How to Target Audits for Better Performance Improvement
Christopher Vallee
System Improvements, Inc. 238 S. Peters Road Knoxville, TN 37923 info@taproot.com 865.539.2139
©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 Behavior or Equipment Violations: 1000 - 4000
Analysis
Root Cause Analysis Then Fix
Root Cause Analysis Then Fix
Categorize
Repair
Categorize
Repair
Is this good Enough?
Fix Only if
Adverse Trend
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
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.
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.
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.
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.
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.
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
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Why Use a Risk Rating Process for Audits? Why not just assess by Severity of Risk Only?
Severity of Risk
1. Staph Infection
Area of Opportunity
1. Emergency room OR 2. Intensive Care Unit?
1
2
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Severity?
Risk Patient acquires Staph Infection Area of Opportunity Emergency Room Severity Detectability Frequency Value
3
Intensive Care Unit
X
X
=
Patient acquires Staph Infection
9
X
X
=
1 = Not Hazardous to Patients 3 = Hazardous to Some Patients 9 = Very Hazardous to Most Patients
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Detectability?
Risk Patient acquires Staph Infection Area of Opportunity Emergency Room Severity Detectability Frequency Value
3
Intensive Care Unit
X
3
1
X
=
Patient acquires Staph Infection
9
X
X
=
1 = Can be easily detected before / after it occurs 3 = Can be detected sometimes before / after it occurs 9 = Usually can not be detected before / after it occurs
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Frequency?
Risk Patient acquires Staph Infection Area of Opportunity Emergency Room Severity Detectability Frequency Value
3
Intensive Care Unit
X
3
1
X
9
3
=
Patient acquires Staph Infection
9
X
X
=
1 = Rarely occurs 3 = Sometimes occurs 9 = Often occurs
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Value?
Risk Patient acquires Staph Infection Area of Opportunity Emergency Room Severity Detectability Frequency Value
3
Intensive Care Unit
X
3
1
X
9
3
=
81
27
Patient acquires Staph Infection
9
X
X
=
Which System is in Control?
Where do ER patients sometimes get transported to?
Where would you focus a more Deep Dive Audit?
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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
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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
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Discussion
What Gaps to you see in your existing audit system? How does the audit system drive the business costs? What are the barriers to making it better?
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.
References
Images:
1. Green Target Map: email.eva.mpg.de/~walsh/img/ebola-spread.gif 2. First iceberg: System Improvements, Inc. 3. Titanic with Iceberg: http://blocs.xtec.cat/jvvmusica/2008/06/08/286/ 4. More than one ice-berg: http://www.travelswithsheila.com/day7biggestberg1.JPG.jpg http://images.brisbanetimes.com.au/2008/11/13/267046/sink375_gallery__545x400-600x400.jpg http://1.bp.blogspot.com/_Es5C1U7Ynfc/SZ4rQQ87OnI/AAAAAAAAHJE/OLW2mY_mkQ/s400/Picture+2.png http://igoralexander.files.wordpress.com/2009/06/sinkingship.jpg 5. Swimming Diver: http://www.divesource.com/aboutus.html 6. Process Map; http://www.flickr.com/photos/40508391@N05/3728335634/ 7. ER: http://www.americanprogress.org/issues/2008/07/img/emergency_room_wait.jpg 8. ICU: http://www.sgrh.com/dept/criticare/critical.htm 9. Multiple Shipwrecks: http://static.panoramio.com/photos/original/2930039.jpg
©Copyright 2009 by System Improvements, Inc., Knoxville, TN. All Rights Reserved Worldwide. Duplication Prohibited.