Source: Root Cause Analysis: the Core of Problem Solving and Corrective Action

Root Cause Analysis for Process Improvement

This model is provided to standardize the work of a root cause analysis in the support Process Improvement Team for the Division of Family Services. The basic model of process improvement includes five steps, Define, Measure, Analyze, Improve and Control. Process improvement is continual and ongoing so that we reach the best possible methods and processes to serve children and families.

The eight steps identified here expand the model into greater detail to aide in learning and implementation. This model will be supplemented with resources and tools.

Source: Root Cause Analysis: The Core of Problem Solving and Corrective Action – The DO IT Problem Solving Model - By Duke Okes Note: Some context is modified from the author’s original work to fit VDSS and LDSS

Find It 1. Define the problem 2. Collect and analyze the data Diagnostic 3. Understand the process Phase 4. Identify possible causes

1. Identify & select possible solutions Fix It 2. Implement solution(s) Solution 3. Evaluate the effect(s) Phase 4. Communicate & institutionalize the change

Step Questions Outputs . What is the right problem to work on (frequency, cost, risk) . Is it scoped to a reasonable size and only . Develop a Problem statement one issue covering what, where, 1. Define the problem . Is it the same over time or sporadic? when/how often, how much . Utilize Data to define the problem . What is it, where, when and how much does it occur?

. What data exists to inform the problem statement? . Sources of Data : . What additional data is need to describe o Qualitative case review the problem and the frequency? o Transformation Measures 2. Collect & analyze the . How does the problem link to Safe Measures data performance measures and outcomes? o . What does the data indicate about our o LDSS data and information problem statement?

3. Understand the . Describe the process steps involved with . Process flow chart 1 Root Cause Analysis PIT April 2009 Step Questions Outputs the problem statement. . What are the boundaries – beginning and end of the process? process . What are the major steps between the boundaries?

. Ask the questions to get beyond the surface issues to get to root causes. . List of most likely causes (flow . What changes may have been made/and 4. Identify possible chart, 5 why analysis, logic tree, or occurred in the process that impact the causes brainstorming, cause & effect problem statement? diagram) . What barriers may exist?

Is the improvement strategy SMART?

. What could prevent the problem? Specific – behaviorally specific . Which solution is best, based on Measurable – quantifiable 5. Identify & Select economics, technical impact, time/effort, Achievable – can it be done? possible solutions required to implement, impact on other Realistic – practical and variables and capability to sustain? reasonable, Time Limited – what is the time frame for accomplishment

. What needs to be done or acquired? . What training and communications need . Implementation plan with action to occur? item list, responsibilities and 6. Implement the . Where will resistance occur and how to timing. solution offset it? . A list of who, does what, by . Who should do each item and when? when?

. Chart/graph/data showing how . Did the problem go away? process performance is now . If it is better is it because of the action different. taken? 7. Evaluate the effects . Analysis of Transformation . What process measures and outcome Measures and Safe Measures measures have changed?? . Impact on children and families

. What actions need to be taken to make the change permanent? . Revisions to process, . What will be done to monitor the process procedures and for how long to insure sustained 8. Communicate & . Communication to other improvement? Institutionalize the process owners, managers, . Where else in agency or state might this change supervisors about how the solution be useful? knowledge gained may be . What was learned in the process that useful. could help us be more effective in the future?

2 Root Cause Analysis PIT April 2009