1. WIC Conference Presentation: Root Cause Analysis October 23, 2014 By Dan Ward, MPA Performance Improvement Manager Idaho Department of Health and Welfare, Division of Public Health

2. How deep is a frog’s lake? 2

3. Knee-Deep! 3

4. Key points for discussion: 3 Key Questions to QI PDSA Root Cause Analysis Plan DoStudy Act 4

5. 3 Key Questions to QI 1.WHAT ARE WE TRYING TO ACCOMPLISH? 2.WHAT CHANGE CAN WE MAKE THAT WILL RESULT IN AN IMPROVMENT? 3.HOW WILL WE KNOW THAT A CHANGE IS AN IMPROVEMENT? 5

6. Plan DoStudy Act PDSA The process for doing CQI 6

7. 3 Key Questions to QI 1.WHAT ARE WE TRYING TO ACCOMPLISH? 2.WHAT CHANGE CAN WE MAKE THAT WILL RESULT IN AN IMPROVMENT? 3.HOW WILL WE KNOW THAT A CHANGE IS AN IMPROVEMENT? Plan DoStudy Act 7

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9. Root Cause Analysis 9

10. The new way of thinking (Deming) Focus on Processes not people. It’s not about blame... It’s about solutions.

12. The goal of Root Cause Analysis is: To find out what happened, Why it happened, and How to prevent it from happening again. 12

13. Multiple tools for root cause analysis Today – Tree Diagram – What is it? – What is its’ purpose? – How to use it 13

14. What is it? It is a QI tool that helps to illustrate: – A problem you want to address – List possible reasons why there is a problem and – List possible solutions for resolving the problem 14

15. What is its’ purpose? To peel the layers of what might be the root cause(s) to a problem To show all of your possible root causes Put your thoughts, and others, all on one page! - Little picture and big picture - List possible solutions (Corrective Actions) to select. 15

16. How to use it 16

17. Tree Diagram – - Possible Root Causes and Corrective Actions Dan is late for work Doesn’t get up early enough Takes the long route Stops for donuts Problem Statement Corrective Actions Why? 17

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19. Cause and Effect -Fishbone Diagram Helps to identify possible root cause(s) to the WHY question Materials Methods Inaccurate ordering Many new streets experience 19

20. Questions? 20

21. Tree Diagram – Declining caseload for tribal programs - Possible Root Causes and Corrective Actions Declining caseload clients don’t keep appointments Staff will make reminder appointment calls and/or text reminders AND allow walk ins and flex sched (i.e. lunch time) Clients forgot, lack of transportation or a crisis Don’t have a reminder system. Limited free transportation High provider turnover and poor communication with WIC staff Provider suggested an item that’s no longer available by WIC Budgetary constraints Small staff Few employees to provide WIC services Changes in food package Cancelled appointments due to small staff Cross train staff Promoting food package: what WIC has and communicate to med. Staff what WIC offers AND Problem Statement Corrective Actions Why? 21