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Marita Thou Industrial Engineering Undergraduate CBE 555 April 9, 2012.

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Presentation on theme: "Marita Thou Industrial Engineering Undergraduate CBE 555 April 9, 2012."— Presentation transcript:

1 Marita Thou Industrial Engineering Undergraduate CBE 555 April 9, 2012

2  Rarely associated with the goal of customer satisfaction  Easily used for blaming  Perceived as time-consuming  Associated with employees involved in quality assurance and quality control

3  Perceptions of RCA  Definition  RCA Team  Types of Errors  RCA Forms  RCA Trees  Case Studies/ Exercises

4  Problem Statement: “The customer service representative input the wrong part number when processing the customer’s order.”  Investigation: ◦ Talked with the sales representative who explained the procedure  Root Cause: “The customer service representative put the wrong information in the computer.”

5  Diverse group of people not involved in the event/problem ◦ Cross-functional ◦ Cross-departmental ◦ Intradepartmental  Everyone should understand the process  Individuals should have different and unique skills and expertise

6  Explain various tasks and responsibilities  Teach them the tools and techniques of the RCA process ◦ How to use forms ◦ How to make RCA trees/diagrams ◦ Other tools  Remind them that their effort has significance

7  Top Management  Managers  Accounting Personnel  Human Resources  Supervisors  Customer Service/ Sales  Information Technology Department  Purchasing  Engineering  Quality Department

8 Top ManagementManagers  Allocate resources  Make decisions for the organization with the RCA results  Ensure managers are cooperating  Less likely to participate than managers  Provide access to records  Assign employees to work on tasks  Participate in investigation

9 EngineeringQuality Department  Provide information about product and process design  Help others understand requirements and specifications  Facilitate design of experiments  Train individuals about the RCA process  Manage the Corrective Action Process  Teach others how to investigate  Facilitate meetings  Take part in data analysis

10  Active Errors –Errors performed by individuals (something caused it to happen)  Latent Errors – Errors which occur because the organization or environment lead an individual to fail

11  Root Cause Analysis Forms  Cause-and-Effect Diagrams  Root Cause Analysis Trees  Ways to get information ◦ Find and read documents and records ◦ Conduct interviews ◦ Make flowcharts ◦ Ask the Five Whys

12 (Robitaille, 2004)

13  Problem: Spoiled product that had to be disposed ◦ Why? Product was stored at room temperature. ◦ Why? Refrigerator was full. ◦ Why? The units consigned for shipment wasn’t removed. ◦ Why? Shipping labels didn’t print because printer was offline. ◦ Why? The server was down. (Robitaille, 2004)

14 (Robitaille, 2001)

15 (Colorado Foundation for Medical Care, 2010)

16  Shows a physical representation of how failures can occur  It starts with an event or problem that occurred ◦ Written in a box  It is followed by immediate actions (causes) that caused the event to happen ◦ Ask why or what caused it

17  Proximal causes – the immediate action or cause in which the event occurred ◦ Typically there are at least two and connected with an AND gate ◦ Written in a box  Continue to ask yourself questions until you get to the last action where you had control  Progenitor causes – last action which you had control ◦ Written in a oval

18 (Colorado Foundation for Medical Care, 2010)

19  These can be root causes of the event or problem  They can also be conditions in which you couldn’t prevent ◦ Example: Employee was sick

20  You have to go to the basement to put away your box of winter clothes.  Your Chihuahua is asleep on the stairs  You are holding the box of clothes  You trip down the stairs

21  A nuclear medicine technologist prepares to give a patient an injection of 201 Tl for a diagnostic cardiac scan.  The technologist gets called to give an injection to a different patient on a treadmill which cannot wait, and sets the syringe for the 1st patient on the corner of the hot-lab bench, and leaves to make the injection.  A radiotherapy resident comes to see if the therapeutic 89 Sr injection (high dose of a very different material) is ready for the radiotherapy patient in the hall.  The resident sees the 201 Tl syringe on the bench, thinks that it should not be left out and puts it in the lead shielding cupboard.  The resident then finds the 89 Sr syringe in the cupboard and takes it out, puts it on the corner of the bench and goes out to bring the patient in for the injection.  The nuclear medicine technologist returns, picks up the syringe since it was where she had left the diagnostic dose, and injects the cardiac patient.  The radiotherapy resident returns with the 89 Sr patient, and asks about the syringe. At that point, they both realize that the therapeutic dose was given to the diagnostic patient. (Thomadsen, 2012)

22  Colorado Foundation for Medical Care. (2010). Root cause analysis. Retrieved from htm  Thomadsen, B. (2012). Root cause analysis. ISyE 559. Lecture conducted from University of Wisconsin Madison.  Robitaille, D. (2004). Root cause analysis basic tools and techniques. Chico, California: Paton Press LLC.  Robitaille, D. (2001). The corrective action handbook. Chico, California: Paton Press LLC.


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