healthcare occupational safety center of district … · root cause analysis is: from wikipedia:...

HEALTHCARE OCCUPATIONAL SAFETY CENTER OF

DISTRICT 1199C TRAINING FUND

District 1199C Training Fund HWWH SH-29634-SH6

ROOT CAUSE ANALYSIS

This material was produced under grant SH-29634-SH6 from OSHA, the Occupational Safety and Health Administration, U.S. Department of Labor. It does not necessarily reflect the views or policies of the U.S. Department of Labor, nor does mention of trade names, commercial products, or organizations imply endorsement by the US government.


LEARNING OBJECTIVESØROOT CAUSE ANALYSIS AND MANAGEMENT SYSTEMS

ØVITAL IMPORTANCE OF HAZARD REPORTING AND INVESTIGATION

ØCAUSAL FACTORS AND ROOT CAUSES

ØISHAKAWA FISHBONE AND SIX CATEGORIES

ØFIVE WHYS

ØAPPLYING WHAT WE LEARN:

ØROOT CAUSE ANALYSIS SKIT

ØROOT CAUSE ANALYSIS GROUP EXERCISE

ØREPORT BACKS


Root Cause Analysis Is Not:


ROOT CAUSE ANALYSIS IS:

FROM WIKIPEDIA:

• ROOT CAUSE ANALYSIS (RCA) IS A METHOD OF PROBLEM SOLVING THAT TRIES TO IDENTIFY THE ROOT CAUSES OF FAULTS OR PROBLEMS.

• A ROOT CAUSE IS A CAUSE THAT ONCE REMOVED FROM THE PROBLEM FAULT SEQUENCE, PREVENTS THE FINAL UNDESIRABLE EVENT FROM RECURRING.

• A CAUSAL FACTOR IS A FACTOR THAT AFFECTS AN EVENT'S OUTCOME, BUT IS NOT A ROOT CAUSE.

• THOUGH REMOVING A CAUSAL FACTOR CAN BENEFIT AN OUTCOME, IT DOES NOT PREVENT ITS RECURRENCE FOR CERTAIN.


ROOT CAUSE ANALYSIS EXPLORES MANAGEMENT SYSTEMS

• JSA: JOB SAFETY ANALYSIS, HAZARD ASSESSMENTS

• POLICIES, PROCEDURES

• STAFFING, TRAINING

• FIRE, EMERGENCY RESPONSE, EVACUATION

• SECURITY, MAINTENANCE

• INSPECTIONS, EVALUATION

• ENFORCEMENT, MOREDistrict 1199C Training Fund HWWH SH-29634-SH6

WHY FOCUS ON SYSTEMS?

ØPROBLEMS LARGER THAN ONE OCCURRENCE

Ø‘TIP OF THE ICEBERG’

ØSYSTEM ANALYSIS LEADS YOU TO FIX PROBLEMS INSTEAD OF FIXING BLAME.

LEADS TO BETTER RECOMMENDATIONS

System Analysis District 1199C Training Fund HWWH SH-29634-SH6

SYSTEM ANALYSIS NEEDS REPORTING

HAZARDS SHOULD NOT BE SECRETS!SHARE THE DETAILS TO GET IT FIXED

If you are not aware of a problem, it is hard to solve it!


Reporting ResolvingTalk about it Get it Fixed• Workplace Accidents and Incidents• Near Miss and Close Calls


WHY DON’T ACCIDENTS OR INCIDENTS GET REPORTED MORE OFTEN?

vFEAR• BLAME OR RETALIATION (KILL THE MESSENGER)

• WORK RECORD OR REPUTATION DAMAGE

• HASSLE, LOST TIME, RED TAPE, PAPERWORK

vLACK OF UNDERSTANDING ABOUT

IMPORTANCE OF REPORTING(ACCIDENT-FREE INCENTIVE PROGRAMS ARE ILLEGAL)


WHAT HAPPENS WHEN YOU

START ASKING EMPLOYEES

TO REPORT CLOSE CALLS

AND NEAR MISSES AS WELL

AS ACCIDENTS AND

INJURIES?


IT WILL LOOK AS IF YOUR ACCIDENT AND INCIDENT RATES HAVE GONE WAY UP!


CHOOSE WHAT TO INVESTIGATE

• INJURIES WITH LOST DAYS

• OCCUPATIONAL ILLNESSES

• FIRES, EMERGENCIES

• WORKPLACE VIOLENCE

• NEAR MISS, CLOSE CALLS


WHO INVESTIGATES?

SMALL GROUP- CROSS SECTION

ØLINE WORKERS & MANAGEMENT.

