon character was used on the slide that referenced the idea that “onions have layers”?
Shrek
What are the 5 Whys
The 5 whys is a simple yet powerful tool used for problem-solving and root cause analysis. It’s centered on the principle of asking the question “why” five times to delve into a problem and identify its root cause. The aim is to get past the symptoms and reach the fundamental origin of an issue.
Define likelihood
Likelihood (probability) of harm occurring
rare or remote
unlikely
possible
likely
probable
#2 Ask the first why
Ask “why”
Search for an immediate cause that directly led to the problem
Make sure that your answer is based on facts, not assumptions
FINISH THE SENTENCE: LFS identifies and strives to eliminate all occupational accidents and diseases, and foreseeable
physical, chemical, biological and psychosocial hazards.
How many Why's do we ask
5
Corrective Actions =?
CHANGE
Define corrective actions
Corrective actions are the things we do to address a problem, and stop the same issue from happening again. They involve finding the root cause, fixing the mistake from reoccuring
#6 develop and implement corrective actions
Develop corrective actions
that directly address the root cause
are practical
are achievable
Implement corrective actions
Corrective action action Plan:The corrective action must be:
clearly defined
achievable
timebound
assigned to specific workers to complete
Where can the Worker Incident Report Form be found?
On the T drive
How to complete the 5 Whys
#1 Define the problem
#2 Ask the first why
#3 Ask the next why based on the first answer
#4 repeat the process
#5 identify the root cause(s)
#6 develop and implement corrective actions
#7 monitor the results
Define Investigation
An investigation is taking the time to look deeper into a situation, ask questions, gather the facts, and understand the full story before deciding on the best solution or next steps.
#3 Ask the next why based on the first answer
•Start with the answer from the first why and ask why again
Investigations rely on three key factors. What are they?
essential to involve more than just one person
comprehensive perspective
involvement from stakeholders creates buy-in
what is the ULTIMATE goal of RCA?
is to prevent future harm by eliminating the underlying errors or system problems – prevention rather than cure.
What is LFS Commitment ?
Policy -
Lethbridge Family Services (“LFS” or the “organization”) is committed to ensuring the health, safety and well-being of all workers in all worksites.