Root Cause Analysis

[@isoamauditor3965]

What the medical industry will discover through root cause analysis, as I did over nearly 3 decades of being involved with quality management, is that there is no such thing as "Root Cause" relative to a process failure. Operational process are a complex assembly of many working bits, not simply a single operational entity (like machines). Therefore, thinking that there is a single root of causation which lead to a process failure is ludicrous. The single best tool that the medical industry could use to discover process failure is to map the process in swim lane format with all of the relative players involved. This map becomes a picture of the process, and all of its inherent points of failure. This is a time consuming process, so its very often ignored and replaced with a more inefficient activity such as 5 why or fishbone analysis (aka guess the causes). The whole of the point is that rarely do organizations ever understand the complexity of their interacting processes. Further, since such processes are not well understood, they often fail and they do such repeatedly. Secondly, I have learned through experience, that its accountants (not quality professionals) who understand and apply process controls most effectively. ----- The healthcare industry could learn quite a bit from: Quality folks about variation Insurance folks about risk assessment Accounting folks about Process control

[@falstaff_the_genuine]

excellent comment, thank you. Yes, so far (studying RCA for about a month now) seems to come closest to a "who can we blame" game. I see some value in it, but it's not the whole picture. I need to look up the "swim lane" tool you mentioned. Sounds interesting and valuable.

[@timtruett5184]

See UML (unified modeling language) or BPMN (business process modeling notation).See "systems analysis".

[@ismailgasimov1861]

Infinite gratitude goes to your fabulous master class. Please provide the PDF! Thank you ahead!!!

[@aishasaleh275]

How could we find it? So you think it’s available in their website maybe?

[@moatzelmalawany6993]

Thank you Need Powerpoint please??

[@Potencyfunction]

I would make a excel sheet with those steps in order to develop my critical thinking. There are persons in Autism spectrum, that can not process for instance analyzing the cause analysis, the causal explanations or even what is working in a field, where you have been educated on sustainability ( if you know what that means ) social responsAbility and your role in the team as, a functionar when taking an action. In teams the role cant can be leader... but it be moderator, observator, or participant in the team role. Paretto is good for findining defects roots. Also ABC parallel ( activity based cost). Landet from the 2 nd dimension...We actually have 3 dimenesions ... They are too stupids both in knowledge/ education and thinking.

[@hasuguedwin-jw9vt]

good