ØSAFETY & HEALTH

ØUNION AND/OR WORKER REPRESENTATIVES

ØSUPERVISORS

ØIMPACTED PERSONNEL

COLLABORATIVE APPROACH

MOST EFFECTIVEDistrict 1199C Training Fund HWWH SH-29634-SH6

INTERVIEWSØQUIET PLACEØ IF NOT QUIET, THEN PRIVATE

ØTAKE NOTES

ØNEUTRAL AND NON-JUDGMENTAL

ØNO LEADING QUESTIONS

ØNO:

SO, MRS. JONES, WHO WERE YOU TEXTING WHEN YOU CRASHED INTO THAT WALL?

ØYES:

MRS. JONES, CAN YOU PLEASE TELL ME, STEP BY STEP, WHAT HAPPENED?


INTERVIEWING QUESTIONS

* HOW * WHEN * WHERE * WHAT *

ØDID YOU SEE/PERCEIVE ANYTHING UNUSUAL?

ØCAN YOU SHOW ME/TELL ME HOW IT HAPPENED

STEP BY STEP?

Ø“AND THEN WHAT HAPPENED?”

Ø“IS THERE ANYTHING ELSE YOU WOULD LIKE US TO KNOW?”


MAKE A TIMELINE WITH YOUR INFORMATION

Work order to

clean extra room

Sprayed chemicals in eyes at 4:35 pm

Rinsed eyes for

15 minutes

Saw supervisor at 4:50

In hospital emergency room

at 5:30 pm


DESIGN VS ‘AS BUILT’

EXPLORE DIFFERENCES BETWEEN WHAT WAS DESIGNED, PLANNED, & WHAT IS ACTUALLY DONE

ØREVIEW PROCEDURES & POLICY

ØREVIEW TRAINING RECORDS

ØREVIEW INSPECTION REPORTS & DOCUMENTATION

ØTALK TO WORKERS!


ROOT CAUSE ANALYSIS IDENTIFIES CAUSAL FACTORS

AS WELL AS ROOT CAUSE

CAUSAL FACTORS• OFTEN DIRECTLY RESPONSIBLE FOR THE INCIDENT

• OFTEN CAN BE IMMEDIATELY ADDRESSED:

• SUBSTITUTE LESS HAZARDOUS SUBSTANCE OR PROCESS*

• INSTALL GUARDS, BETTER ENGINEERING CONTROLS*

• POST WARNING SIGNS*

• REVISE SAFETY TRAINING*

• SUPPLY MORE PERSONAL PROTECTIVE EQUIPMENT (PPE) *

• REPAIR WHAT IS BROKEN, ETC.

* HIERARCHY OF CONTROLSDistrict 1199C Training Fund HWWH SH-29634-SH6

RCA IDENTIFIES ROOT CAUSES

ROOT CAUSE LOOKS AT MANAGEMENT SYSTEMS

AND THE NEED TO REVISE THEMDistrict 1199C Training Fund HWWH SH-29634-SH6

ROOT CAUSE LEADS TO ROOT SOLUTIONS

CHANGE • POLICY & PROCEDURES

• PROCESS MANAGEMENT

• PROCUREMENT CHOICES

• TRAINING CONTENT & FREQUENCY

• STAFFING LEVELS

• MANAGEMENT OF CHANGE

• CAPITAL SPENDING, BUDGET, ETC.


HOW TO PERFORM ROOT CAUSE ANALYSIS(ONE METHOD AMONG MANY)


Machines Materials

Management People EnvironmentEnvironment

Incident or Accident: What Happened

Methods

Organizing Data with Fishbone Cause and Effect Diagram

….developed by Dr. Kaoru Ishakawa, Univ. of Tokyo(石川馨 Ishikawa Kaoru, 1915 - 1989)


SIX CATEGORIES OF INFORMATION

Facilities, equipment, machines and tools (durable)

Chemicals, products, disposable tools, things that get used up

How the work gets done -procedures and work practices


SIX CATEGORIES OF INFORMATION

Policies, work schedules, shifts, safety systems, inspections, supervision,

enforcement

Personalities, health, fatigue, experience, workers and supervisors, contractors,

patients, public, staffing levels

Physical Environment: weather, temperature, cleanliness, trip hazards,

noise, moisture, animals, lighting, location, time of day, etc.

