Best Practices Session 8
Trending with the TapRooT® V5 Software
Ed Skompski Christopher Vallee
System Improvements, Inc. 238 S. Peters Road Knoxville, TN 37923 865.539.2139 info@taproot.com
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
09/2009 Version
Why Focus on Audit Information during a Trending Session?
Reactive Analysis
1 1 Spring SnapCharT® Plan Investigation – Get Started! Determine Sequence of Events
Proactive Analysis
Root Cause Tree®
Equifactor® Summer SnapCharT® Equifactor® CHAP Change Analysis
1 2 3
4 3 2
1
Plan Audit (Flow Chart Process, Decide Scope of Audit, & Prepare for Audit) Perform Audit & Record Successes & Failures
Identify & Define Significant Issues
(Causal Factors)
SnapCharT® Root Cause Tree® Equifactor® SnapCharT® Equifactor® CHAP Change Analysis SnapCharT® Equifactor® Safeguards Advanced Trending Techniques Root Cause Tree®
2
2 3 3
Define Causal Factors
Autumn SnapCharT® Equifactor® Safeguards Analysis Root Cause Tree®
4
Analyze Each Causal Factor's Root Causes
Analyze Each Significant Issue's Root Causes
5
Analyze Each Root Cause's Generic Causes
Root Cause Tree® Corrective Action Helper® Corrective Action Helper® SMARTER Matrix Safeguards Analysis Winter SnapCharT®
5
Analyze Each Root Cause's Generic Causes
Root Cause Tree® Corrective Action Helper® Corrective Action Helper® SMARTER Matrix Safeguards Analysis Winter SnapCharT® TapRooT® Software
6
Develop & Evaluate Corrective Actions Present / Report & Implement Corrective Actions
6
Develop & Evaluate Corrective Actions Present / Report & Implement Corrective Actions
7
7
TapRooT® Software
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
09/2009 Version
Significance – Rate – Analysis - Workload
Significance
Serious Incident: 1-5
Incident: 30 - 100 Near Miss: 100 - 1000
Analysis
Root Cause Analysis Then Fix
Root Cause Analysis Then Fix
Categorize
Repair
Categorize
Behavior or Equipment Violations: 1000 - 4000
Repair
Is this good Enough?
Fix Only if
Adverse Trend
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
09/2009 Version
Ice-Berg Theory
If the largest part of the Ice-Berg needs to be audited…..
How thorough is your IceBerg Audit?
Note: Diver (Auditor) not to Scale of the Ice-berg!
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
09/2009 Version
Guess what…. More than one Ice-Berg!
Limited on what we can focus deeply on!
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
09/2009 Version
What Guides your Current Audit System?
……Regulatory? Global (all processes)?
……Encouraged after an Incident? ……By Risk? Risk to Who? ....What is the goal of your Audit System?
….How do you know your Audit System is Successful?
Note: A recent Survey indicated that only 13% of Auditors sampled, took the audit to the Root Cause level!
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
09/2009 Version
Understand Your Ice-Bergs!
Costumer Needs
Supp ly Chai n
Proc ess
Prod uct Deliv ery
Barriers to Success
“Know thy Value Chain/Stream!”
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
09/2009 Version
Each Ice-Berg has A Process Map!
For Each Process there are “Critical” Inputs and Outputs that Must be Measured!
“Know thy Process!”
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
09/2009 Version
Critical to…….
Customer Satisfaction and Safety
Repeat Customer New Customer Company Reputation
Employee Safety
Incidents Near Misses
Business Financials
Indirect Costs Direct Costs These are lagging Indicators….. Now what? Rate the Inputs
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
09/2009 Version
Risk Value to the Rescue?
Risk Area of Opportunity Severity Detectability Frequency Value
Patient acquires Staph Infection
Emergency Room
3
Intensive Care Unit
X
3
X
9
=
81
Patient acquires Staph Infection
9
X
1
X
3
=
27
Which System is in Control?
Where do ER patients sometimes get transported to?
Where would you focus a more Deep Dive Audit?
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
09/2009 Version
Focus Deep Drilldown on Critical inputs!
Determine the Critical Inputs using Past Data and Process Experts…. Use the TapRooT® Root Cause Tree and Dictionary for Human Performance Clues.
Determine the Risk Rating of Each Critical Input
Focus on Highest Risk Rating Values first Trend Data using a Process Behavior Chart
Reassess Risk Rating Criteria if Risk Rating Values have been reduced and there is no change to Lagging Indicator Outputs
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
09/2009 Version
Understanding the Metrics
Companies Lagging Indicator
Risk Rating Value 1
Risk Rating Value 2
What should a significant decrease in a Risk Rating Value demonstrate?
Have a top driver here, Investigate!
Do not have a top driver; Evaluate Need to Deep Dive Audit
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
09/2009 Version
Metrics Only Measure What They were Selected to Measure!
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
09/2009 Version
Now that You Understand your System, do you Understand what’s in TapRooT® V5 Software?
Department Location Causal Factors Employee
Basic Cause Categories
Symptom Causes Root Causes
Equipment
Significant Issues
Classification Equip. Symptoms
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
09/2009 Version
Lets start with the Software Variable Location: Reactive/Proactive
Area of Incident/Opportunity
Setting up the Location Software Dropdown Menu based on where the greatest risk occurs and needs to be audited just makes good sense.
Area of Responsibility
Many companies set up the Location Category by area of responsibility for the person who is investigating or the department the person is assigned to that was hurt……
this however can be identified in the employee/Department section
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
09/2009 Version
The Underused Classification System! What are the most common Classification Categories used in TapRooT® software?
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
09/2009 Version
The Problem of Perspective and Clarity of Audits! TapRooT® is not just an EH&S System
Accounting
EH&S
Really talking about the Same Problem but can’t see past your corner of the world to realize it.
Operations
Senior Leadership
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
09/2009 Version
Solution to Clarity and Perspective: Talking the same Risk and the same Company!
Accounting
All TapRooT® Trained Employee
Lean/ Six Sigma Black Belts And Green Belts
Senior Leadership
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
09/2009 Version
Combine Classifications and Area of Opportunity (Location)
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
09/2009 Version
What about Causal Factors and Significant Issues? How do they help with Classification and Risk?
For each Risk/ Hazard that you identified Earlier with the Risk Assessment Tool….
Include this in the Text of the Causal Factor (You don’t have to write the CF’s the same just the type of Risk!
For Example:
Mechanic A left Valve Open (Risk: Flammable Fluid Release) Surgeon B Touched Un-sterile Surgical Tool during surgery (Risk: Biological Contamination)
Don’t Forget, there are also Hazards to Process and Transactions too!
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
09/2009 Version
Remember: A Number is Only a Number!
Some expected this session to talk about numbers and trending calculations! Problem is that I can buy a Fancy calculator and get some fancy outputs…. But what to they really mean?
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
09/2009 Version