The first step of the Cause Mapping strategy of root cause analysis is to define the problem with respect to the organization’s goals. In order to do this, you need to know what an organization’s goals are. While we provide Cause Mapping root cause analysis templates that will give you an idea of where to start, your organization may wish to personalize their investigations so that they correspond to your particular goals.
To define your organization’s goals, try to imagine a perfect day for your organization. For the healthcare industry, that perfect day doesn’t include anyone getting hurt or killed due to the actions (or lack of action) of the organization’s employees. This is the patient safety goal. Additionally, a perfect day would not include any injuries or deaths of employees. This is the employee safety goal.
Additionally, most industries have a goal of not impacting the environment. However, a healthcare industry may have a base level of environmental impact, such as a standard amount of hazardous waste disposal or an appropriate number of x-rays. In this case, your goal might be to not surpass that level rather than having no impact. This is the environmental goal. Environmental impacts usually result from leaks or spills of any material other than water, but may also result from improper storage or disposal of hazardous material. Misuse of diagnostic equipment such as radiographs may result in an environmental impact.
The medical and insurance industries have defined some events that should not happen on a perfect day. The Joint Commission has its list of “never events” which are events that should never happen, and Medicare has a list of “hospital acquired conditions” which are conditions caused or worsened by medical provider actions for which Medicare will no longer reimburse. This is the regulatory or compliance goal.
A healthcare organization exists to provide services to its patients. If patients are not receiving appropriate services in a reasonable amount of time, this impacts the patient services goal.
Another area of concern for almost all organizations is cost. An incident that results in additional costs to the organization impacts the material and labor goal. If an incident results in many costs, it’s possible to itemize them within the problem outline. Quantifying all the costs associated with an incident can help prioritize which incidents require the most immediate attention. It also provides a bound for the cost of solutions – installing a $100,000 machine to solve an infrequent $20,000 problem doesn’t make sense. (Of course, for incidents that involve impacts that can’t be easily quantified – human safety, regulatory requirements, patient services, etc. – these impacts must be considered above and beyond the “cost” of the incident.)
Once you’ve determined all of the goals that are meaningful to your organization, you’re ready to make an outline for the first step of the Cause Mapping method of root cause analysis – define the problem. But what order do you put the goals in? Generally, the goals go in order from most to least important. The safety goal is almost always at the top. Your organization’s mission statement is an excellent resource to determine the order of the goals. Ideally, they’ll follow along with your mission statement, with any goals not specifically called out (such as the “material and labor” goal) listed below. It’s also possible to use a different order so that the biggest impacts from an incident are listed at the top. However, your organization may prefer to always use the same order for consistency.
If an incident resulted in no impact to one of your organization’s goals, don’t delete the goal from the problem outline. Instead, write “N/A” next to the goal. That way, it’s clear that the goal was considered but it was determined that there was no impact. Deleting the goal may lead others to believe that it’s no longer a goal of the organization! Shown below is a standard outline for a healthcare organization.
ThinkReliability has specialists who can solve all types of problems. We investigate errors, defects, failures, losses, outages and incidents in a wide variety of industries. Visit our website to find out more about our investigation services and root cause analysis training.