Management


ORGANIZE DATA INTO SIX CATEGORIES ANSWERS CAN FIT INTO MORE THAN ONE CATEGORY

SOME RCA SYSTEMS USE DIFFERENT CATEGORIES

• WHAT POLICIES WERE IN PLACE WHEN THE ACCIDENT HAPPENED? MANAGEMENT

• ACTUAL WORK PRACTICES & PROCEDURES? METHODS

• HOW DO THESE COMPARE TO WRITTEN POLICY?METHODS & MANAGEMENT


ORGANIZE DATA INTO SIX CATEGORIES ANSWERS CAN FIT INTO MORE THAN ONE CATEGORY

SOME RCA SYSTEMS USE DIFFERENT CATEGORIES

• WERE WORKERS & SUPERVISORS ADEQUATELY TRAINED? METHODS

• WAS EQUIPMENT IN GOOD WORKING ORDER? MACHINES

• WHAT SUPPLIES WERE AVAILABLE & USED? MATERIALS


• WHAT WAS THE ENVIRONMENT LIKE? HOT, COLD, LOUD, SLIPPERY, DUSTY, EMPTY, DARK? ENVIRONMENT

• WERE THERE ALARM SYSTEMS IN PLACE? MACHINES

• DID ALARM SYSTEMS WORK? MANAGEMENT , METHODS, MACHINES


• WAS STAFFING ADEQUATE & APPROPRIATE?

PEOPLE, MANAGEMENT

• WERE PERSONAL PROBLEMS OR HOME LIFE EFFECTING THE PERSON’S BEHAVIOR?

PEOPLE, ENVIRONMENTDistrict 1199C Training Fund HWWH SH-29634-SH6

INTRODUCTION TO ‘FIVE WHYS’

• ONCE DATA IS CATEGORIZED, CHOOSE ONE CATEGORY AT A TIME

TO ANALYZE

• CHOOSE THE FIRST MOST LIKELY CAUSE (IN THAT CATEGORY) TO EXPLORE

• ASK WHY:

• WHY DID SOMETHING HAPPEN?

….AND WHY DID THAT HAPPEN?





FINDING ROOT CAUSES

KEEP ASKING ‘WHY’ UNTIL YOU GET AN ANSWER YOU CAN NO LONGER ASK ‘WHY’ ABOUT (JUST BECAUSE- THAT IS HOW IT IS)

•ROOT CAUSE • OFTEN POINTS TO SYSTEM ISSUE


Eyewash station was not used by employee

Why didn't employee use

eyewash station?

• Too far away from place of chemical use• After getting chemical sprayed in his eyes, employee

could not see or locate eyewash

Why was the eyewash

station so far away?

• Eyewash located where cleaning chemicals mixed & dispensed - not where chemicals are used.

• Hazard not anticipated or planned for

Why?

• Inadequate Job Safety Analysis/Risk Assessment

• Inadequate emergency response planning, procedures & training

WHY? WHY? WHY? WHY? WHY?


Machines Materials

Management People EnvironmentEnvironment

Incident/ Accident

Methods

Plug your answers into the Fishbone diagram for a ‘visual map’ of root cause


DEVELOPING RECOMMENDATIONS

SHORT TERM

• SPECIFIC

• IMMEDIATE

• INCLUDES RESPONSIBLE PARTY

• INCLUDES TIME LINE & REALISTIC COMPLETION DATES

• WILL PROBABLY ADDRESS ‘CAUSAL FACTORS’

LONG TERM

• MAY TAKE TIME TO IMPLEMENT

• IMPROVEMENTS HAPPEN SEQUENTIALLY

• ADDRESSES ROOT CAUSES

• IMPACTS WORKPLACE SYSTEMS


ROOT CAUSE ANALYSIS EXERCISE:

ü ASK FOR 3 VOLUNTEERS

ü STEVEN, DOCTOR AND JOSEPHINE

ü READ ROLE-PLAY SKIT OUT LOUD

ü INSTRUCTOR IS NARRATOR

ü CLASS WILL DISCUSS ROOT OF INJURY AND COMPLETE ROOT CAUSE ANALYSIS OF PROBLEM

ü GENERATE RECOMMENDATIONS

ü QUESTIONS AND REVIEW


ROOT CAUSE EXERCISE – CLASSROOM GRIDMaterials

What happened? Problem? Recommendations Causes

People


Machines


Methods


Management


Environment



Recommendations – Include Responsible Party and Completion Date1A. Research, purchase & provide less toxic products for EVS cleaning needs.1B. Identify & remove corrosive cleaning chemicals from circulation.1C. Provide & document OSHA compliant HAZCOM training for new chemicals & processes.

2A. Institute regular inventory process of EVS supplies & equipment. 2B. Train employees to recognize and turn in damaged supplies & equipment.2C. Discard broken equipment and replace immediately, document.

3A. Update Hazard Analysis for EVS job. 3B. Procure additional, appropriate PPE for EVS tasks. 3C. Retrain employees & managers on PPE use. 3D. Train workers & supervisors to recognize damaged PPE, remove from service.3E. Institute PPE replacement program. 3F. Enforce PPE usage.4A. Train EVS employees to recognize when they need help.4B. Train employees to communicate with supervisors about problems with equipment or assigned tasks.

