root cause analysis & environmental assessments
TRANSCRIPT
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Root Cause Analysis & Environmental Assessments
Karin Hoelzer, DVM, Ph.D. November 9, 2017
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Outline of today’s presentation
• What is RCA & why is it needed?
• Pew’s RCA initiative
•Some lessons learned about RCA
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Outline of today’s presentation
• What is RCA & why is it needed?
• Pew’s RCA initiative
•Some lessons learned about RCA
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Why rootcause analysis (RCA) is needed?
“It is our view that complex systems almost always fail in
complex ways, and we believe it would be wrong to reduce the
complexities and weaknesses associated with these systems to
some simple explanation. Too often, accident investigations blame
a failure only on the last step in a complex process, when a
more comprehensive understanding of that process could reveal
that earlier steps might be equally or even more culpable.“
Columbia Space Shuttle Accident Investigation Board, 2003
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RCA: explain why disaster strikes & how to prevent it
1986: Space Shuttle Challenger disaster Live on CNN
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From Challengerto Columbia: root causes reoccur
• Challenger investigation• Root causes identified
• Physical causes • NASA history • NASA culture
• Corrective actions suggested
• Seventeen years in-between• System returned to status quo
• Columbia investigation• Root causes reoccurred
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The goals of RCA: prevent disaster reoccurrence
Root causes are
• Causal influences• Caused event or
• Increased impact
• Controllable • Manageable
• Within control
• Usually > 1 RC
RCA focus
• Learn from past
• Why system failed• Events
• Interactions
• Root causes
• Prevent repeat
RCA approach
• Systematic
• Comprehensive • Physical factors
• Human factors
• Organization
• Other
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Systems theory: attributes of complex systems
consist of multiple interdependent parts
have ‘set points’ shaped by these interactions
changes require deep knowledge of interactions
system is prone to return to ‘set points’
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• Basic premises• Humans are fallible• Errors happen
• Understand why • Adapt conditions
• Understanding is key to prevention
• Complex systems have many safety barriers • Every safety barrier has weaknesses• Accidents happen when ‘holes’ align• Need to understand ‘near misses’
Understanding accidents: Swisscheese model
James Reason, 2000
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Outline of today’s presentation
• What is RCA & why is it needed?
• Pew’s RCA initiative
•Some lessons learned about RCA
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Why is root cause analysis a priority for Pew?
Foundation of a prevention-based food system
Not always done; ineffectively shared; lost opportunities
Improvements require collaborative approach
Alignment among FDA, CDC, FSIS, state & local; industry
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Root cause analysis project approach
• Other models (e.g., NTSB, CSB, NuReg)
• RCA best practicesResearch
• RCA value; obstacles; definitions
• Communicating RCA findings
• RCA best practices Convenings
• Conference presentations (IAFP, InFORM)
• Publication in trade magazine (upcoming)Outreach
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Pew’s work on RCA: Goals and objectives
RCA description
definition
value
obstacles
Best practices
current practice
other models
recommendations
Learning from RCA
challenges
success stories
pilot project
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Pew’s work on RCA: Goals and objectives
RCA description
definition
value
obstacles
Best practices
current practice
other models
recommendations
Learning from RCA
challenges
success stories
pilot project
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Outline of today’s presentation
• What is RCA & why is it needed?
• Pew’s RCA initiative
•Some lessons learned about RCA
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Pew’s work on RCA: Learning from other models
RCA in other high-risk industries
• Transportation, chemical, nuclear industries
• Occupational safety; consumer product safety
• Recreational scuba diving
3 Key research questions
• How are RCAs conducted? (When, why & how)
• How are key findings disseminated & used?
• What is working & what is not?
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Three distinct but related types of investigations:
• What can go wrong & how to prevent it?
• Based on risk assessment, fault tree analysis, etc.
• Site licensing, standard setting, regulations, etc.
Predictive
(before operations)
• Are safety measures implemented & adhered to?
• Based on inspection, surveys, etc.
Operational
(during operations)
• What went wrong & why? What actually worked?
• Based on root cause analysis
Investigational
(after accident)
Key finding: Not every investigation is a RCA
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RCA: learning from past to prevent future
Root cause analysis Inspection
- What went wrong and why?
- How to prevent reoccurrence?
- What could create future problems?
- Is operation in compliance?
- How to restore compliance?
- How to prevent future issues?
retrospective prospective
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Accident or incident
New & catastrophic
RCARecommend
changes
Known factor
Monitor Trend
analysis
Minimize occurrence
Training & outreach
Rules & regulation
Recommend changes
Key finding: Not every event requires a RCA
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After the accident
How well did the post-event response work?
What has been learned and what changes have been made?
During the accident
What went wrong and why? What went right?
Before the accident
What was the general situation before the event?
What specific events led up to the event?
Key finding: Effective RCAs reconstruct events
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Key finding: Effective RCAs consider 4 types of factors
• Weather
• Post response
• Regulations
• ….
• Policies
• Structures
• Culture
• ….
• Performance
• Decision-making
• Communication
• ….
• Structures
• Systems
• Impacts
• ….
Physical Operation
External Organization
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Timely investigation
Frequent stakeholder communications
Comprehensive & systematic Appropriate technical expertise available
Unbiased & transparentConclusions based on & driven by evidence
Clearly & concisely reported
Key finding: Properties of effective RCAs
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Conclusion: RCA valuable for foodborne outbreaks
• Systems-based approach for prevention
• Key in prevention-based food system• Understand why outbreak happened• Find weaknesses in food system• Identify how to prevent reoccurrence
• Other high-risk industries rely on RCA• Opportunities to learn from them
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To continue the discussion beyond today please contact:
Karin Hoelzer, DVM, PhD
Senior Officer, Health Programs
The Pew Charitable Trusts
901 E Street, NW, Washington, DC 20004
p: 202-540-6986 | e: [email protected] |
www.pewtrusts.org
Source: New Yorker, 12/06/2004
Thank you for your time & attention