5A. Update and implement Emergency Response policies & programs to address exposures to corrosive chemicals. 5B. Train EVS managers and employees on emergency equipment use (eyewash and showers) in case of chemical exposure.5C. Retrain supervisors & management on emergency medical response to provide immediate medical care to injured employees.


QUESTIONS?


LEARNING REVIEWØROOT CAUSE ANALYSIS AND MANAGEMENT SYSTEMS

ØVITAL IMPORTANCE OF HAZARD REPORTING AND INVESTIGATION

ØCAUSAL FACTORS AND ROOT CAUSES

Ø ISHAKAWA FISHBONE AND SIX CATEGORIES

ØFIVE WHYS

ØAPPLYING WHAT WE LEARNED:

Ø ROOT CAUSE ANALYSIS SKIT

Ø ROOT CAUSE ANALYSIS GROUP EXERCISE

Ø REPORT BACKS


EMPLOYEE RIGHTS UNDER OSHA


• RIGHTS OF EVERY EMPLOYEE

OSHA RIGHTS AND WHISTLEBLOWER PROTECTIONS

OSHA LAWS GIVE WORKERS THE RIGHT TO:

• PARTICIPATE IN SAFETY AND HEALTH ACTIVITIES

• REPORT WORK RELATED INJURIES OR ILLNESSES

• REPORT SAFETY VIOLATIONS


Employer cannot take action against you for using your OSHA rights.

RETALIATION IS AGAINST THE LAW


• FIRING OR LAYING OFF

• BLACKLISTING

• DEMOTING

• DENYING OVERTIME OR PROMOTION

• DENIAL OF BENEFITS

• DISCIPLINING

• FAILURE TO HIRE OR REHIRE

• INTIMIDATION

• MAKING THREATS

• REASSIGNMENT AFFECTING PROSPECTS

FOR PROMOTION

• REDUCING PAY OR HOURS

NO

No ‘Adverse Actions’ for Safety Activities

WHAT IF YOU GET IN TROUBLE FOR COMPLAINING?WHISTLEBLOWER TIME LINE

• OSHA LAW

UNDER SECTION 11(C) OF THE OSH ACT, EMPLOYEES ARE PROTECTED FROM RETALIATION WHEN THEY:

• FILE A SAFETY COMPLAINT

• PARTICIPATE IN A SAFETY INSPECTION.

• TO BE PROTECTED

IF EMPLOYEES EXPERIENCE RETALIATION, THEY MUST FILE A COMPLAINT WITH OSHA

WITHIN 30 DAYS.

• IF EMPLOYEES WIN A COMPLAINT CASE, THEY COULD BE ENTITLED TO BACK PAY AND COMPENSATION FOR DAMAGES

• IF EMPLOYEES LOSE A COMPLAINT

CASE, THEY HAVE 15 DAYS TO “APPEAL” THE DECISION.

• SECOND CHANCE TO WIN


FIVE WAYS TO COMMUNICATE WITH OSHA

1.E-MAIL WITH AN INTERACTIVE ONLINE FORM

2.CALL OSHA3.IN-PERSON VISIT4.FAX A COMPLAINT5.MAIL A LETTER


HOW TO CONTACT OSHA• WWW.OSHA.GOVUS DEPARTMENT OF LABOR/OSHAPHILADELPHIA AREA OFFICETHE WANAMAKER BUILDING100 PENN SQUARE EAST, 12TH FLOORPHILADELPHIA PA 19107

TELEPHONE: (215) 597-4955

• FAX: (215) 597-1956

• TOLL-FREE NUMBER: 1-800-321-OSHA (6742)

OSHA WILL KEEP YOUR INFORMATION CONFIDENTIAL District 1199C Training Fund HWWH SH-29634-SH6

FOR MORE INFORMATION

DISTRICT 1199C TRAINING & UPGRADING FUND

HEALTHCARE OCCUPATIONAL SAFETY CENTER

100 SOUTH BROAD STREET, 10 FLOOR

PHILADELPHIA, PA 19119

215 568 222O

ELLIE BARBARASH – [email protected]


THANKS TO

• DISTRICT 1199C TRAINING & UPGRADING FUND

• DISTRICT 1199C OF THE NATIONAL UNION OF HOSPITAL AND HEALTHCARE EMPLOYEES, AFSCME, AFL-CIO

• DREXEL UNIVERSITY SCHOOL OF PUBLIC HEALTH

• JEFFERSON SCHOOL OF POPULATION HEALTH


healthcare occupational safety center of district … · root cause analysis is: from wikipedia:...

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